Cleft lip and palate and prosthesis neonates

Cleft lip and palate

1. Cleft Lip & Palate
Dr / Ahmed Taha Ahmed
Oral and maxillofacial surgeon

2. Anatomy

3. Normal anatomy of the palate

4. Soft palate muscles
There are five paired muscles of the soft palate :
1-Musculus uvulae:
✓lies entirely within the uvula
✓Shortens and broadens the uvula.
✓The uvula is used to articulate a range of consonant sounds
2-Levatorvelipalatini :
✓elevate the soft palate closing the velopharyngeal space
3-Tensor velipalatini:
✓tenses thesoft palateand by doing so, assists thelevatorvelipalatiniin
elevating the palate to occlude and prevent entry of food into the
nasopharynx during swallowing
✓opens the auditory tube during swallowing or yawning and thereby equalizes the
pressure (“pops the eardrums”) between themiddle earand thenasopharynx.

5. Soft palate muscles
There are five paired muscles of the soft palate :
4-Palatopharyngeusmuscle:
✓pulls the pharynx upward during swallowing.
5-Palatoglossus muscle:
✓elevate the posterior portion of the tongue.
✓It also draws the soft palateinferiorly, thereby narrowing the diameter of the
oropharyngeal isthmus.
✓This action plays a significant role during swallowing by propelling the food bolus
towards the esophagus and occluding the oral cavity, thereby preventing retrograde
flow of the food

6. Normal anatomy of the palate

7. Abnormal insertion of the velar muscles
1. Hard palate.
2. Palatine process of maxilla.
3. Palatal aponeurosis.
4. Greater palatine artery.
5. Tendon of the tensor veli palatini.
6. Hamulus.
7. Tensor veli palatini muscle.
8. Levator veli palatini.
9. Palatopharyngeousand palatoglossus muscles.
10. Uvularismuscle

8. •Group I –Defects of the soft palate only
•Group II –Defects involving the hard palate and soft
palate
•Group III –Defects involving the soft palate to the
alveolus, usually involving the lip
•Group IV –Complete bilateral clefts
Classification Of Cleft Lip/Palate
Veauclassification
divides the cleft lip and palate into 4 groups :

9. Oral Clefts
Etiology
Developmental
disturbance
Diagnosis
Management
A
B
Surgical and proshetic
C

10. Timing of treatment in the cleft patient.
Prenatal
Diagnosis and parental counseling
0–6 months
➢General assessment for associated anomalies
➢ENT evaluation –breathing, feeding, swallowing, and hearing
➢Presurgical orthopedics (0–3 months)
➢Primary lip repair (3–4 months)
6 months –2 years
➢Speech and oral sensory motor assessment
➢Grommets/ear tubes (as needed)
➢Primary palate repair (9–12 months)
Preschool: 3–5 years
➢Dental care
➢Speech assessment and therapy (continue as needed)
➢Assess need for lip revision

11. Timing of treatment in the cleft patient.
Childhood: 6–12 years
➢Correction of velo-pharyngeal dysfunction (as needed)
➢Orthodontic treatment –phase I
➢Alveolar cleft repair (8–11 years)
Adolescence: 13–18 years
➢Orthodontic treatment –phase II
➢Orthognathic surgery (if needed) –14–16 years
(female),
➢16–18 years (male)
➢Revision chielo-rhinoplasty
➢Replacement of missing teeth (as needed)

12. Prosthetic Management
of oral Clefts in
Newborns

13. Prosthesis used in Cleft Palate Patients
A.Prosthesis in infancy period:
(i)Feeding obturator,
(ii) premaxilla positioning appliances,
(iii) palatal lift prosthesis,
(iv) speech aid or speech bulb prosthesis (3
rd
and 4th given in adult patient also).
B. Obturator:
➢Palatal obturator with solid or hollow bulbs meatus.
C. Prosthesis for tooth replacement:
• Removable prosthesis
• Complete dentures prosthesis
• Fixed prosthesis
• Implant prosthesis.

14. Prosthesis used in Cleft Palate Patients
Feeding Obturator
Prosthetic aid that is designed to close the cleft and provide
the separation between oral and nasal cavities.
1. It helps in feeding
2. Reduces nasal regurgitation
3. Prevents tongue from entering the defect
4. Allows spontaneous growth of palatal shelves
5. Contribute to speech development
6. Reduces incidence of otitis media and other pharyngeal
infections.

15. A feeding appliance

16. A feeding appliance

17. NasoalveolarMolding ( NAM Appliancae)

18. NasoalveolarMolding ( NAM Appliancae)

19. Prosthesis used in Cleft Palate Patients
Premaxilla Positioning Appliances
The premaxilla positioning appliance is a nonsurgical technique that retracts and
rotates the malposed segment to a more favorable position for lip repair
They are :
Active appliances
Passive appliances

20. Alveolar molding
Active appliances
mold the separate alveolar processes into position by applying active forces on
them or, in other words, by directing them to grow or to be moved into a
preplanned position

21. Alveolar molding
Passive appliances
They are constructed on the poured study model and fit directly onto the alveolar
processes. The clinician at the chairside may add flowable acrylic or remove
acrylic in a process called negative sculpting. This alteration in the shape of the fit
surface of the appliance will allow the alveolar processes to grow passively as
planned by the clinician

22. Prosthesis used in Cleft Palate Patients
Palatal Lift appliance
When the surgically repaired soft palate is of adequate length but of inadequate
mobility to elevate soft palate the condition is known as velopharyngeal
incompetency. Here, there is absence of velopharyngeal closure so air escapes
through the nose affecting the speech and producing abnormal sounds which are
difficult to understand

23. Prosthesis used in Cleft Palate Patients
Speech Bulb
This prosthesis is fabricated when the soft palate is of inadequate length even
though there is adequate mobility leading to absence of velopharyngeal closure
and air escape through the nose affecting the speech. The prosthesis has two
sections the palatal section and the pharyngeal or bulb section. The bulb section
extends posteriorly to provide proper velopharyngeal closure thus helping for
speech production.

24. Prosthesis used in Cleft Palate Patients
Obturator
Function :
1.A palatal obturator covers the opening and contributes to normal speech
production.
2.It eliminates hypernasality and assists speech therapy for correction of
compensatory articulations. The obturating portion can be made either hollow or
solid

25. Lip strap/lip taping
In combination with the intraoral mouth plates, external tapes and elastics may be
strapped to the cheeks to provide some external forces in the alveolar molding
process. Elastic forces will exert a retracting, backward pressure against the
protruding premaxilla, and careful use of forces on the cleft segments will improve
their positions and allow definitive lip skin and muscle repair.

26. Clinical case 1
A 2-day-old neonate was referred from a pediatric
private practitioner to the Department of
Prosthodontics, Sri Siddhartha Dental College and
Hospital, Tumkur, with a chief complaint of
difficulty in feeding. On examination, it was found
that the child was born with unilateral cleft lip and
palate on the left side [Figure 1a]. After discussion
with child's parent, it was found that the mother
had difficulty in breastfeeding the newborn, as an
immediate concern at that time was feeding and
nutrition of the infant,

28. Clinical case 2
A 2-day-old neonate was referred from
a pediatric private practitioner with a
chief complaint of difficulty in feeding.
On examination, it was found that the
child was born with bilateral cleft lip
and palate on the left side [Figure 1a].
After discussion with child's parent, it
was found that the mother had
difficulty in breastfeeding the newborn,
as an immediate concern at that time
was feeding and nutrition of the infant,

30. Thank you!