Cleft Lip & Palate-overview

8/3/2019 Cleft Lip & Palate-overview

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CLEFT LIP & PALATE

- AN OVERVIEW

Dr. Munizeh Khan

S.R Orthodontics


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Incidence

1 in 500 live births

1 in 6 children have additional malformations

CLP: 46%

CP: 33%

CL: 21%

UL > BL

Left > Right


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Etiology

Syndromic

Non-syndromic

Environmental


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Syndromic Clefts


More than 400 syndromes associated with CLP

Commonly associated:

Van der Woude

DiGeorge

Pierre Robin sequence

Treacher-Collins

Stickler

Velocardiofacial (VCFS)


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Non-syndromic Clefts


Incidence increases with:

Family history

Race Negroids least affected

Asians more commonly affected

Afghan population shows high rate

Gender

Males = CLP Females = CP

Site

Left > Right side

Maternal Age

More than 38years = twice as much risk of CLP


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Environmental Factors

Folate deficiency

Smoking

Alcohol

Epilepsy

Drug abuse

Medications:

Aspirin

Dilantin

Valium

6-mercaptopurine


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Clinical Features

Unilateral CLP:

Flaring of unilateral alar cartilage

Maxillary deficiency - anteroposterior

Oronasal fistula

Posterior crossbite

Lack of bone support for canines and incisors


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Clinical Features

Bilateral CLP:

Mobile premaxillary segment

Flattened upper lip & philtrum

Severe maxillary transverse deficiency


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General Management Overview

Immediately after birth:

Counselling, feeding instructions

Within first few weeks: PNAM

Age 10-12 weeks:

Surgical repair of cleft lip (rule of 10)

Before age 1:

Surgical repair of cleft palate


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Up to 6 years of age:

Team evaluation for speech, lip & nose revision

Continued monitoring of ears, language, psychosocial issues

7 years:

Palatal expansion, Facemask therapy

Between 9-11years:

Alveolar bone grafting

12 years:

Phase II orthodontics


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At end of orthodontic treatment:

Placement of final prosthesis (bridge, implants etc)

When growth is complete: Orthognathic surgery, if required

Final lip & nose revision, if required


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Orthodontic Intervention

Infant orthopedics

Primary dentition

Mixed dentition

Permanent dentition


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Infant Orthopedics

After 1-2 weeks of birth

Appliances given to adjust position of cleft segments

into more ideal relationship prior to definitive lip repair

PNAM

Active appliances

Passive appliances

Does not eliminate need for orthodontics

Especially important in bilateral CLP


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Primary dentition stage

Caries control

Diagnosis of developing malocclusion

Anterior crossbite

Equilibration

Tongue-blade therapy, removable appliance

Posterior crossbite

Expansion with quad-helix or fan-shaped expander


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Mixed dentition stage

Incisor alignment

Rotated, malformed, hypoplastic, malposed

Supernumerary, absent, peg-shaped

Maxillary expansion

Preferable at this stage

Quad-helix, fan-shaped

Maxillary protraction orthopedics

Facemask, distraction osteogenesis

2-3 mm in 12-15 months


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Mixed dentition stage

Alveolar bone grafting

Cleft alveolus

Early = lateral incisor present, erupting Secondary = before eruption of canine

Gold standard: autogenous bone

Sites: iliac crest, rib, mandibular symphysis


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Permanent dentition stage

Management of dentition

Align, level

Settling of occlusion

Space closure, prosthetic replacement


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Orthognathic surgery

Maxilla deficient- 3 planes of space

Mandible prognathic


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Long-term retention

Maxillary palatal arch

No mid-palatal suture, heavy palatal scar tissue


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Cleft Lip & Palate-overview

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