ORTHODONTIC MANAGEMENT OF CLEFT LIP AND PALATE PATIENTS.

ORTHODONTIC MANAGEMENT

OF CLEFT LIP AND PALATE

PATIENTS

Normal Lip and Palatal Development

1. Fusion of lip 4– 6th week I.U.

2. 8th to 12th week fusion of palate

- Palate closure facilitated by the epithelial break down and proliferation of

mesenchyme

Etiology of C.L./C.P.

1. Heredity

- Genetic Disorder

- Deficient Neural crest cells.

- Decreased migration of Neural Crest Cells

Etiology of C.L./C.P.

1. Environment:-

- Teratogens

- Late Pregnancies

- Folic acid deficiency

Cleft lip

• Failure of fusion between the median and lateral nasal processes and the maxillary prominance , during the 6th week of development

• Midline cleft of the upper lip could develop because of a split within the median nasal process.

• A notch in the alveolar process will accompany a cleft lip even if there is no cleft of the secondary palate.

Cleft palate • Closure of the

secondary palate by elevation of the palatal shelves follows that of the primary palate by nearly 2 weeks.

• About 60% of individuals with cleft lip also have a palatal cleft

Classification

1. Davis and Ritchie

2. Veau

3. Fogh-Anderson

4. I.P.R.S.

Treatment approach to a CL/CP patientInter disciplinary management essential

 Cleft lip and/or palate team consists of :-1. Plastic surgeon2. Maxillofacial surgeon3. Pediatrician4. Orthodontics5. Speech therapist6. Pedodontics 7. Prosthodontist8. General Physician9. General dentist

Clinical features associated to cleft patient:

1.   Natal or neonatal teeth 2.   Congenitally missing teeth 3.   Supernumerary teeth4.    Ectopic eruption of teeth5.    Anomalies in tooth morphology6.    Decreased periodontal support to permanent teeth erupting adjacent to cleft site7.    Mobile premaxilla.8.    Anterior and posterior crossbite.9.    Deficient maxilla.

Role of Orthodontics

a. Infant Orthopedics

b. Treatment in deciduous dentition

c. Treatment in mixed dentition

- Early

- Late

d. Treatment in permanent dentition

Role of presurgical orthopedics  Proposed Benefits 1.   Control and modify the post-natal maxillary and Orofacial development2.    Stimulation of palatal shelf growth3.    Constriction of expanded anterior part of maxilla.4. Reposition of premaxilla to aid the surgeon prior to lip repair or primary bone grafting.

Appliance:- Bonnet Bulb prosthesis

Acrylic plates

Treatment in Deciduous dentition

- No treatment- Regular Check up

If needed, equilibration of C’s

Mixed Dentition :-

Maxillary protraction

Maxillary protraction is done using face mask

Face mask therapy

Indications

1.   Sagittal deficiency of maxilla2.    Anterior cross bite3.    Low mandibular plane angle Contraindication :-- True mandibular prognathism - High mandibular plane angle.

Advantage:- No Need of RME.

CORRECTION OF CROSSBITE

1.Rapid maxillary expansion. 2.Slow expansion screw.

3.Quad-helix

Alveolar bone grafting

Types :-

- Primary bone grafting – 2yrs of age.

- Secondary bone grafting – 6-15years, 1/3 of the unerupted root formed

- Delayed secondary grafting.

Indications for Alveolar bone Graft

1.  To stabilize the premaxilla2.  To close the oronasal fistula3.  To ensure better periodontal support to erupting teeth and teeth adjacent to cleft site. 4.  To lend support to the depressed lip over the cleft.5.  To provide bony continuity in the alveolus for tooth eruption and for orthodontic movement of teeth adjacent to cleft into their optimal position .

 Donor Site- Cancellous bone from Iliac crest. Orthodontic movement of teeth into or through the cleft site is not recommended unless bone grafting is done. Alveolar bone grafts have no effect on growth. 

Treatment in permanent Dentition 

This is the phase of comprehensive

Orthodontic treatment.

Treatment in permanent Dentition Main features including :-

1.    Face mask therapy prior RME2. Tooth movement to finalize the occlusion. 3.  Management of arches4.    Correction of individual tooth irregularity 5.    Closure of spaces wherever possible6.    Planned space maintenance in areas of missing teeth for prosthetic replacement.7.   Pre and postsurgical orthodontics.

Distraction Osteogenesis Indicated in cases of severe maxillo- mandibular discrepancy. Advantages:-

Less relapse tendency.

Retention:-

One of the nightmares for an orthodontist Greater chance of relapse in CLP patients b’coz of the Surgical scar. Usually require a long term retention. 

Appliances:- - Fixed lingual retainer - Upper Hawley’s retainer

Responsibility of Orthodontist in treatment of CLP.

 THE MANAGEMENT OF THE DENTITION AND BASAL

BONE RELATIONSHIP WITH PROPER SEQUENCING

FOR ACHIEVING MAXIMAL FACIAL GROWTH,

FUNCTIONALLY STABLE OCCLUSION AND PLEASING

FACIAL ESTHETICS.

“There is no area of dentistry more

fascinating and satisfying than

rendering dental care to the

unfortunate patients with cleft lip

and palate”.