Cleft Lip and Palate

CLEFT LIP AND PALATE

DEPARTMENT OF ORTHODONTICSSWAMI DEVI DYAL DENTAL COLLEGE

BY ANUBHA TIWARIINTERN

CLASSIFICATION OF CLEFT LIP AND PALATE

• KERNAHAN AND STARK (1958)A.CLEFTS OF PRIMARY PALATE ONLY1. Unilateral complete incomplete2. Median complete(premaxilla absent) incomplete(premaxilla rudimentary)3. Bilateral complete incomplete

B. CLEFTS OF SECONDARY PALATE ONLYCompleteIncompleteSubmucosalC.CLEFTS OF PRIMARY AND SECONDARY PALATE1.Unilateral complete or incomplete2.Median complete or incomplete3.Bilateral complete or incomplete

KERNAHAN’S STRIPED “Y”

1. BLOCK 1 AND 4 – LIP

2. BLOCK 2 AND 5 – ALVEOLUS

3. BLOCK 3 AND 6 – HARD PALATE ANTERIOR TO INCISIVE FORAMEN

4. BLOCK 7 AND 8 – HARD PALATE POSTERIOR TO INCISIVE FORAMEN

5. BLOCK 9 - SOFT PALATE

MILLARD’S MODIFICATION

• MILLARD added two triangles over the tip of the “y” to denote the nasal floor

1. BLOCK 1 AND 5 – NASAL FLOOR2. BLOCK 2 AND 6 – LIP3. BLOCK 3 AND 7 – ALVEOLUS4. BLOCK 4 AND 8 – HARD PALATE ANTERIOR TO

INCISIVE FORAMEN5. BLOCK 9 AND 10 – HARD PALATE POSTERIOR TO

INCISIVE FORAMEN6. BLOCK 11 - SOFT PALATE

LAHSHAL’S CLASSIFICATION

• OKRIENS(1987)L - lipA - alveolus bilateralH - hard palateS - soft palate unilateralH - hard palateA - alveolusL - lip

Iowa Classification

DEVELOPMENT OF LIP

LOWER LIP – • The mandibular process of the two sides

grows towards each other and fuse in the midline.

• Fused mandibular process gives rise to lower lip and jaw.

UPPER LIP

• MAXILLARY PROCESS grows medially and fuses first with the lateral nasal process and then with the medial nasal process• Medial and lateral nasal process

also fuses with each other

• UPPER LIP:A.The mesodermal basis of the

lateral part of the lip is formed from the maxillary process.

B. The mesodermal basis of the median part of the lip is formed fromed FNP

DEVELOPMENT OF PALATE

• From each MAXILLARY PROCESS a plate – like shelf grows medially . This is called as PALATAL PROCESS.

• Basically there are three components from which the palate will be formed

1. the two palatal processes2. the primitive palate formed from the

frontonasal process

• The definitive palate is formed by fusion by:a. Each palatal process fuses with the posterior

margin of the primitive palate.b. The two palatal processes fuse with each

other in the midline. - their fusion begins anteriorly and proceedsBackwardsc. The medial edges of the palatal processes fuse

with the free lower edges of the nasal septum thus seperating the two nasal cavities from each other , and from the mouth.

• At a later stage the mesoderm in the palate undergoes intramembranous ossification to form the hard palate.

• Ossification does not extend into the most posterior portion which remains as the soft palate .

• The part of the palate derived from the frontonasal process forms the premaxilla which caries the incisor teeth.

PRIMARY PALATE

• PALATAL development begins in week 5 but weeks 6-9 are most critical

• Formation of intermaxillary segment from merged MNP

• Primary palate forms from MNP• Ossifies as premaxillary portion of the maxilla

• Lateral palatine process• Ingrowth from maxillary process• Eventually project horizontally above the

tongue• Fuse with each other ,primary palate, nasal

septum• Nasal septum• Downgrowth of MNP• Fusion of lateral palatine process starts

anteriorly then moves back

• Hard palate• Primary palate – premaxilla• Secondary palate – maxillary process

• Soft palate• Unossified portion of the lateral palatine

process

CLEFT LIP

• DEFINATION – Cleft lip occurs because of failure of fusion between the medial and lateral nasal processes and the maxillary process which occurs during 6th week of development.

