CLEFT LIP AND PALATE IN ORTHODONTICS.pptx

Dr. ZANAB FARHEEN FAYAZ,MDS(ORTHODONTICS & DENTOFACIAL ORTHOPEDICS)

1. Under The Guidance Of: (Prof) Dr. Muhammed Mushtaq. Head Of The Department Department Of Orthodontics and Dentofacial orthopedics. Alveolar Bone Grafting In Cleft Lip & Palate Patients Presented by: Dr. Zanab Farheen Fayaz PG 2 nd Year

2. INTRODUCTION HISTORICAL BACKGROUND EPIDEMIOLOGY OF CLEFT LIP & PALATE EMBRYOLOGY CLEFT LIP & PALATE ETIOLOGY OF CLEFT LIP & PALATE CLASIFICATION OF CLEFTS TREATMENT OF CLEFT LIP AND PALATE: - INFANT ORTHOPEDICS - TREATMENT IN MIXED DENTITION - TREATMENT IN PERMANENT DENTITION - SURGICAL ORTHODONTICS - DISTRACTION OSTEOGENESIS CONCLUSION

3. Introduction: Orofacial clefts are among the most common congenital anomalies requiring a multidisciplinary care. Such anomalies include several handicaps such as impaired suckling, defective speech, deafness, malocclusion, gross facial deformity and severe psychological problems.. Cleft lip and the palate is a condition, that occurs at such a strategic place in the orofacial region and at such a crucial time that it becomes a complex congenital deformity.

4. The successful treatment of patients suffering from clefts of the lip and palate requires a continuous interdisciplinary therapy from birth until early adulthood, which involves the application of all available operative and conservative procedures for treatment. The osseous closure of the alveolar cleft required for the formation of a regular upper dental arch, occupies a special position within the whole concept of cleft lip and palate therapy.

5. Orthodontists and Cleft Care: Some Historical Facts 6 The cleft and craniofacial care triangle Surgery Orthodontics Speech

6. History of Orthodontics & Cleft Care in USA Calvin S Case (1847-1923): Pioneer of cleft palate rehabilitation Norman Kingsley (1829-1913):Published more than 100 articles on cleft palate rehabilitation. The first cleft-palate-team was established by Herbert K. Cooper, an Orthodontist, with financial aid from Rotary Club of Lancaster, Pennsylvania, U.S.A. in 1930s.( World Renowned Mecca of Cleft Care). On October 21,1998, the NIDR(National Institute of Dental Research) officially became NIDCR (National Institute of Dental and Craniofacial Research) to accurately reflect its research base. 7

7. Department of Plastic Surgery at K.G. Medical College, Lucknow, employed a full time orthodontist on faculty in early 70s. Prof. C. Balakrishnan, the Father of Plastic Surgery in India, formed the cleft palate team by including a Prosthodontist , a Pediatric Dentist and an Orthodontist in early 70s at PGI Chandigarh. Today the PGI cleft palate team is listed in the directory of American Cleft Lip and Palate Association. The Indian Society of Cleft Lip, Palate and Craniofacial Anomalies (ISCLP & CA) was formed in the year 2001 and the members are from all disciplines of dentistry & surgery. The 3rd President of ISCLP & CA, unanimously elected was an Orthodontist, Prof.(Dr). Ashok Utreja . 8 History of Orthodontics & Cleft Care in India

8. Epidemiology :

9. Epidemiology : Cleft lip and palate is a global problem , occurring in 0.28-3.74/1000 live births globally. The Least incidence is seen in the Negroids (0.4%) and maximum incidence is seen in the mongols (4.9%). In Caucasians 1 case is seen in every 1000 individuals. In India 1.7 cases are seen in every 1000 individuals. In India - CL+CP-1.25/1000 ,CP 0.46/1000 CRANIOFACIAL DEVELOPMENT- Sperber

