cleft lip and Cleft Palate Rehabilitation

Cleft lip
Physical split or separation of two sides of upper lip and appears as narrow opening or gap in skin of upper lip
This separation often extends beyond base of nose and includes bones of upper jaw and/or upper gum

Cleft Palate
congenital fissure or elongated opening in soft and/or hard palate
opening in hard and/or soft palate due to improper union of maxillary process and median nasal process during second month of intrauterine development( GPT-8)
Cleft lip and palate are most common congenital craniofacial anomalies treated by plastic surgeons.
Cleft care - collaborative multidisciplinary team approch
Successful treatment of these children requires technical skill, in-depth knowledge of abnormal anatomy, and appreciation of three-dimensional facial aesthetics

1. Cleft Palate habilitation 17 th March 2015

2. Contents Introduction Etiopathogenesis Incidence Classification Management Treatment timing and sequencing Abnormal pattern of growth Diagnosis Early intervention and counseling Principles of treatment Infancy Primary dentition Mixed dentition Adolescence Adult Prosthetic rehabilitation Conclusion References 2

3. Cleft lip Physical split or separation of two sides of upper lip and appears as narrow opening or gap in skin of upper lip This separation often extends beyond base of nose and includes bones of upper jaw and/or upper gum Cleft Palate congenital fissure or elongated opening in soft and/or hard palate opening in hard and/or soft palate due to improper union of maxillary process and median nasal process during second month of intrauterine development( GPT-8) Cleft lip  and cleft palate are facial and oral malformations that occur very early in  pregnancy , while the  baby  is developing inside the mother. Clefting results when there is not enough tissue in the mouth or lip area, and the tissue that is available does not join together properly 3

4. Introduction Cleft lip and palate are most common congenital craniofacial anomalies treated by plastic surgeons . Cleft care - collaborative multidisciplinary team approch Successful treatment of these children requires technical skill, in-depth knowledge of abnormal anatomy, and appreciation of three-dimensional facial aesthetics 2 nd most birth defect Incidence 1: 800 births Etiology- exactly unknown Genetic Environmental factors Cleft is apparent by 3 rd month of fetal development Common oral clefts Between intermaxillary segment and maxillary process on one or both sides at about sixth to eight week of fetal development Along line or fusion of right and left palatal shelves and intermaxillary process at about 10 th -12 th week 4

5. Embryological Background 5

6. Development of Facial Prominences Development of head and neck is contributed by pharyngeal arches Pharyngeal arches play an important role in formation of face At the end of 4th week of development the centre of the face is formed by stomodeum, which is surrounded by first pair of pharyngeal arches 6

7. Pharyngeal Arches: F ormed by core of mesenchymal tissue covered on outside by ectoderm and inside by epithelium of endodermal origin Neural crest cells migrate to arches to form skeletal components of face. Mesoderm give rise to musculature of face and neck. 7

8. M uscular components of each arches have their own cranial nerve and arterial component 8

9. Role of Neural Crest cell in craniofacial development P lay critical role in development of the vertebrate head F acial mesenchyme is derived principally from neural crest cell not mesoderm of embryonic third germ layer N eural crest cell formed during neurulation in embryonic period(3rd – 8th week) T he ectomesenchymal neural crest cells interact with epithelial and mesodermal cell present within pharyngeal arches leading to formation of craniofacial bones,cartilages and connective tissues 9

10. Neural Crest Derivatives 10

11. Formation of Facial Prominences Embryo of 24 days shows the centre of fac e formed by stomodeum temporarily closed by buccopharyngeal membrane with five mesenchymal prominences 11 At the end of 4th week facial prominences seen: M axillary promineces lateral to stomodeum M andibular prominences caudally F rontonasal to upper border of stomodeum

12. 12 Local thickenings on both sides of frontonasal prominences forms the nasal(olfactory) placodes During 5th week nasal placodes invaginate to form nasal pits In doing so ridge of tissue surrounds the pit forming nasal prominences

13. P rominences on outer edge of pit are lateral nasal prominences and on inner edges are medial nasal prominences 13

14. Later maxillary prominences increase in size medially compressing medial nasal prominences towards midline fusing with it forming upper lip Lower lip formed by mandibular prominences fusion 14