Cleft Lip

• Complete closure at 35 days postconception:– Lateral nasal, median nasal, and maxillary

mesodermal processes merge.• Failure of closure can produce unilateral,

bilateral, or median lip clefting.• Left side unilateral cleft is the most common.

UNILATERAL

• Forms persistent labial groove• Grooves should disappear as maxillary

prominences fuse with merged medial nasal prominence.

• Stretching of epithelium causes tissue breakdown and cleft formation.

• SIMONARD BAND – bridge of tissue spanning the cleft (arrow below)

BILATERAL

• Similar • Central soft tissue mass that moves freely

ANTERIOR CLEFT

• Clefting of the alveolar process of the maxilla as well as lip.

• Complete cleft extends to the incisive foramen.

• Complete bilateral anterior cleft isolates the anterior and the posterior parts of the palate

POSTERIOR CLEFT

• CLEFTS EXTENDING THROUGH BOTH SOFT AND HARD PALATE TO INCISIVE FORAMEN

• Isolates anterior and posterior parts of the palate

• Result from failure of the lateral palatine process to grow medially and fuse to each other

EtiologyGenes

• Control cell patterning, cell proliferation, extracellular communication, and differentiation

• Clefting usually represents a genetically complex event

• 2 to 20 genes are thought to interact to result in facial clefting

Etiology• TGF-beta-3 gene – Expressed just prior to palatal fusion. – Results in isolated cleft palate.

• IRF 6. • Identified in -Autosomal dominant vander

woude syndrome

Etiology• Dlx gene – Direct the destination of the distal skeletogenic

mesenchyme elements to the palate. – Mutations of these genes result in isolated palatal defects.

• Sonic hedgehog gene – Protein that mediates ectodermal functions, might

regulate the outgrowth and fusion of the facial domains.• TGF-alpha variant – Receptor ligand, usually a rare variant of TGF-alpha – Family histories of cleft defects– Additive teratogenic effect with agents such as cigarette

smoking and alcohol

Etiology• Cigarette smoking – Noted with mothers of children with facial clefting, both

CL/P and CP.– Teratogenesis has been attributed to hypoxia as well as a

component of tobacco (cadmium).• Alcohol – Associated with an increased risk of fetal facial clefting. – Alterations in cell membrane fluidity or reduced activity of

specific enzymes such as superoxide dismutase.• Folate deficiency – Contributes to a range of birth defects. – Evidence is emerging for a similar association with the

development of CL/P.

Environmental agents• Several agents that are associated with an

increased frequency of midfacial malformation.

• Medications —phenytoin, sodium valproate, methotrexate.

• With corticosteroids there is no evidence of an increase in malformations.– Possible association could not be excluded

Prenatal Diagnosis• Diagnosed until the soft tissues of the fetal

face can be clearly visualized sonographically (13 to 14 weeks).

• The majority of infants with cleft lip also have palatal involvement:– 85% of bilateral cleft lips – 70% associated with cleft palate. – Cleft palate with an intact lip comprises 27% of

isolated CL/P

Prenatal Diagnosis• The sensitivity is highest when is associated with

other structural anomalies. • Isolated CL/P in a low risk population, the sensitivity

may only reach 50 percent. • Cleft palate with an intact lip is the most difficult

orofacial malformation to diagnose prenatally.• Detected in only 13 of 198 cases in one large series.• Three-dimensional ultrasound, can provide a clear

image of the malformation

Prenatal Diagnosis

PROBLEMS ASSOCIATED

• FEEDING• PSYCHOLOGICAL : Disfigurement caused by the condition causes psychological

stress for the patient and the family

DENTAL: Clefts are associated underdeveloped maxilla 1. Multiple missing teeth 2. Mobile premaxilla3. Impacted teeth