10. Epidemiology : Among Indians it seen most commonly in the Aggarwal & Brahmin communities(1.7%). The incidence of oral clefts is seen more in males than in females. Cleft lip alone- occurs more in males than females Cleft palate-occurs more in females than males

11. Various syndromes associated with cleft lip and palate Autosomal Dominant Van der woude Syndrome Treacher Collins Syndrome Cleidocranial Syndrome Ectodermal Dysplasia Stickler’s Syndrome Autosomal Recessive Roberts Syndrome Apert Syndrome Christian Syndrome Meckel Syndrome

12. Etiology: 1] Genetic: CLP Is Transmitted through a sex linked recessive gene. Predisposition for cleft lip is 40% while only 18-20% for cleft palate. It is transferred as: Monogenic/ single gene disorder-conforming to mendelian inheritance pattern. Polygenic/ multifactorial inheritance- showing familial tendency but not mendelian inheritance. Chromosomal abnormalities: - Down’s Syndrome - Edwards Syndrome (trisomy 18) - Trisomy D and E CRANIOFACIAL DEVELOPMENT- Sperber

13. 2] Environmental Factors: CLP Usually occur due to various influences during the first trimester of pregnancy . The various environmental influences can be: A . Environmental teratogens like: Ethyl Alcohol- causes FAS (fetal alcohol Syndrome). Cigarette smoking- causes 30% increase in cleft lip and palate incidence and 20% increase in cleft palate incidence during pregnancy. Anti seizure drugs like: diphenyl hydantoin and trimethadione .These drugs cause growth retardation, craniofacial dysmorphism & mental deficiency .

14. 3] Malnutrition : Hypervitaminosis A: Acute maternal exposure to 13-cis retinoic acid during first trimester OF Pregnancy causes cell death in the Pharyngeal arches leading to facial Clefting . -Folic Acid Deficiency affects virtually every organ system. It affect the neural tube leading to abnormalities in neural crest cell migration and differentiation. - Anemia and anorexia. 4]Infection during pregnancy: Rubella infection during the first 3 months is associated with Clefting . 5]Parental age: Shaw et al presented evidence that women above the age of 35 had a doubled risk of having a child with CLCP and having children above 39- tripled the risk. Consanguineous marriages also increased risk of CLCP in the child.

15. Embryology CRANIOFACIAL DEVELOPMENT- Sperber

16. Cleft Lip; Two causes have been postulated for the development of CL. One is failure of fusion of maxillary process with the medial nasal process. Other is incomplete penetration of mesoderm into epithelial membrane of maxillary and median nasal processes leading to their breakdown. This breakdown may be total or partial depending upon the degree of penetration of the mesoderm.

17. Clefting of lip occurs because of failure of fusion between median and lateral nasal processes and the maxillary prominence which is seen during 6th week of development in humans.

18. Cleft Palate Following reasons can result in cleft palate; Failure of elevation of the shelves. Failure of fusion of the shelves. Post fusion rupture of the shelves. Micrognathia as in Pierre Robin Complex

19. A cleft of the palate occurs if the palatal shelves fail to fuse together as may happen if the tongue fails to descent due to underdevelopment of the mandible. Incomplete penetration of the mesoderm into the palatal shelves can give rise to a submucous cleft palate

20. Classification of cleft lip and palate 1. DAVIS AND RITCHIE CLASSIFICATION (1922): B ased on the position of the cleft in relation to the alveolar process. Group I - Pre alveolar clefts include Lip clefts only with subdivisions for unilateral, median, bilateral. Group II - Post alveolar clefts include degrees of involvement of soft and hard palate to be specified till the alveolar ridge, submucous clefts included . Group III - Alveolar clefts is complete clefts of palate, alveolus ridge and lip with subdivisions for unilateral, median, bilateral . Surgical orthodontic treatment- Proffit and White

21. 2. VEAU’S CLASSIFICATION (1931): Group I - Cleft of soft palate only. Group II - Cleft of hard and soft palate, extending no further than the incisive foramen thus involving the secondary palate alone . Group III - Complete unilateral cleft of soft and hard palate, lip and alveolar ridge. Group IV- Complete bilateral clefts , resembling group III but are bilateral , pre-maxilla is suspended from the nasal septum.