15. M axillary and lateral nasal prominences initially seperated by deep furrow , nasolacrimal groove become canalized to form nasolacrimal duct M axillary prominences enlarge to form cheecks and maxilla 15

16. Intermaxillary Segment Medial growth of maxillary and two medial nasal prominences merge at deeper level to form it 16 Intermaxillary segment comprises : L abial component forming philtrum of upper lip U pper jaw component carrying four incisors P alatal component forming primary palate

17. Secondary palate A lso called definitive palate F ormed by two shelflike outgrowth from maxillary prominences I n 6th week ,these outgrowth appear directed obliquely downward on each side of tongue In 7th week ,it ascend to attain a horizontal position above tongue and fuse to form secondary palate 17

18. A nteriorly shelves fuse with primary palate with incisive foramen being the midline landmark At same time nasal septum grows down and join with cephalic aspect of newly formed palate 18

19. 19

20. Various theories Alteration in intrinsic palatal shelf force Failure of tongue to drop down Non fusion of shelves Rupture of cyst formed at the site of fusion 20

21. Etiopathogenesis Singh D et al. Etiopathogenesis of Clefts of Lip and Palate – An Invited Review Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 2, June-July, 2014, pp- 188-197 Clefts of lip and palate may be isolated deformities or may be part of a syndrome Non syndromic clefts are multifactorial in origin 21 Van der Woude syndrome

22. ETIOPATHOGENESIS Both environmental teratogens and genetic factors are implicated in the genesis of cleft lip and palate Intrauterine exposure to the anticonvulsant phenytoin is associated with a 10-fold increase in the incidence of cleft lip . Maternal smoking during pregnancy doubles the incidence of cleft lip Genetic abnormalities can result in syndromes that include clefts of the primary or secondary palates among developmental fields affected . The most common syndrome associated with cleft lip and palate is van derWoude syndrome DiGeorge, or conotruncal anomaly syndromes are the most common diagnoses associated with isolated cleft palate. 22

23. 1. Genetic factors ( i ) Mutant genes. There are a number of rare syndromes with relatively simple Mendelian inheritance that include cleft lip, with or without cleft palate, as one component. These include lobster-claw defect with or without cleft palate, as one component . (ii) Chromosomal aberrations. Cleft lip occurs as a feature of several syndromes resulting from chromosomal aberrations, notably the D- trisomy syndrome. In these cases other major malformations are present as well 2. Environmental teratogens . Several specific agents known to damage the embryo (e.g., rubella virus, thalidomide) sometimes cause cleft lip or cleft palate or both presumably when acting on a genetically predisposed embryo. These agents account for only a small proportion of cases. 3. Multifactorial inheritance. The great majority of cases of cleft lip and cleft lip and palate fall in this category. There is a strong familial tendency, but it does not conform to a simple Mendelian pattern, and there are no demonstrable chromosomal aberrations. Singh D et al. Etiopathogenesis of Clefts of Lip and Palate – An Invited Review Indian Journal of Mednodent and Allied Sciences Vol. 2, No. 2, June-July, 2014, pp- 188-197 23

24. Incidence More common in south far Asians: 1 in 500 Less frequent in Africans: 1 in 2000 Prevalence in Europeans and Americans: 1 in 750 Prevalence in Pakistan: 1 in 523 Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A. Epidemiology of cleft lip and cleft palate in Pakistan. Otolaryngol Clin North Am. 2007 Feb; 40(1):27-60 24

25. Boys are more affected than girls by 3:2 Cleft Lip and Palate occur twice as often in boys as in girls Isolated Clefts of Palate are more often in girls 75% of Clefts are Unilateral, rest are Bilateral Left side is more involved than right side Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A. Epidemiology of cleft lip and cleft palate in Pakistan. Otolaryngol Clin North Am. 2007 Feb; 40(1):27-60 25

26. I ncidence in Nepal 1.64/1000 live births per year clefts of the lip alone 0.61/1000 per year cleft lip and palate 0.67/1000 per year cleft palate only 0.35/1000 per year Prevalence higher than what is reported for Caucasian and African populations. male predominance individually CLP and CL were more common in males CP was more common in females Singh VP,  Sagtani R,  Sagtani A. Prevalence of cleft lip and cleft palate in a tertiary hospital in Eastern Nepal.Mymensingh Med J.2012 Jan;21(1):151-4 total birth prevalence of cleft of the lip ± cleft of the palate (CL±P) was 26