4. Supernumaries5. Multiple decayed teeth6. Periodontal complication

ESTHETIC : The patients with unrepaired clefts are badly

disfigured due to the nature of the deformity

SPEECH AND HEARING: 1. Definitive speech problems2. Are associated with infections of the middle ear

TREATMENT

Principles of ManagementAssessment

Indications: restoring normal morphologic form and functionImportant for normal dentition, mastication, speech, hearing, and breathingContraindications: malnutrition, anemia or other conditions that render infant

unable to tolerate general anesthesia- airway obstruction, otitis media

Work-up

(1) Thorough PE to uncover any associated anomaliesAdditional work-up determined by physical findings that suggest involvement of other organ systems

(2) Weight, oral intake, growth/development are of primary concern and must be followed closely (3) Routine lab studies generally not required; Hgb level before surgery

Clinical Aspects of Cleft Lip/Palate Reconstruction

Surgical Management

Multidisciplinary approach

Beyond lip repair are other issues:Hearing (otolaryngologists)Speech (speech pathologists)Dental (oromaxillofacial surgeons ,orthodontists)

Psychosocial

Integration with team-based approach

Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her development

Cleft Lip and Palate

Clinical Aspects of Cleft Lip/Palate Reconstruction

Surgical Management

Staging and Timing of SurgeryDifferent institutions = different practice

Rule of 10’s

Hgb = 10g

Weight of 10lbs

Age 10wks

Cleft Lip Cleft Palate

9-12 months of age

Clinical Aspects of Cleft Lip/Palate Reconstruction

Surgical ManagementUnilateral Complete Cleft Lip

Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral dimple and ; natural appearing Cupid’s bow; functional muscle repair

Surgical Principle: Lengthen medial side of cleft so that it equals the vertical dimensions of non-cleft side

Flap designs:1) Triangular (Tennison-Randall)

2) Quadrangular

3) Rotation-advancement (Millard*, Mohler)

Millard Technique

Scar placed in more anatomically correct position along philtral column

“Cut as you go” technique

1) Medial flap rotates downward to achieve necessary lengthening

2) Lateral flap advances into the defect produced by downward displacement of medial flap

3) Small pennant-shaped medial flap can be used to restore nostril

Preserves’ cupid’s bow and philtral dimple

Tension of closure under the alar base; reduces flair and promotes better molding of the underlying alveolar processes

In simple medical student terms:

Clinical Aspects of Cleft Lip/Palate Reconstruction

Clinical Aspects of Cleft Lip/Palate Reconstruction

Post-op Management

1) Feedings administered with catheter tip syringe fitted with small red rubber catheter for the first 10 days post-op2) Nipples are avoided to minimize strain on the muscle/skin sutures3) Velcro arm restraints to protect repair from flailing hands/fingers4) Suture line care: cleansing with half strength peroxide followed with polymixin B-bacitracin ointment

Cleft Lip

Clinical Aspects of Cleft Lip/Palate Reconstruction

Dr. Christine Underhill

Orthodontic treatment:- performed at different stages of development.

• Neonatal maxillary orthopaedics as an infant• Orthodontic-orthopaedics in deciduous dentition.• Orthodontics in the mixed dentition.• Orthodontics alone or in conjunction with

maxillofacial surgery (+/_distraction osteogenesis) in the permanent dentition.

(Patients with cleft of lip only or soft palate only, defect will not effect dentition.)

12th July 2008

Dr. Christine Underhill

STAGE 1 (Neonatal Orthopaedics)• FROM BIRTH TO 24 MONTHS Performed on new

born before surgical repair of lip.• Rationale...realignment of the collapsed segments before surgery• STRAPPING OF PREMAXILLAFirst collapsed maxillary posterior segments must be expanded

laterally and then pressure against premaxilla can be applied .