22. 3.Kernahan’s striped “y” classification (1971): The Incisive foramen is taken as the reference point . The arms of the ‘Y’ are each divided into three sections, representing the lip, the alveolus and the primary palate as far back as the incisive foramen. The stem of the “Y” is also divided into three parts, representing varying degrees of clefting of the hard and soft palates. Eppley B. Alveolar cleft bone grafting (part 1): Primary bonegrafting . J Oral Maxillofac Surg 1996;54:74—82.° 11. Rosenstein SW. Early bone grafting of alveolar cleftdeformities . J Oral Maxillofac Surg 2003;61:1078-81.

23. 4.Millard’s classification (1977): A modification of kernahan’s striped “Y” classification. The inverted triangles represent the nasal arch the upright triangles represent the nasal floor.

24. 5.Lahshal classification : by kriens O L- lip A- Alveolus H- hard palate S– soft palate

25. Michael Mars and Olav Bergland in 1987. GOSLON YARDSTICK

26. Treatment of CLCP

27. OSLO PROTOCOL WARSAW PROTOCOL

28. Multidisciplinary sequencing of treatment in clefts in four stages: The three major goals in the treatment of CLP is to maintain and provide adequate nutrition for infants performing presurgical orthopaedics , parent and patient counselling. Stage I: Maxillary Orthopedic Stage (Birth to 18 months) . Stage II: Primary Dentition Stage (18 months to 5 Years of age). Stage III: Late Primary or Mixed Dentition Stage (6 to 10 or 11 yrs of age). • Stage IV: Permanent Dentition Stage (12 to 18 years of age). Baik et al. surgical orthodontic treatment in patients with clcp : conventional surgery vs maxillary distraction, world J Orthod;2:331-40

29. Stage I: Maxillary Orthopedic Stage (Birth to 18 months) . Feeding aids . Lip repair Management of cleft palate. Correction of velopharyngeal insufficiency . Primary ABG(O—2.5 years, usually at the time of lip repair) Stage II: Primary Dentition Stage (18 months to 5 Years of age) Primarily focused on establishing oral health and prevention of dental caries .

30. Stage III: Late Primary or Mixed Dentition Stage (6 to 10 or 11 yrs of age) Major role is played by the orthodontist . Includes; -arch expa nsion. -maxillary protraction. -secondary bone grafting. Stage IV: Permanent Dentition Stage (12 to 18 years of age). Final orthodontic correction of malaligned teeth. Prosthetic rehabilitation. Lip revision surgery. Rhinoplasty. Orthognathic surgery.

31. Treatment of CLCP : A brief Overview

32. When a cleft lip is present, it may be difficult for the baby to make a good seal around the nipple. Babies with cleft palate usually need special bottles and techniques to feed properly. There are three types of bottles for feeding babies with clefts: The Mead-Johnson Cleft Palate Nurser, The Haberman Feeder and The Pigeon Nipple. Feeding techniques

33. Feeding obturator The feeding obturator is a prosthetic aid that is designed to obturate the cleft and restore the separation between the oral and nasal cavities . It creates a rigid platform The obturator also prevents the tongue from entering the defect and interfering with spontaneous growth of the palatal shelves. Reduces nasal regurgitation, Reduces the incidence of choking , Helps in the development of the jaws and contributes to speech.