27. Classifications 27

28. Veau classification(1938) Group I (A) Defects of the soft palate alone Group II (B) Defects involving the hard and soft palates (not extending anterior to the incisive foramen) Group III (C) Defects involving the palate through to the alveolus Group IV (D) bilateral clefts. Complete BMJ 2014 28

29. Kernahan and Stark classification(1958) Embryology-based classification system proposed in 1958 that designates the incisive foramen as the dividing line between the primary and secondary palates The incisive foramen is a funnel-shaped opening through which neurovascular bundles pass. It is located in the hard palate behind the middle upper teeth (incisors). This structure is an important embryological landmark, which is used to define the boundary between the primary and secondary palate. Primary palate includes those structures anterior to the incisive foramen (lip, pre-maxilla, anterior septum). Secondary palate includes those structures posterior to the incisive foramen (lateral palatine shelves, soft palate, and uvula). BMJ 2014 29

30. Kernahan classification(1971) Areas 1 and 4 represent right and left side of the nasal floor, respectively Areas 2 and 5 represent right and left side of lip, respectively Areas 3 and 6 represent right and left side of paired alveolar segment, respectively Area 7 represents primary palate. Areas 8 and 9 represent secondary palate BMJ 2014 Classification system based on the resemblance of an intra-oral view of a cleft lip and palate to the letter 'Y', proposed in 1971. The area affected by the cleft is marked on the 'Y' and labelled from 1 to 9, each of which represents a different anatomical structure. Combinations of the numeric values represent the appearance of the cleft lip, alveolus, or palate.  View image 30

31. MILLARD’S CLASSIFICATION(1977) Modification of Kernahan’s striped “Y” classification. Inverted triangles represent nasal arch upright triangles represent the nasalfloor 31

32. Harkins' classification(1962)   Cleft of primary palate Cleft lip Alveolar cleft Cleft of secondary palate Soft palate Hard palate Mandibular process clefts Naso -ocular clefts: involving nose towards medial canthal region Oro-ocular clefts: extending from oral commissure towards palpebral fissure Oro-aural clefts: extending from oral commissure towards the auricle 32 BMJ 2014

33. Spina classification(1974) Group I - Pre-incisive foramen clefts (lip ± alveolus) Unilateral Bilateral Median Group II- Trans-incisive foramen cleft (lip, alveolus, palate) Unilateral Bilateral Group III - Post-incisive foramen clefts (secondary cleft palate) Group IV- Atypical (rare) facial clefts BMJ 2014 33

34. Tessier's classification(1976) Unilateral or bilateral Complete, incomplete, or microform (e.g., sub-mucous cleft palate) Clefting of lip with or without palate, or of the palate in isolation Atypical cranio -facial clefts BMJ 2014 34

35. Problems Associated With Cleft Lip and Palate Feeding Dental problems Nasal Deformity and Esthetic Problems Ear Problems Speech Difficulties Associated Anomalies 35

36. MULTIDISCIPLINARY CLEFT CARE 36

37. Management Diagnosis Parent counselling Presurgical orthopedics Primary surgery Pedodontic and preventive care Speech development, assessment, early intervention and treatment 37

38. Assessment and surgical management of velopharyngeal incompetance Orthodontics Secondary surgery of lip, nose, palatal fistulae Alveolar bone grafting Orthognathic surgery Restorative dental treatment Management of treatment failures  38

39. Treatment timing Infancy – primary lip surgery, primary palate closure Primary dentition Mixed dentition Adolescent Adults 39

40. Management 40

41. Treatment modalities in management of unilateral cleft lip and palate Timing Procedure After 16wks of pregnancy Cleft lip diagnosis by ultrasound images Prenatal Consultation with geneticist Neonatal Cleft palate- specilized nipple and bottle to improve feeding 12weeks Cleft lip repair 6-12 months Cleft palate one stage repair with intravelar veloplasty 5years Secondary rhinoplasty Ladeira P. Alonso N .Review Article Protocols in Cleft Lip and Palate Treatment: Systematic Review .Plastic Surgery International Volume 2012 41