This movement can be accomplished by light elastic strap

• Definitely makes lip and anterior palate surgery easier at the time

12th July 2008

• Fabrication of a feeding plate or a obturator

OBTURATOR – is a passive prosthetic appliance which aids in sucking

Prevents maxillary arch from collapsing further

Dr. Christine Underhill

Pre surgical plates, moulding plates, feeding plates…….

12th July 2008

Dr. Christine Underhill

Feeding plates to assist in early feeding

• Obturator plate

12th July 2008

NAM

• NAM(nasoalveolar moulding) :Is a nonsurgical method of

reshaping the gums lip and nostrils before cleft lip and palate surgery lessening the severity of the cleft .

To start NAM, parents work with an orthodontist. Within the first couple of weeks after birth, babies are fitted with a custom-made molding plate that looks like an orthodontic retainer.

The device is attached with a small orthodontic rubberband that is taped to the baby's face.

Unlike some older techniques, the molding plate does not push or stretch the delicate tissues; it only helps gently direct the growth of the gums

• Adjustment of the molding plate is done by the orthodontist weekly or every other week depending on progress. Each appointment takes 40-60 minutes.

•Once the cleft gap in the gums is small enough (around one quarter-inch), a post is attached to the molding plate and is inserted in the nostril. This post is then slowly adjusted to lift up the nose and open the nostril.

•By the time of the surgery, the nose has been lifted and narrowed, the gap in the gums is smaller and the lips are closer together.

• A smaller gap means less tension when the surgeon closes the cleft.

Dr. Christine Underhill

NAM Nasoalveolar moulding

12th July 2008

STAGE 2 (FROM 24 MONTHS TO 6YRS)

• ORTHODONTISTS basically observe• Bring about changes in the obturator plate to

incorporate the deciduous teeth• CROSS BITES can be corrected at this stage

Dr. Christine Underhill

Orthodontic orthopaedic treatment in the deciduous dentition

• STAGE 3 - (6 YRS TO 12 YEARS In vicinity of cleft alveolus ….delayed eruption, malformation or absence of deciduous lateral incisor

• Unilateral or bilateral cross bites often present.

• soft tissue drape often disguises skeletal defect at this stage.

12th July 2008

ARCH EXPANSION Arch expansion can be done using a quad

helix

Dr. Christine Underhill

Mixed dentition…common since event of alveolar bone grafts (ABG)

• Requires careful assessment of problem, risks and benefits

• Timing of treatment closely related to timing of planed bone graft.. either before lateral incisor erupts (argued can effect maxillary growth), or before canine erupts

• When root of canine 1/3 to ½ developed.• Orthodontic treatment involves expansion to

develop favourable arch form, alignment ..care not to move roots into cleft defect.. correct root angulation post grafting

12th July 2008

Dr. Christine Underhill

Repaired cleft palate in 8 year old

12th July 2008

Dr. Christine Underhill

Brackets to keep roots away from cleft

12th July 2008

Dr. Christine Underhill12th July 2008

Dr. Christine Underhill

Alveolar bone grafting (ABG)

• Provides continuity of alveolar ridge…• Provides bone for canine to erupt • Osseous support for adjacent teeth• Majority of canines erupt spontaneously…others

require surgical exposure often in combination with orthodontics.

• The erupting teeth often appear to then stimulate the formation of new alveolar bone

12th July 2008

Feedings• Infants with CL/P have few feeding problems. • If the cleft involves the hard palate, the infant

is usually not able to suck efficiently. – Experiment (special nipples or alternate feeding

positions)• The infant should be held in a nearly sitting

position during feeding– Prevents flowing to the back into the nose.

• Should be burped frequently, (q 3-4min).

Haberman Feeder

• Activated by tongue and gum pressure.

• Milk cannot flow back.• Replenished continuously

as the baby feeds.• Prevents the baby from

being overwhelmed with milk.

• A gentle pumping action to the body of the nipple will increase flow.

THANK YOU