34. Infant orthopedics; Pioneered by BURSTONE in late 1950’s. Severe arch distortion makes surgical repair of the lip extremely difficult. Therefore orthodontic intervention to reposition the segments of the arch may be required prior to surgical repair. Infant orthopedics is started at about 3 – 6 weeks of age followed by lip closure at 10 weeks. Two types of movements of the maxillary segments are usually carried out. a ) lateral expansion posterior segment. b) pressure against premaxilla to push it posteriorly and align it with the arch. Berkowitz reported the present consensus is that these procedures offer less long term benefit than expected. Hence now used in severely displaced premaxilla cases only. Baik et al. surgical orthodontic treatment in patients with clcp : conventional surgery vs maxillary distraction, world J Orthod;2:331-40

35. ELASTIC TRACTION

36. MOLDING PLATE

37. PIN RETAINED APPLIANCE

38. Presurgical nasoalveolar moulding- grayson etal , ( 1999 ) Nasoalveolar molding is a nonsurgical method of reshaping the gums, lip and nostrils before cleft lip and palate surgery, reducing the severity of the cleft. Surgery is performed after the molding is complete, approximately three to six months after birth. Grayson etal , Pre surgical naso alveolar molding, cleftliip - craniofacial journal 1999:35

39. Lip Closure Surgical closure of a cleft lip is done as early in infancy as is compatible with a good long-term result usually at 10 to 12 weeks of age. Therefore PNAM should be completed by then. Rule of ten is used to ascertain the fitness of the child before the surgery. Child should be 10 weeks old, should have 10 gm of hemoglobin ,10 pound weight . Techniques Millard’s repair . Tennison- randall’s repair. Veau repair

40. Techniques Millard’s repair . Tennison- randall’s repair Veau repair

41. Surgical management of cleft palate; can be done by one stage or two stage; 1] one stage repair; Hard palate repair is done by using mucoperiosteal flap technique at 12 to 18 months repair . 2] In two stage repair; soft palate repair is done first before 18 months followed by obturation of the hard palate till the second stage repair. hard palate repair is done at 4 to 5 years. Palatoplasty is carried out between 12 to 18 months of age The main objective of it is to facilitate normal speech pattern. Advances in management of cleft palate: Edwards and Watson

42. Velopharyngeal Disorders Velopharyngeal insufficiency is a disorder resulting in the improper closing of the velopharyngeal sphincter (soft palate muscle in the mouth) during speech, allowing air to escape through the nose instead of the mouth. During speech, the velopharyngeal sphincter must close off the nose to properly pronounce strong consonants such as "p," "b," "g," "t" and "d." The two main speech symptoms of velopharyngeal insufficiency are: -hypernasality and -nasal air emission. Baik et al. surgical orthodontic treatment in patients with clcp : conventional surgery vs maxillary distraction, world J Orthod;2:331-40

43. Types of VPD; Velopharyngeal Mislearning: due to articulation difficulties Velopharyngeal Incompetence: Due to functional abnormalities,(paresis, dysarthia ) Velopharyngeal Insufficiency: Structural problems like cleft or bifid uvula etc

44. Diagnostic Procedures Measurement of nasal airflow McKay- Krummer instrument Aerophonoscope Fiberoptic naso -endoscopy Videofluoroscopy Voice resonation Evaluation - Articulation assessment -Oral motor assessment

45. Treatment of VPI; Speech Therapy Some speech problems linked with VPI, such as mispronouncing words, can be treated by speech therapy. Treatment focuses on teaching the child the correct manner of articulation. Sometimes an obturator is recommended to treat VPI. An obturator is like a modified dental retainer with a speech bulb or palatal lift attached to the back. Each obturator is shaped uniquely to fit the patient’s muscle movements. Speech Surgery: Palatoplasty Sphincter pharyngeoplasty Baik et al. surgical orthodontic treatment in patients with clcp : conventional surgery vs maxillary distraction, world J Orthod;2:331-40

46. Mixed Dentition; A tentative decision on extraction of supernumerary teeth and over retained teeth. Correction of cross bite- SME (using appliances like a quad helix),RME. Maintainence of space for proper eruption of teeth. Expansion of the collapsed segment to improve surgical access to the graft site. Traumatic occlusion is eliminated in preparation of alveolar graft. (By aligning offending tooth)

47. Correction of jaw relationship using Face mask Therapy; Done in mild maxillary deficient cleft patients. Orthopaedic force 350-500 gm per side over 10-12 hr / day for an average of 12-15 months.