42. management of bilateral cleft lip and palate Ladeira P. Alonso N .Review Article Protocols in Cleft Lip and Palate Treatment: Systematic Review .Plastic Surgery International Volume 2012 Timing Procedure Prior to cleft lip repair Presurgical infant orthopedics Primary dentition Orthodontic treatment for maxillary expansion Mixed dentition Orthodontic treatment for maxillary expansion and maxillary protraction Before eruption of permanent dentition Orthodontic treatment for dental arches alignment After fully eruption of permanent dentition dental arches aligment and end of maxillomandibular growth Orthodontic surgery for maxillary advancement After orthognathic surgery Postsurgical othodontics for closure of residual spaces and occlusion final adjustment 42

43. Treatment Sequence Lip repair Palatal repair Orthodontic treatment Secondary surgical procedure Pharyngeal flaps Bone grafting the cleft Repairing the nasal deformity Orthognathic surgery Replacing missing dentition 43

44. Abnormal patterns of facial growth 44

45. Problem of premaxilla Early surgical efforts to close cleft lip and make infant appear “normal” were accomplished by removal of premaxilla Premaxilla - contributes to formation of middle third of upper lip, columella , alveolar process and incisor teeth and part of palate anterior to incisive foramen 45 Removal of premaxilla produced only temporary improvement in appearance and caused damage that later could be only partly camouflaged by removable prosthesis(thus removable of premaxilla was abandoned)

46. Another approach To remove section or wedge from vomer to allow premaxilla to be set back Indication Special circumstances- primarily to permit satisfactory lip closure Difficulty remain that premaxilla once set back doesnot grow forward , usually very mobile and it will fall behind expected development of rest of face 46

47. Recently Popular treatment for protrusive premaxilla that complicates lip closure takes advantage of flexibility of cartilagenous septum in first few weeks after birth At this time – easy to apply external traction and by means of controlled forces rotate the lower part of premaxilla to more surgically advantageous position 47

48. Infant with bilateral complete cleftof lip and palate. Protruding premaxilla makes primary lip closure difficult. Removing intermaxillary segment or setting it back to achieve better apperance in very young child can have serious effects on development of facial form in lateral years. To facilitate lip closure, appliance fitted to premaxilla can be used to reduce protrusion of alveolar part in 1 st few weeks after birth. B. Intermaxillary segment of infant in A shown after repositioning by elastic appliance covering anterior part of premaxilla . Surgical closure of lip can be more easily be accomplised and developmental potential of intermaxillary segment can contribute to mid facial development 48

49. Tracing of cep of bilateral complete cleft of lip and palate. Solid line – position of premaxilla and mandible at age 6 years. Markedly protruding premaxilla is close to position achieved at age 17, represented by dotted line when growth of mandible is nearly completed.Had premaxilla been removed or set back to provide normal apperance at an early age, result in late adolesence would have severe mid facial retrusion rather than acceptable proportions now observed 49

50. Identification of secondary adaptations to cleft deformity Abnormal pattern of growth – not only confined to premaxilla Medial position of maxillary segments, curved nasal septum, distorted nasal alae , reduced maxillary development, apparently large mandible, open gonial angle, low tongue posture and frequent anterior open bite all suggest abnormality 50

51. Experimental finding Shape and position of zygoma is relatively independent of position of maxilla Pattern of development of parts of craniofacial skeleton can be changed by altering functional environment Narrowing of maxilla forced tongue away from palatal vault and resulted in aternations in relationships in shape of mandible 51 Experimental finding In young rhesus monkey in mixed dentation Surgical cleft were produced in normal animal – piriform aperture- end of hard palate- appliance used to induce medial movement of cleft maxillary segments Within 6months cephalometric examination of these animals showed maxilla was markedly distorted and nasal septum and nasal conchae changed shape – as expected incisor teeth adjacent to cleft tilted across midline and erupting posterior teeth became alingned in crossbite relation