48. ALVEOLAR BONE GRAFTING IN CLEFT LIP & PALATE PATIENTS Baik et al. surgical orthodontic treatment in patients with clcp : conventional surgery vs maxillary distraction, world J Orthod;2:331-40

49. Timing of ABG Primary (birth—2.5 years, usually at the time of lip repair) Early secondary (2-5 years, before the eruption of permanent incisors) Secondary (6—13 years, before the eruption of the permanent canines) Late (> 13 years, after the eruption of the permanent canines) v on Eiselsberg (1901) and Lexer (1908) were the first to use autogenous bone to graft the cleft maxilla by a free bone or pedicled soft tissue and bone of the little finger. Drachter (1914) was the first to report the closure of a cleft with tibial bone and periosteum.

50. Primary ABG Primary alveolar bone grafting is performed simultaneously with lip repair. Any grafting that is performed at less than 2 years of age is considered primary grafting. Primary grafting is performed before the palate is repaired. The indication for primary bone grafting was- elimination of bone deficiency, stabilization of the pre-maxilla, creation of new bone matrix for eruption of teeth in the cleft area and augmentation of the alar base.

51. Primary grafting performed at the time of lip repair usually results in an unfavourable outcome for the patient. Long-term studies show that it leads to; -abnormal maxillary development with maxillary retrognathia, -a concave profile, -increased frequency of crossbites compared with patients without grafts Primary grafting performed after the closure of the lip and before the closure of the palate has proven successful in a limited number of ceases when a very specific protocol is followed. Eppley B. Alveolar cleft bone grafting (part 1): Primary bonegrafting . J Oral Maxillofac Surg 1996;54:74—82.° 11. Rosenstein SW. Early bone grafting of alveolar cleftdeformities . J Oral Maxillofac Surg 2003;61:1078-81.

52. Advantages; Early maxillary arch stabilization. Improved arch form with out collapse. Teeth adjacent to cleft erupt into grafted bone. Disadvantages; The operative technique that involves the vomero -premaxillary suture was found to cause inhibition of maxillary growth.Though a few centres still perform the early bone grafting procedure it was abandoned in most cleft lip and palate centres worldwide. Development of crossbites and a concave profile.

53. Early Secondary ABG 2—6 years of age To provide support for eruption of the permanent incisors. Disadvantages; Significant transverse growth and sagittal growth may be affected. Literature does not support the early secondary grafting.

54. Intermediate Secondary ABG - 9-11 years. Secondary bone grafting, meaning bone grafting in the mixed dentition, became an established procedure after abandoning primary bone grafting. Furthermore, secondary bone grafting can stabilize the dental maxillary arch, improving the conditions for prosthodontic treatment such as crowns, bridges and implants. Secondary bone grafting can also be used to augment the alar base of the nose to achieve symmetry with the non-cleft side, thereby improving facial appearance. Most commonly done before eruption of canine when 1/3rd to 2/3rd of canine root has formed. Only vertical growth remains at this age. Physiological migration & spontaneous eruption of the canines through the grafted bone is observed .

55. Rationale for grafting during this time period include the following : Minimal maxillary growth after age 6 to 7years. The effect of grafting at this time will result in minimal to no alteration of facial growth. Cooperation with orthodontic and preoperative care is predictable. The donor site for graft harvest is of acceptable volume for predictable grafting with autogenous bone. Grafting during this phase allows placement of the graft before eruption of permanent canine into the cleft site – one of the primary goals of grafting. Eppley B. Alveolar cleft bone grafting (part 1): Primary bonegrafting . J Oral Maxillofac Surg 1996;54:74—82.° 11. Rosenstein SW. Early bone grafting of alveolar cleftdeformities . J Oral Maxillofac Surg 2003;61:1078-81.