52. Diagnosis in cleft palate treatment Diagnosis and examination Intrauterine Sonographic diagnosis Karyotyping Post partum Clinical Radiographic (intra and extraoral ), cineradiography, laminography , pantography ) Additional aids (speech and sound recording, measurement of nasal and oral pressures, psychiatric examination)  52

53. Early Intervention and counseling Requisites Accurate information should be given by expert in field Support must be available soon after diagnosis Parents and members of family given opportunity to express concern and emotional response Give a clear view of how the baby is likely to look 53

54. Discussion on pregnancy termination based on accurate information Promote early adjustment and acceptance of the baby by the parents and family Long term dependence on counselor should be avoided and normalization of family life should be encouraged 54

55. Principles of treatment May be useful to identify some of characteristics of cleft palate patients at various ages and identify which factors support favorable prognosis Team EvaluationTeams are usually comprised of an audiologist,geneticist , genetic counselor, nursecoordinator , oral and maxillofacial surgeon,orthodontist , otolaryngologist, pediatrician,pedodontist , plastic surgeon, prosthodontist,speech pathologist, and social worker. 55

56. Infancy 56

57. Early feeding management Most immediate problem caused by cleft lip or palate is likely to be difficulty with feeding 57 Many babies with a cleft lip can breastfeed However, some have difficulty in forming a vacuum in order to suck properly Babies with these problems may need a special teat and bottle that allows milk to be delivered to the back of the throat where it can be swallowed FEEDING TECHNIQUESWhen a cleft lip is present, it may be difficult for the baby to make agood seal around the nipple.Babies with cleft palate usually need special bottles and techniques tofeed properly.There are three types of bottles for feeding babies with clefts –the Mead-Johnson Cleft Palate Nurser,the Haberman Feeder andthe Pigeon Nipple

58. Early feeding management A more upright feeding position controls nasal regurgitation In infants with failure to thrive because of cardiac problems, laryngospasm , gastric tube feeding is adviced Under these conditions small prosthesis to obturate cleft is indicated to encourage oral feeding, presently considered largely unhelpful Babies who find it difficult to feed may gain weight slowly at first, but have usually catch up by the time they are six months old 58

59. Feeding obturator Prosthetic aid that is designed to obturate cleft and restore separation between oral and nasal cavities Creates rigid platform Obturator also prevents tongue from entering defect and interfering with spontaneous growth of palatal shelves Reduces nasal regurgitation and incidence of choking Also helps in development of jaws and contributes to speech 59

60. Pre surgical orthopedics Principal aim is to realign the bony elements of the cleft to provide a more normal base for surgery 60 Displacement of segment make lip repair more difficult  Orthopaedic appliances are used to resposition the segment in early infancy, before lip closure  These appliances also act asTwo types of orthopaedic appliances “feeding plate” for infantsActive : pin retained,controlled forcesPassiv

61. Nasoalveolar molding Nonsurgical method of reshaping gums, lip and nostrils before cleft lip and palate surgery, reducing severity of cleft Surgery is performed after molding is complete, approximately three to six months after birth 61 PRESURGICAL NASO ALVEOLAR MOLDING(Grayson etal , 1999) Actively mold and reposition the deformed nasal cartilages and alveolar processes and lengthen the deficient collumella .

62. Nasoalveolar Molding Appliance Reduce size of intraoral alveolar cleft  Mold and position surrounding soft tissues including deformed soft tissue and cartilage in cleft nose 62

63. 63

64. Nasoalveolar Molding Protocol Early intervention <1m Late intervention 1-2hrs/wk x 12-24wks Bilateral cleft Need 5-6mths molding Unilateral cleft Need 3mths molding 64 Alveolar or nasoalveolar molding from birth to 12 wks   12-14 wks primary cleft lip repair, nasal, and GPP ( gingivoperiosteoplasty ) in one stage Grayson BH, Santiago PE, Brecht LL, Cutting CB. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J. 1999;36:486

65. Fabrication of oral portion of NAM appliance Cast made from the master cast-wax blockout . Oral portion of PNAM device made of clear acrylic resin.   Completed device on altered cast. Note posterior extension. Excessive length in this area will precipitate gagging Fill the cleft region of the palate and alveolus to approximate the contour & topography of an intact arch Fill in cleft with wax   Restore palatal contours   Duplicate cast   All tissue border must be smooth Proper contour and finish for tongue space   Limit posterior extension to avoid gagging 65 a. During impression, infant’s head must in an upright position and well supported. b. Impression of silicone putty. c. Master cast.

66. Unilateral clefts How to retain oral molding appliance Retain appliance with Adhesive tape and elastics Oral molding portion plus nasal extension 66 Nasoalveolar molding is nearly complete. The columella is approaching midline and the nostril on the cleft side is becoming more symmetrical. It usually takes 4-6 weeks to attain proper alignment of the alveolar cleft segments. At 3 months most patients are ready for surgery

67. Result of NAM Overall improvement in esthetics of naso -labial complex – Less scarring   Minimize extent of surgery and overall number of surgical procedure 67

68. Surgical Phase 68

69. Primary lip surgery Timing of primary lip closure is at choice of surgeon Done within 1 st few months after birth when infant is thriving Rule of tens Lips is repaired when patient is 10weeks old 10pounds in weight Within hemoglobin count of 10 The first surgery is usually performed at about 3 months. This period may be extended to complete NAM, particularly in patients with bilateral clefts 69

70. Lip Repair Methods of closure were developed based on nature of cleft, deficiency of tissues associated with cleft and consequences of scar contracture for lip closure.A : Development of flaps. B: Flaps prepared forclosure . C: Lip closure. 70 Modified Le Mesurier surgical technique

71. Primary Palate closure Clefts of primary palate Timing of surgery- Approximately 10 months Arbitrary criteria 1. Child must be free of any systemic or local disease 2. Minimum weight of 7 lb and in weight gaining phase 71

72. Methods of closure vary depending upon: Extent of cleft   Availability of tissue   Experience of surgical team 72  

73. Timing of closure- 2 opinion Delayed closure (Zurich approach) – Less inhibition of maxillary growth  Early closure – Better speech patterns develop early Palatal push back and closure procedure 73

74. Complications associated with palatal repair Short soft palate resulting in velopharyngeal insufficiency Speech will be hypernasal 74

75. Secondary operations Residual unilateral / bilateral deformities Collumellar lift: Barsky Modified Marcks procedure Modified Erich procedure to create symmetry of nose Lip shave operation Delayed bone grafting 75

76. Cleft of secondary Palate Surgical period varies from any where between 18months to 4yrs 76

77. Primary dentition Position of obtained maxillary segments is not lasting as dental cross bite is incidental as long as bone continuity in upper arch is not established Children with bilateral cleft, premaxilla is prominent at this age Lateral incisors may be in cleft and must be preserved 77

78.  Parents must be instructed in preventive dental practices Fistulae of palate or labial sulcus may be present (Hawley type prosthesis ) - for speech improvement Repositioning of cleft segments seldom necessary before permanent incisors erupt  78

79. Mixed dentition Treatment should be designed to secure optimal vertical height of maxilla, position of teeth and arch form Lateral incisors are most commonly missing Supernumerary teeth may be present adjacent to cleft, their prognosis is determined & extracted  79

80.  Premolar teeth when absent complicates development of adequate upper arch Appliances used to reposition maxillary segments Speech and hearing evaluation Secondary revision of lip, nose, palate considered Use of quad helix for arch expansion 80

81. Adolescence  Orthodontic treatment initiated to achieve Normal positioning of maxillary segments Adequate vertical development of maxilla Alignment of teeth for efficient occlusion Esthetics Positioning of teeth to permit conservative prosthodontic replacement of missing teeth 81

82. Orthodontic Correction 82

83.  When canine final positioning has been attained, permanent stabilization of the arch by establishing bone continuity considered Bone grafting accomplished safely at 14 – 16 years Inlay grafts Onlay grafts Combination Prosthdontic replacement of missing teeth can be carried out  83

84. Bone Grafting 84

85. Removable dentures given to maintain space and esthetics Fixed prosthesis, implants planned in late adolescence Final cosmetic revision of lip and nose may be planned in late adolescence Consideration- orthognathic surgery - improve esthetics 85 by correcting skeletal malrelationship  