56. Factors to be considered in timing of grafting during the mixed dentition. Dental age vs chronologic age. Presence and position of the lateral incisor. Degree of rotation/angulation of the central incisor. Trauma/mobility of premaxillary segments Bilateral clefts Occlusion Need for adjunctive procedures. Social issues Skoog T: The use of periosteum and surgicel for bonerestoration in congenital clefts of the maxilla. Scan J PlastReconst Surg 1: 113, 1967e Wood RJ, Grayson BH, Cutting CB: Gingivoperiosteoplastyand midfacial growth. Cleft Palate Craniofac J 34:17-20,1997e Carstens MH: Functional matrix cleft repair. principlesand techniques. Clin Plast Surg 31.159-189, 2004

57. The grafting is determined on the basis of dental rather than chronologic age. If a lateral incisor is present and appears to be well formed, earlier grafting may be beneficial. If the lateral incisor is located in the posterior segment, earlier grafting maybe necessary to preserve the lateral incisor. The maxillary permanent central incisor will often erupt in a rotated and angled position, If a decision is made to rotate these teeth into alignment, it may be necessary to graft the alveolar defect prior to this orthodontic tooth movement.

58. Late Secondary Grafting; (> 13 years, after the eruption of the permanent canines) Patients older than 12 years of age who undergo grafting have been reported to have decreased success when evaluated using the Bergland scale.Loss of osseous support of teeth adjacent to the cleft, and increased morbidity has been associated with late secondary grafting

59. History & physical Examination for ABG procedure; Focused examination are done on: Any previous repair. Presence of Oro nasal fistulae. Alar support. Size of alveolar defect. Mal positioned teeth in the cleft region. Alignment of teeth. Position & mobility of premaxillae . Adequacy of soft tissue for tension free closure. Oral hygiene

60. Radiographic Evaluation; OPG Occlusal view. Peri apical view

61. Pre Surgical Preparation of a Patient; The Premaxillary Segment in bilateral cases is stabilized by arch wires since mobile premaxilla will cause the grafted bone fail to consolidate. Oral Hygiene Prophylaxis. Ortho treatment -Correction of crossbite & alignment of arch. Supernumerary or Retained Deciduous teeth in cleft area should be removed atleast 6 — 8 week before surgery to ensure adequate width & continuity of soft tissue flaps.

62. Options for ABG; Autogenous ; -iliac bone -rib -tibia -calvarium -Symphysis. Alloplastic allogenic

63. Graft used for ABG ; Johanson and Röckert (1961) proved in histological and micro-radiographical clinical and experimental studies, that cancellous autogenous bone grafts, harvested from either tibia or iliac crest, were transformed to the same structure as the surrounding palate. Site; Iliac crest Advantages; -Large quantity of cancellous bone. -Decreased operative-time with 2 team approach. -No growth disturbance. -Easy to condense & pack -is proven successful Disadvantages; -Mild transient gait disturbance. -Donor site morbidity is reported in literature CRANIOFACIAL DEVELOPMENT- Sperber

64. Site; proximal tibia . Advantages; -Adequate cancellous . -Minimal soft tissue damage. --Mild post-op discomfort. Disadvantages; - Less bone can be harvested than the iliac graft.

65. Site; Rib Advantages; --Mainly used in primary ABG Disadvantages ; - Poor source of cancellous bone -post-op-pain -Visible scar -Associated morbidity -Unpredictable result

66. Site; cranial bone Advantages; -Incision hidden in hair bearing area -Minimal postop discomfort Disadvantages; -Increased operative time -Associated morbidity CRANIOFACIAL DEVELOPMENT- Sperber

67. Site; Mandibular Symphysis Advantages; -Rapid post- oprative recovery -No external scar Disadvantages; -Sparse amount of cancellous bone --Poor result .