86. Adults Some patients may not have received optimum treatment may require removable prosthesis to camouflage collapsed segments and reduced vertical development of maxilla Use of pharyngeal obturator to aid speech Edentulous cleft patient represents a failure in habilitation  86

87. Prosthodontic rehabilitation 87

88. Role of Prosthodontics in cleft palate treatment 4 Function Replacement of teeth and other missing anatomic structures Stabilization of cleft maxillary segments Retention of tooth position Camouflage for inadequate treatment 88

89. Indications of prosthesis In unoperated patients Wide cleft with deficient soft palate Wide cleft of hard palate Neuromuscular deficiency of soft palate and pharynx Delayed surgery Expansion prosthesis to improve spatial relationships Combined prosthesis and orthodontic appliance  89

90.   In operated patients An incompetent palatopharyngeal mechanism Surgical failures 90

91. Contraindications for prosthesis Surgical repair is feasible Mentally retarded patient Uncooperative child and parents Rampant caries Lack of prosthodontic training or skill  91

92. Different Prosthesis used Feeding Obturator Nasoalveolar molding appliance Palatal Obturator Palatopharyngeal Obturator / speech bulb 92

93. Feeding Obturator Procedures Recommendations Primary impression Polyvinyl siloxane elastomer > Alginate > Impression compound Secondary impression Light body and medium body Polyvinyl siloxane elastomer > Alginate Position of infant during impression Upside down > prone > face down > upright Tray for carrying primary impression material Handle of "0" no impression taking metal tray > finger support > spatula CustomTray Cold cure acrylic Material for feeding plate Heat cure acrylic > cold cure acrylic > thermo- plasticised sheet 93 Porwal et al. : Fabrication of a Feeding Plate for an Infant with Cleft - A Review. Heal Talk. 2014 ;06

94. Function Improves feeding, tongue function and speech development Reduces risk of aspiration as oro -nasal communication is eliminated 94 it is an easier surgical procedure with aesthetic results. It reduces the severity of dental and skeletal deviations and provides a positive psychological impact on the patients as well as on their parents Rizwaan A S, et al, Prosthetic Rehabilitation Of Cleft Compromised Newborns . Journal of Clinical and Diagnostic Research. 2010 December;(4):3632-3638

95. Types of feeding applicance 95

96. Passive plates Provide artificial palate for infant and permit functions like swallowing and feeding Prevent widening of cleft due to activity of tongue Devices consist of a piece of acrylic plate which closes defect and is used in conjunction with a tape across left lip, to help bring the lip segments closer together. 96 Rizwaan A S, et al, Prosthetic Rehabilitation Of Cleft Compromised Newborns . Journal of Clinical and Diagnostic Research. 2010 December;(4):3632-3638 Do not apply any force Do not allow for any adjustment of cleft, unlike active plate

97. Latham's appliance “Fixed” appliance- surgically attached to palate under general anaesthesia and remains in place until manipulation has been completed Consists of two acrylic pieces that fit over alveolar segments - pieces are connected posteriorly with hinged bar 97 palate is manipulated by rotating hinged pieces. A screw is present in the area of the cleft. Over a period of 2-3 weeks, the screw is turned 3/4th of a turn, every day until tight. This appliance can be used in BCLP infants to reposition the protruding premaxilla , while expanding the lateral maxillary segments The advantage of this device is that it allows the manipulation of the palatal segments to the desired location, thereby helping to bring the clefts together, thus making the cleft lip repair easier. The appliance however, does not provide an artificial palate as it does not cover the defect Rizwaan A S, et al, Prosthetic Rehabilitation Of Cleft Compromised Newborns . Journal of Clinical and Diagnostic Research. 2010 December;(4):3632-3638

98. Jackscrew devices Consist of acrylic pieces that fit over alveolar segments. Acrylic pieces are manipulated by single or multiple jackscrews to adjust position of alveolar segments 98 They allow the manipulation of the palatal segments to the desired locations and the screws also keep the tongue out of the cleft. They however do not allow the rotation of the alveolar segments into desired locations, as seen with the molding plates Rizwaan A S, et al, Prosthetic Rehabilitation Of Cleft Compromised Newborns . Journal of Clinical and Diagnostic Research. 2010 December;(4):3632-3638