68. Allogenic graft: derived from a genetically unrelated member of the same species. Advantages; -Comparable to autogenous. - Allows for eruption of teeth. -Avoids donor site morbidity Disadvantages; - No osteogenic potential -Delayed incorporation

69. Alloplastic: inert foreign body material . Advantages; - Avoids donor site morbidity. Disadvantages; Delayed healing Inability of teeth to erupt

70. Surgical technique; Three basic surgical principles must be satisfied for the successful treatment of the alveolar clefts: closure of oronasal fistula, (2) adequate volume of graft material, (3) water tight and tension-free closure.

71. Post-operative instructions; - Liquid diet 7 days. -Avoidance of trauma to the site. -Antibiotics & nasal decongestants. -Meticulous oral hygiene with use of mouthwashes. Skoog T: The use of periosteum and surgicel for bonerestoration in congenital clefts of the maxilla. Scan J PlastReconst Surg 1: 113, 1967e Wood RJ, Grayson BH, Cutting CB: Gingivoperiosteoplastyand midfacial growth. Cleft Palate Craniofac J 34:17-20,1997e Carstens MH: Functional matrix cleft repair. principlesand techniques. Clin Plast Surg 31.159-189, 2004

72. Complications; - Failure of bone grafts (Mainly in mobile premaxilla). -Infection. -Wound breakdown & loss of graft (incomplete oral/nasal closure). -External root resorption. -Bone loss. -Residual fistula .

73. Success of ABG; Indicated by: -Good nasal side closure. -Use of adequate amount of cancellous bone. -A water tight oral side closure. - Adequate amount of attached mucosa in the area of cleft for development of normal periodontal attachment of erupting canine.

74. Pre Vs Post surgical Orthodontics: Controversy exists regarding the use of orthopedic expansion of the cleft segments and the relationship between expansion and grafting. Most authors prefer presurgical expansion because of less resistance & Improved access to the cleft for closure of the nasal floor, better postoperative hygiene, and less chance of reopening the oronasal fistulae. Orthodontic movement of the erupted teeth adjacent to the cleft is another controversial topic ,Some authors suggest that aligning the teeth adjacent to the cleft produces better hygiene and an improved result.

75. Expansion : If Expansion is done before grafting, as the graft matures and sutures fuse it is difficult to expand maxilla later. Also Expanding the arch before grafting increases the size of cleft and thus more area for placement of bone. But increased amount of bone required and requires more soft tissue dissection for closure. Expansion can also be done 6wks after grafting. It has a potential of stimulating immature bone which may enhance graft survival.

76. Other Treatment options for cleft alveolus ; Gingivo periosteoplasty . Distraction osteogenesis

77. Gingivo-Periosteoplasty ; - Boneless grafting technique. Gingivo - periosteoplasty   creates a mucoperiosteal bridge across the alveolar cleft associated with cleft lip and palate . The subperiosteal tunnel allows for bone generation in the absence of bone grafting in young patients. -It Relies on the osteoinductive capabilities of the periosteum. Skoog T: The use of periosteum and surgicel for bonerestoration in congenital clefts of the maxilla. Scan J PlastReconst Surg 1: 113, 1967e Wood RJ, Grayson BH, Cutting CB: Gingivoperiosteoplastyand midfacial growth. Cleft Palate Craniofac J 34:17-20,1997e Carstens MH: Functional matrix cleft repair. principlesand techniques. Clin Plast Surg 31.159-189, 2004

78. Advantages; -Repairs the cleft in anatomic way by a precise reconstruction of the functional matrix (mucoperiosteal matrix of maxilla). -Avoids the need for ABG .

79. Permanent dentition : Clinical feature of this stage : Medial displacement of the maxillary segment giving buccal cross bite Relative maxillary retrognathism, giving reversed incisal overjet. Deficiency of vertical growth of the upper jaw – REDUCED FACIAL HEIGHT rotation, malposition and hypodontia of teeth. Supernumerary teeth Accentuated curve of spee in maxilla Collapsed arch forms Poor oral hygiene and caries

80. Correction Of Lateral Dimension; Correction in lateral dimension is relatively straight forward. By expansion appliance Quad Helix Rapid Maxillary Expansion (RME) - Patients with CLCP usually have class III malocclusion because of maxillary deficiency (A-P and Vertically), coupled with mandibular overclosure. In such cases use of class III elastics after leveling and aligning will result in upper molar extrusion and favorable downward and backward rotation of mandible .

81. Orthognathic Surgery combined with Orthodontics; Due to severe skeletal discrepancy, there is deterioration of esthetics and occlusion, psychological implications leading to low self esteem, defective speech, oronasal fistulas. Such cases require a combined orthodontic and orthognathic approach.

82. Size and position of maxilla is often a problem, thus maxillary advancement and occasional down grafting needs to be performed. To correct the transverse problem multiple segment lefort I osteotomies may be required. For a bilateral CLCP three-piece maxillary surgery that allows rotation of segments is also required while for unilateral CLCP a two piece is sufficient.( Vlachos 1996 )

83. Decompensation: Usually requires 12 months. Multiple segment maxillary osteotomies requires segmental treatment. The bracket positions are altered for teeth adjacent to the osteotomy site. Dental compensations in the lower arch also should be addressed i.e alleviation of crowding and proclination . Skoog T: The use of periosteum and surgicel for bonerestoration in congenital clefts of the maxilla. Scan J PlastReconst Surg 1: 113, 1967e Wood RJ, Grayson BH, Cutting CB: Gingivoperiosteoplastyand midfacial growth. Cleft Palate Craniofac J 34:17-20,1997e Carstens MH: Functional matrix cleft repair. principlesand techniques. Clin Plast Surg 31.159-189, 2004

84. Proffit recommends overcorrecting the anterior crossbite in excess of positive overjet- compensate for post surgical relapse. Post surgical orthodontics: involves detailing of occlusion, closure of residual spaces and maintenance of transverse dimension (overlay arches). Lasts for 4-6 months. Retention: After removal of appliance retainers should be placed immediately. Timing; Never indicated in active facial growth Ideal time : age 18-19

85. Distraction Osteogenesis Dr. Gavriil Ilizarov of Russia- Bone lengthening of leg(1903). It is a procedure that moves two segment of bone slowly apart in such a way that new bone fills the gap. In distraction osteogenesis, a surgeon makes an osteotomy in an bone and attaches a device known as distractor to both sides of osteotomy.

86. The distractor is gradually adjusted over a period of days or week to stretch the osteotomy so new tissue fills it. Distraction osteogenesis allows soft tissue adaptation. Distraction Of maxilla first proposed by Molina & Oritz-Monasterio (1998).

87. Advantages : -Direction of force is well controlled. Disadvantages : -Cranial surgery is required -Esthetics are compromised E xternal Distractors ;

88. Internal Distractors; Advantages: Esthetics. Psychological relief. Disadvantages: Difficult to control the direction of force.

89. Distraction osteogenesis; Advantages; - No need for bone graft. -No donor site morbidity. -Minimal surgical time . -Bone height & width similar to normal adjacent alveolus. -Dental implants possible . -Final orthodontic tooth movement Is good. -Minimal morbidity. Disadvantages; - Long treatment requires patient co-operation & close follow-up

90. Conclusion; Although the repair of the alveolar cleft may be one of the last considerations in the global treatment of a cleft patient, if these goals are achieved, it provides tremendous enhancement of oral function and aesthetics for a cleft patient.

91. CONCLUSION: Orofacial clefts have been identified to have a multifactorial etiology and therefore require an interdisciplinary treatment approach. , A team effort in which an orthodontist plays a vital role and works hand in hand with various specialists to provide the best possible line of treatment with a single minded approach , that is to minimize if not eliminate the physical, social and the emotional hardship that a person with orofacial cleft presents .

92. CONCLUSION: