cleft lip and palate in orthodontics.pptx

cleft lip and palate orthodontics

1. CLEFT LIP AND PALATE 1 Dr.PRINCYMOL.K SECOND YEAR PG MBDC

2. CONTENTS Introduction Incidence Embryology Formation of clefts Etiology Diagnostic considerations Evolution of cleft classification Classification Problems associated with clefts Syndromes associated with clefts The team approach Sequencing of treatment Nasoalveolar Moulding (NAM) Cleft lip repair Presurgical Orthopeadic Treatment (PSOT) Millard-Latham procedure Distraction Osteogenesis Bone grafting for alveolar cleft defects Role of an Orthodontist Conclusion References 2

3. Orofacial clefting (OFC) describes a range of abnormalities which manifest in the new born infant. OFC involves structures around the oral cavity which can extend on to the facial structures resulting in oral, facial and craniofacial deformity. TERMINOLOGY : Cleft lip – Cheiloschisis Cleft palate - Palatoschisis INTRODUCTION 3

4. Cleft of the lip and/or the palate (CL ± P) is a congenital birth defect. Can be complete or partial clefting of the lip and/or the palate. The severity of clefting may vary from the trace of notching of the upper lip to complete non-fusion of the lip, primary palate and secondary palate 4

5. Epidemiology Cl and p constitutes nearly one-third of all congenital malformations. Incidence as 1.6 per 1000 live births excluding those associated with syndromes. 5

6. Highest in Afghans 4.9 lowest in Negroid population , 0.4 per 1000 live births. 30,000 children afflicted with CLP anomaly are born every year in India. 6

7. Sex ratio : CL + CP : Males > Females CP alone : Females > Males Laterality of lesions : Unilateral clefts > Bilateral clefts Left side > Right side. Increase in frequency : - With increase in parents age - N ormal parents- affected one child- 4 % second baby - If two siblings affected-10 % next baby 7 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

8. Development of facial structures starts at the end of 4 th week 5 facial prominences around stomatodeum 1. Unpaired frontonasal process 2. Paireed maxillary prominences 3. Paired mandibular prominences During this time of development, the two nasal (olfactory) placodes or thickenings begin to develop bilaterally at inferior portion of the frontonasal prominence. The nasal placodes invaginate around the fifth week to form the nasal pits. This invagination of the placodes creates a ridge around the pits, referred to as the lateral nasal prominences (outer edges) and the medial nasal prominence (inner edges) Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168 EMBRYOLOGY 8

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10. In following 2 weeks – The 2 medial nasal processes fuse in midline –globular process-Tip of nose,columella,prolabium,primary palate with 4 incisor Maxillary processes fuse in midline – rest of upper lip The maxillary and lateral nasal process separated by nasolacrimal groove/duct Lateral nasal process join with maxillary process – ala of the nose Secondary palate –becomes apparent when outgrowths occur from maxillary prominences around 6 th week of human development called palatine shelves and the shelves fuse to form the hard and soft palate Fuse in midline at 7 th week Incisive foramen – midline landmark between primary and secondary palate 10 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

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12. FORMATION OF CLEFTS 12 Failure of fusion of maxillary and medial nasal processes – anterior to incisive foramen Failure of fusion of palatine shelves – posterior to incisive foramen F ailure of proliferation of mesodermal cells in midline causing a cleft lip unilaterally or bilaterally. Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

13. Development of cleft Cleft of the lip and primary palate Non-fusion of the maxillary process with the median nasal process (MNP) during the early stages of the morphogenesis of the face. The cleft may be unilateral or bilateral . The clefts of the lip and alveolus may have bands of soft tissue bridging across the two sides called Simonart’s bands. 13

14. Cleft of the secondary palate Cleft of the secondary palate develops due to lack of fusion of the right and left palatine shelves . It can occur in a number of ways: 1 . Defective growth of the palatal shelves 2. Delayed or total failure of the shelves to elevate and attain a horizontal position 3. Lack of contact between shelves 4. Post-fusion rupture of shelves 5. Failure of mesenchyme consolidation 14

15. Cleft soft palate only (CPO) Considered as a separate entity and appears to be under the high genetic influence. The cleft of the palate alone is more common in females. which have been hypothesised to be linked with a week’s delay of hard palate closure and therefore a prolonged sensitive embryonic period. Isolated cleft usually associated with Pierre Robin malformation and has a distinct U shape while most of the clefts in the palate make a V-shaped notch 15

16. Submucous cleft palate (SMCP) Clinically invisible. present on the palate as bony defects but are covered with oral mucosa. Submucous cleft palate (SMCP) is a subgroup of cleft palate that presents as (1) bifid uvula (2) translucent zone in the soft palate (3) bony notch in the posterior edge of the hard palate. 16

17. Syndromic and non-syndromic clefts Non-syndromic cleft affected individuals have no other physical or developmental anomalies 70% of cases of CL/P and 50% of CPO are non-syndromic syndromic cleft may appear as a part of multiple congenital anomalies (MCA). More than 350 syndromes are known to have associated cleft lip and palate 17

18. ETIOLOGY Exact Etiology of CL/P is obscure because of its heterogeneous presentation, FAMILIAL AFFILIATION The familial association is greater for cleft of the soft palate alone. Cephalometric studies on normal parents of the cleft lip and palate patients have suggested that a distinct craniofacial pattern exists in normal parents of cleft patients which include short facial heights and wider nasal widths. 18

19. ENVIRONMENTAL CAUSES Anti-abortifacient drugs anti-emetics Phenytoin excessive alcohol and smoking Nutrition Viral infections Mercaptopurine,Methotrexate , Valium, Dilantin 19

20. EPIGENETIC FACTORS/GENE ENVIRONMENT INTERACTIONS The current research is more focused on gene-environment interaction. Studies of twins have shown a lack of 100% concordance in monozygotic twins, which is an indication that genetic events alone are not responsible for the clefting phenotype. Concordance in monozygotic (MZ) twins ranges between 40 and 60% and is 5% in dizygotic twins. Greatly increased MZ concordance does strongly support a major genetic component. 20

21. 21 Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994 Chromosomal anomalies Trisomy 13 (Patau) Trisomy 18 (Edward) Trisomy 21 (Down’s) Velocardiofacial syndrome (22q11 deletion) SYNDROMES ASSOCIATED WITH CLEFTS

22. Inherited syndrome Sticklers (Autosomal D ominant ) Treacher Collins (A utosomal D ominant ) Van der Woude (A utosomal D ominant ) Non-inherited syndrome Pierre Robin Syndrome Goldenhar syndrome 22 Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994 Cleft palate Glossoptosis Retrognathia

23. Teratogenic Fetal alcohol syndrome Fetal phenytoin syndrome Fetal valproate syndrome 23 Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994

24. GENETICS SYNDROMIC CLEFTING I nterferon regulatory factor-6 ( IRF6 ) in van der Woude syndrome P oliovirus receptor related-1 ( PVRL1 ) gene in Ectodermal dysplasia syndrome TCS gene ( TCOF1 ) to human chromosome 5q32-q33.1- Treacher Collins Syndrome 22q11 deletion – di George syndrome 24 The complex genetics of cleft lip and palate Martyn T. Cobourne European Journal of Orthodontics 26 (2004) 7–16

25. NON-SYNDROMIC CLEFTING Endothelin-1(ET 1) TGF α F13A 6p chromosome RARA on chromosome 17 BCL3 on chromosome 19 25

26. MULTIFACTORIAL 26 1) Chances increases if more than one family member if affected 2) More the severity, greater the chances of recurrence in sibling 3) Risk decreases in remotely related individuals 4 ) Consanguinity increases the rate because of sharing of genes John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

27. ENVIRONMENTAL FACTORS 27 Maternal smoking or tobacco exposure Viral infections Poor nutrition – Vitamin B6 deficiency Certain Medicinal drugs Teratogens like: Rubella virus, Cortisone/ steroids, Mercaptopurine,Methotrexate , Valium, Dilantin

28. 28 DIAGNOSIS

29. Prenatal diagnosis 2D ultrasound between 18-24 weeks (18 –complete clefts, 24 – incomplete clefts) All except isolated cleft palate seen in 67-93% cases.

30. The ultrasonographic surface rendered oro-palatal (SROP) allows the simultaneous visualization on a single scan of the superior lip, alveolar ridge and secondary palate. Parent counselling begins from here itself. 3D ultrasonography Lee W, Kirk JS, Shaheen KW, Romero R, Hodges AN, Comstock CH. Fetal cleft lip and palate detection by three‐dimensional ultrasonography. Ultrasound in Obstetrics and Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology . 2000 Sep 1;16(4):314-20.

31. Radiography & Computed Tomography – Radiography is not typically useful for diagnosis of CL&CP CT-is useful in demonstrating bone and dental anomaly before repair of dentofacial deformities. MR imaging-for evaluation of associated intracranial abnormalities in the CL&CP 31

32. 32 Non-invasive diagnostic tool Confirm fetal viability Determine gestational age Establish number of fetuses and their growth Check placental location Examine fetal anatomy for detecting malformations Graber Vanarsdall Orthodontics: Current Principles and Techniques. 6 th ed pg.368 ULTRASOUND TECHNIQUE

33. Transabdominal US Not reliable till gestational age of 15 weeks Done at 20 or more weeks of gestation Transvaginal USG Earlier visualization (12 weeks) Better image resolution Greater specificity and sensitivity 33 Graber Vanarsdall Orthodontics: Current Principles and Techniques. 6 th ed pg.368

34. ADVANTAGES OF PRENATAL CLEFT DIAGNOSIS 34 Graber Vanarsdall Orthodontics: Current Principles and Techniques. Pg.368-369 Psychological preparation for parents to have realistic expectations Parent education for cleft management Preparation for neonatal care and feeding Opportunity to investigate other abnormalities Possibility of fetal surgery DISADVANTAGES OF PRENATAL CLEFT DIAGNOSIS Emotional disturbance High maternal anxiety and dysfunction Termination of pregnancy

35. EVOLUTION OF CLEFT CLASSIFICATIONS FORSTER 1861 (First person to classify malformations of the face ) DAVIS AND RITCHIE 1922 BROPHY 1923 VEAU AND RECAMIER 1931 FOGH-ANDERSEN 1943 KERNAHAN AND STARK 1958 SANDHAM 1958 HARKINS et al., 1962 VILAR-SANCHO 1962 PFEIFFER 1964 BROADBENT et al 1968 DAHL 1970 ELSAHY 1973 SPINA 1973 BALAKRISHNAN 1975 MILLARD 1976 TESSIER 1976 BERLIN 1979 KERNAHAN 1971 WHITAKER et al.,1981 KRIENS O LAHSHAL 1987 FRIEDMAN 1991 KOCH AND KOCH , LAHSN SYSTEM 1995 DAVISON et al., 1998 SMITH 1998 M.R.OTRIZ 2001 QIANG LIU ET AL LAPAL SYSTEM 2007 PERCY ROSSELL-PERRY 2009 35

36. 36 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1) Group I: Prealveolar process cleft (clefts affecting the lip) Unilateral (right/left: complete/incomplete) Bilateral (right: complete/incomplete; left: complete/incomplete) Median (complete/incomplete) Group II: Postalveolar process cleft (clefts affecting the palate) Soft palate Hard palate Group III: alveolar process cleft (any cleft involving the alveolar process) Unilateral (right/left: complete/incomplete) Bilateral (right: complete/incomplete; left: complete/incomplete) Median (complete/incomplete) DAVIS AND RITCHIE’S CLASSIFICATION (1922)

37. 37 . Group I : soft palate Group II : soft/hard palate extending no further than incisive foramen. Group III : complete unilateral cleft, extending from uvula to incisive foramen, then deviating to one side Group IV : two clefts extending forward from the incisive foramen into the alveolus. Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1) VICTOR VEAU’S CLASSIFICATION (1931)

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39. FOGH ANDERSON (1942 ) Group -1 :-They are clefts of the lip . It can be subdivided in to :- Single - unilateral or median clefts. Double – Bilateral cleft Group-2 : They are clefts of the lip and the palate . They are once again sub-classified into: Single – Unilateral clefts Double – Bilateral clefts Group –3 :They are cleft of the palate extending up to the incisive foramen. 39

40. 40 Clefts of the prepalate (cleft of lip and embryologic primary palate ) Cleft lip (cheiloschisis) Cleft alveolus (alveoloschisis) Cleft lip, alveolus, and primary palate (cheiloalveoloschisis) Clefts of the palate (cleft of the embryologic secondary palate) Cleft of the hard palate (uranoschisis) Cleft of the soft palate (staphyloschisis or veloschisis) Cleft of the hard and soft palate ( uranostaphyloschisis ) 3. Clefts of the prepalate and palate ( alveolocheilopalatoschisis ) Facial clefts other than prepalatal and palatal Cleft of the mandibular process Naso -ocular clefts Oro-ocular clefts Oroaural clefts Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1) AMERICAN CLEFT-CRANIOFACIAL ASSOCIATION(ACPA) CLASSIFICATION (1962 )

41. INTERNATIONAL CLASSIFICATION (BROADBENT ET AL ., 1969) Two-tier system of classification 1.Classification of the lip, alveolus, and palate (based on embryologic principles): 1. Clefts of the anterior (primary) palate 2. Clefts of the anterior (primary) and posterior (secondary) palates 3. Clefts of the posterior (secondary) palate 2.Classification of rare facial clefts (based on topographical findings): A. Median clefts of the upper lip, with/without hypoplasia or aplasia of the premaxilla B. Oblique clefts ( oro -orbital) C. Transverse clefts ( oroauricular ) D. Clefts of the lower lip, nose, and other very rare clefts 41

42. KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971): In this classification the incisive foramen is taken as the reference point “Y” logo are each divided into three sections, representing the lip, the alveolus and the hard 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. 1,4-lip 2,5-alveolus 3,6-Hp ant to IF 7,8-Hp post to If 9-soft palate Olin, W. H. "Dental Anomalies In Cleft Lip And Palate Patients." The Angle Orthodontist 34.2 (1964): 119-123.

43. SYMBOLIC REPRESENTATION OF MILLARD (1977 ) 43

44. FRIEDMAN SYMBOLIC REPRESENTATION (1991) 44 Friedman HI, Sayetta RB, Coston GN, Hussey JR. Symbolic representation of cleft lip and palate. Cleft Palate J 1991; 28: 252

45. 45 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1) LAHSHAL is a p alindrome representing the anatomic areas affected by the cleft ,proceeding from the patient’s right side towards left side L – lip A – alveolus H – hard palate S – soft palate H – hard palate A – alveolus L – lip THALLWITZ CLASSIFICATION BY KRIENS(1987)

46. Dental Skeletal Nasal Feeding Ear problems Speech Associated anomalies 46 Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20 PROBLEMS ASSOCIATED WITH CLEFT LIP AND PALATE

47. 47 Tooth agenesis, hypodontia , Supernumerary teeth Enamel hypoplasia (CI) , Crossbites Ectopic eruption, transposition Taurodontism, dilacerations Natal and neonatal teeth , Microdontia,Delayed tooth maturation Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20 DENTAL

48. Maxillary deficiency Mandibular prognathism Class III malocclusion Concave profile Ana Paula et al , Dental Anomalies of Number in The Permanent Dentition of Patients With Bilateral Cleft Lip: Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476. SKELETAL 48

49. Oronasal fistulas Draining of oral fluids in nasal cavity and vice versa Bottle, cup and spoon, tube feeding Infant held at 30-45 angle to aid swallowing FEEDING PROBLEMS 49 Lewis CW et al., The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate AAP Volume 139, number 5, May 2017

50. SPEECH PROBLEMS Results from velopharyngeal dysfunction Inability of soft palate to move upward to provide a contact with nasal cavity results in a passing of air through the nose instead of oral cavity. This condition is known as hypernasality speech Treatment : Pharyngeal flap and sphincter pharyngoplasty and Obturator prosthesis is used Palatal obturator - to correct defects of palate or velum Palatal lift- Velopharyngeal Incompetency Speech bulb obturator/Speech aid appliance- Velopharyngeal Insufficiency when velum is short relative to the depth of the posterior pharyngeal wall ,resulting in a VP opening during speech,the bulb serves to fill in the pharyngeal space. 50 Dakshaini et al., Prosthontic management in conjuction with Speech therapy in cleft Lip and Palate: A review and case report .Journal of International oral health 2015;7(supp2):106-111

51. 51 VP incompetancy VP insufficiency

52. HEARING PROBLEMS AND EAR INFECTIONS Otitis media is a condition where a fluid is accumulated in the middle ear and results in ear infection. This is due to the abnormal action of Eustachian tube opening by two muscles which are tensor veli palatine and levator veli palatine. This leads to the lack of ventilation to the middle ear cavity and accumulation of fluid inside the middle ear. This condition is presented in the child with cleft palate in the first six months of life 52

53. 53 MANAGEMENT

54. THE TEAM APPROACH 54 Graber Vanarsdall Orthodontics: Current Principles and Techniques. 6 th ed pg.368

55. PRIMARY TEAM OR CORE TEAM The cleft surgeon/plastic surgeon undertakes the primary and secondary repair. The speech therapist monitors speech from 9 months onwards and institutes measures for normal development of the speech. The audiologist quantifies and locates the cause of hearing problems. The orthodontist monitors dental development, occlusion, skeletal problems and institutes interceptive therapy, dentofacial orthopaedics and prepares for secondary alveolar bone graft. 55

56. Orthodontist’s expertise in cephalometry and craniofacial growth uniquely qualifies him or her to monitor craniofacial growth, dental development and treatment results. Oral surgeon . Secondary alveolar bone graft and orthognathic surgery if required. Plastic surgeon . Correction of nose deformity, secondary deformities of lip and scar revision. 56

57. SEQUENCE OF THE TREATMENT 57 Repositioning palatal segments can facilitate lip repair; done less frequently now May be preceded by preliminary lip adhesion as an alternative to Pre surgical orthopedics Closing only the soft palate initially is an alternative, but one stage closure of the hard & soft palate is the usual procedure Articulation errors often develop as child tries to compensate for cleft Usually incisor alignment and maxillary transverse expansion Needed before permanent canine erupt; timing determined by stage & sequence of dental development Pre surgical infant orthopedics Lip closure Palate closure Speech therapy Early orthodontics Alveolar grafting 1-4 Weeks 8-12 weeks 18-24 Months 6-11 Years 7-8 Years 6-10 Years STAGE AGE COMMENT

58. STAGE AGE COMMENT 58 comprehensive orthodontics Pharyngeal flap surgery Orthognathic surgery Fixed prosthodontics 11-14 Years 9-19 Years 17-19 Years 17-19 Years Class III elastics often very helpful Only if required to overcome nasal air leakage during speech; sometimes needed after loss of lymhoid tissue in the naso pharynx at adolescence or following maxillary advancement Maxillary advancement, perhaps combined with mandibular setback; not done until growth completed Replacement of missing lateral incisors: consider temporary bonded bridge when fixed orthodontic appliance removed, comprehensive treatment only after growth completed. Surgical orthodontic treatment- William R.Proffit and Raymond P. White - 4th edition

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60. Immediately on birth The following specialists are required to evaluate the child: Neonatologist, paediatrician Feeding specialist nurse Clinical psychologist Clinical geneticist to assess for syndromic associations. Newborn children with clefts present the risk of aspiration and airway obstruction, which may lead to acute asphyxia in children with small mandibles like in Pierre Robin syndrome. Such cases may require tracheostomy at birth. 60

61. First few weeks Recurrent chest and throat infections: care by the neonatologist and paediatrician . First few months Primary surgery of lip and anterior palate: done by a cleft surgeon who could be an oral surgeon/plastic surgeon/ paediatric surgeon 61

62. Feeding appliance Feeding in a normal child involves two mechanisms: Sucking Swallowing The sucking mechanism is disturbed while the swallowing is normal. The feeding appliance or feeding obturator is intended to block the continuity of the oral cavity with the nasal cavity. 62

63. ROLE OF THE ORTHODONTIST Timing and sequencing of orthodontic care may be divided into four distinct developmental periods. These periods are defined by age and dental development and should be considered as time frames in which to accomplish specific objectives. 63

64. Neonate and Infant (Birth to 2 Years of Age) PRESURGICAL ORTHODONTICS OR NEONATAL MAXILLARY ORTHOPEDICS pioneered and introduced by McNeil in the 1950s initiated during the first or second week ability to adjust the position of the cleft segments into a more ideal relationship before definitive surgical repair of the lip Improve speech ability Dental function Facial aesthetics Reduces the size of cleft; Aids in Surgery Partial obturation aids in feeding 64

65. 65 Displacement of segment make lip repair more difficult Orthopaedic appliances are used to resposition the segment in early infancy, before lip closure. These procedures offer less long term benefit than expected  Hence, now used in severely displaced premaxilla cases

66. Two movements were carried out- expansion of the collapsed segments and pressure against premaxilla to reposition it posteriorly to its correct position . Done by placing light elastic strap across the anterior segment that applies a contraction force. In severe cases pin retained appliances may be required. These appliances also act as “feeding plate” for infants 66

67. Traction by external elastic with headcap Lip adhesion Intra-oral elastic devices Surgical setback of the premaxilla Pre-surgical Orthopedic (PSO) appliances - custom-made acrylic base plate that provides improved anchorage in the molding of lip, nasal and alveolar structures during presurgical phase. Duration – 2-3 months Latham appliance: screw retained device - significant growth restriction of midface Grayson’s naso -alveolar molding appliance: non pin retained Quinn – Georgiade appliance 67

68. Latham appliance Georgiade and Latham(1976). A pin-retained , active appliance to retract the premaxilla and expand the posterior segments simultaneously . Mechanically manipulates the maxillary segments into close approximation. 68

69. A MILLARD-LATHAM PROCEDURE 69 Latham manipulated the palatally pinned presurgical orthopaedic appliance – mechanical expansion of the lateral palatal segments is followed by the retraction of the protruding premaxilla into position within the arch Floor of nose is surgically closed Gingivoperiosteoplasty – migration of alveolar bone cells – close alveolar gap Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184

70. Modified appliance – a premaxillary stainless steel pin 7/10 mm in diameter is inserted through the posterior stem of the premaxilla. 3 Oz force per side for premaxilla retraction 8-14 days – premaxilla is positioned within the palatal segments Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184 70

71. Along with lip adhesion, the gingivoperiosteoplasty (GPP) provides stabilisation of the maxillary segments and reconstruction of the nasal floor. The appliance is inserted 4 weeks before lip surgery. Advantages -a fixed appliance which provides quick results in 2.5–3 weeks. Disadvantage- Need of additional surgery for its placement under general anaesthesia 71

72. HOTZ PLATE(1987) A passive orthopaedic to slowly align the cleft segments by grinding away the acrylic in specific areas. AIM Take advantage of natural development potential. Not to facilitate surgery or to stimulate growth. Therefore, after a lip operation at the age of 6 months, palate repair was postponed until 5 years of age to allow growth through intrinsic growth potential 72

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74. PRE SURGICALNASOALVEOLAR MOLDING (PNAM) it is very difficult to reach an esthetically pleasing result in the treatment of cleft lip and palate due to the actual anatomical deformity of the nose, which includes abnormal nasal cartilage morphology deviated nasal septum and columella asymmetry of the alar short or even absent columella 74

75. Dr. Grayson and Dr. Cutting emphasize the importance of presurgical correction of the nasal cartilage and soft tissue deformity which can be achieved by a combination of nasal and alveolar orthopedic molding -NAM 75

76. PNAM APPLIANCE Palatal plate that is constructed on an infant’s maxillary cast prepared on an accurate impression. consists of an acrylic bulb (nasal stent) attached to the maxillary plate with a rigid wire. The bulb lifts the nasal dome and moulds the shape of the nostril and soft tissue of the cleft region. The construction of the nasal stent is delayed until the cleft of the alveolus is reduced to 5–6 mm. 76

77. A retentive arm is part of the plate which is attached at 45° near the cleft lip region. A small opening of 6–8 mm is provided in the plate to maintain the patency of the airway in case the plate gets dislodged posteriorly and chokes the airway. Typically, PNAM is initiated within the 1st week after birth and needs to be modified and activated on a weekly basis 77

78. Reduce severity of initial cleft deformity Reduction in the width of the alveolar cleft segments until passive contact of the gingival tissues is achieved. Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition pg.451-458 OBJECTIVES 78

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81. A heavy-bodied impression material is used to take the initial impression as soon after birth as possible. Grayson and Maull (1999) held infant in upside down position to keep the tongue forward which permitted fluids to draw off the oral cavity when impression tray is placed Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition ch.21 pg.451-458 . PROCEDURE 81

82. 82 Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition pg.451-458 .

83. Plate – clear self-cure acrylic, trimmed with a denture soft material 2–3 mm in thickness The retention arm – 40 degrees to get appropriate activation and to avoid dislodgement of the NAM plate from palate 83 Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition pg.451-458

84. The nasal stent is added to the intraoral molding plate when the cleft alveolar gap is reduced to 5mm or less Stent – 0.036-in gauge round stainless steel wire The intranasal portion is formed from hard acrylic, covered with a thin layer of soft spongy acrylic denture liner 84 Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition pg.451-458 .

85. Elastics used are 0.25 inch and it should be stretched about two times the diameter for activation force of about 2 Oz 85 Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition pg.451-458 .

86. 86 Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition Chapter 21 P g no 451-8. Short-term : the tissues are well aligned prior to primary lip and nose repair Long-term: change in nasal shape is stable Reduced number of surgical revisions reduced need for secondary bone grafts lengthen the columella Reduction of treatment cost . reduction in the width of the alveolar cleft segments until passive contact of the gingival tissues is achieved BENEFITS

87. 87 Irritation of the oral mucosal or gingival tissue Ulceration of intraoral tissues The intranasal lining of the nasal tip can become inflamed Skin irritation due to tape usage Parent compliance required Moulding plate may get dislodged and obstruct the airway Samuel Berkowitz. Celft Lip and Palate. 2006. 2 nd edition pg.451-458 COMPLICATIONS

88. Lip Closure (Primary palate) 88 Surgical closure of a cleft lip is done as early in infancy as is compatible with a good long-term result. The contemporary consensus is that this is at 8 to 12 weeks of age. Therefore PNAM should be completed by then . Correction of lip immediately after birth was popular in 1960’s  psychological advantages to mother  surgical morbidity

89. Timing of surgery Millard "rule of ten’s ”: 10 weeks old, 10 grams Hb,10 pounds weight, WBC count of 10,000/mm3 Randall - repair in first ten days of life , as soon as health permitted - maximal healing potential exists, prevents a separate hospitalization and parents leave the hospital with a relatively normal appearing child Delay of closure - time to complete pediatric evaluation, understanding of the congenital defects Landmarks more visible as age increases.

90. 10 weeks of age 10 pounds of weight (4.5 Kg) 10g/dl of haemoglobin 10 K WBC 90 Cleft Lip(Millard’s rule) Cleft Palate 9-12 months of age Rule of 10’s

91. CHEILORRHAPHY 91 Many surgical techniques have been developed for primary lip closure. The surgical correction of the cleft lip deformity  Cheilorrhaphy ( Cheilo = lip; raphy = junction by seam or suture) Objectives: Functional Esthetic These procedures serve to restore symmetry not only to the lip but also to the nasal tip

92. 92 U/L CLEFT LIP Millard’s rotational advancement Modifications of millard’s technique: Millard II Skoog’s Technique Mohler’s Technique Tennison-Randall Triangular flap Delaire’s Functional lip closure Afroze technique B/L CLEFT LIP Straight line closure Columella lengthening Millard repair Tennison-Randall triangular flap Other techniques: Bauer Method Manchester method Skoog method Wynn method Barsky technique – Modified Veau II Primary Abbe’s flap TECHNIQUES OF REPAIR

93. TECHNIQUES 93 Tennison – Randall (Z-Plasty) Millards rotation advancement repair Rose – Thompson straight line repair

94. 94 (1) Millard’s rotation flap for lip repair. (A) Incision lines, (B) after rotation and suturing

95. 95

96. Secondary Palate Closure: 96 The timing of secondary palate by the age of 12 months. Intact palate facilitates normal speech , hearing and improves swallowing Bone transplants taken from rib, iliac bone, mandibular symphysis, tibial bone, or outer table of parietal bone

97. Palatorrhaphy : 97 Usually performed in one operation, but occasionally it is performed in two. Soft palate closure ( Staphylorrhaphy ) Hard palate closure ( Uranorrhaphy )

98. Objectives: 98 Primary purpose –to create a mechanism capable of speech and deglutition without significantly interfering with maxillary growth. Partitioning of nasal and oral cavities is important .

99. Various Surgical Techniques for palate closure : 99 V-Y ( Veau-Wardill-Kilner ) technique Von Langenbeck Widmaier technique-1964 Malek and Psaume technique-1983 Most common methods:

100. Other Methods: 100 Von Langenbeck's Bipedicle Flap Technique Veau-wardill-Kilner Pushback Technique Bardach's Two-flap Technique Furlow Double Opposing Z- plasty Alveolar Extension Palatoplasty (AEP) Primary Pharyngeal Flap Intravelar Veloplasty Vomer Flap Buccal Myomucosal Flap

101. Von Langenbeck Technique: 101

102. Vomer flap technique: 102

103. Soft palate closure: 103 W-Y push back procedure ( Wardill ) U shaped pushback procedure( Dorrance and Brown)

104. W-Y Pushback Procedure : 104

105. PRIMARY DENTITION STAGE : (2 to 6Years of Age) Treatment priorities is to correct crossbite by using removal plates or lingual arch. To control or eliminate oral habits , functional shift or space loss after premature loss of primary teeth Severe skeletal discrepancies -Modification or redirection of growth After the first phase, a removable retainer (at least night time) is worn till the next phase is begun. 105

106. MIXED DENTITION STAGE (7 TO 12YEARS OF AGE) A tentative decision on extraction of supernumerary teeth and overretained teeth. Correction of cross bite- jack screw, RME, quad helix, Niti expanders Maintain space for proper eruption of teeth. Expand collapsed segment to improve surgical access to the graft site. Traumatic occlusion is eliminated in preparation of alveolar graft. (By aligning offending tooth) Correction of jaw relationship- Face mask Therapy

107. FACE MASK THERAPY Used in mild maxillary deficient cleft patient Orthopaedic forces for maxillary protraction Orthopaedic force 350-500 gm per side over 10-12 hr / day for an average of 12-15 months. Stability…….(Questionable) Because of two reasons Counter pressure of a tight lip on the maxilla. Which inhibits its growth Scarring in pterygo maxillary region after extensive tissue mobilization for palatal closure

108. 108 ALVEOLAR BONE GRAFTING

109. RATIONALE FOR BONE GRAFTING To restore physiologic continuity of arch for esthetic and hygenic replacement To provide bone for stability of dental arch and the premaxillary segment Bone is provided into which unerupted teeth may erupt. At the time of placement of graft, patent oronasal fistulas can be closed To allow orthodontic alignment of teeth To provide support for the lip and the alar base and the nasal tip.

110. 110 Primary alveolar bone grafting: done at the time of lip closure at around 10-12 weeks. Common in 1950s. Causes hinderence in maxillary growth. Secondary alveolar bone grafting : done after lip closure at later stage. This is can be divided into three: Early (2-5 years): performed in primary dentition . Rationale is to allow eruption of the lateral incisor if present. Can affect growth of midface. Intermediate (6-15years ): performed in late mixed dentition time to allow the eruption of the permanent canine in the graft. There is minimal interference in growth. Late secondary alveolar bone grafting (adolescence to adulthood): Aids in replacement of missing teeth with implants.

111. Alveolar Grafting: 111 Surgical Technique: Successful grafting procedure nasal mucosal as well as oral mucosal coverage over the bone graft is necessary Iliac crest

112. 112

113. GRAFTING MATERIAL Autogeous Advantages Iliac crest adequate quantity easily condensed & placed little donor site morbidity Tibia adequate volume quality similar to iliac crest Rib for infants. Cranial bone inadequate quantity less resorption rapid vascularization predictable quality Allogenic grafts : it acts a scaffold into which new bone develops. Freeze dried bone( increased chances of immune reaction, HIV infection, longer post operative phase) REVASCULARISATION OF GRAFT IS SLOW.

114. Orthodontic considerations associated with secondary bone grafting . transverse dimension incisor alignment, eruption of the maxillary canines 114

115. EXPANSION: 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

116. Maxillary Expansion in Cleft Lip and Palate using Quad Helix and Rapid Palatal Expansion Screw 116 Maxillary Expansion in Cleft Lip and Palate using Quad Helix and Rapid Palatal Expansion Screw; Col MR Vasant ( Retd ), Col S Menon, Maj S Kannan - MJAFI 2009; 65 : 150-153

117. Incisor alignment . If appliances have been placed presurgically , individual orthodontic tooth movements should be delayed until 2 to 6 months following placement of the bone graft. The early movement of the roots into the grafted bone appears clinically to consolidate the alveolar bone and improve the crestal alveolar height. 117

118. Eruption of the maxillary canine Following surgery, the maxillary canine erupts through the grafted bone With orthodontic movement of teeth, sufficient space is created in the arch to allow the canines to erupt successfully Missing laterals-erupt close to centrals 118

119. Post-bone graft follow-up Retention of the expansion either by a fully bonded appliance or by reinserting a passive expansion appliance Bergland and co-workers have given an index to evaluate the success of the grafted bone based on the height of the interdental septum. 119 Type I – normal Type II – 75% of the normal bone height Type III – less than 75% Type IV – no bony ridge.

120. 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

121. ALIGNMENT OF INCISOR TEETH Incisors usually rotated and in crossbite. Corrected by means of fixed orthodontic appliance. CORRECTION OF LATERAL DIMENSION Lack of bony union between two sides of the maxilla, correction in lateral dimension is relatively straight forward. By expansion appliance Quad Helix Rapid Maxillary Expansion (RME) Patients with clcp have class III malocclusion bcoz 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.

122. M achos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204. Severe skeletal discrepancy, oronasal fistulas, speech deformity Maxillary surgery – multiple segment Le Fort I osteotomy with down- grafting Presurgical orthodontic treatment – 12 months AP discrepancy – more than 8mm – bijaw surgery needs to be planned TREATMENT BY ORTHODONTICS COMBINED WITH ORTHOGNATHIC SURGERY 122

123. Post-surgical orthodontic – 4 to 6 months Transverse maxillary stabilization by transpalatal arch Immediate retainers – Hawley’s type Cemented lingual arch in maxilla Vaccum formed retainers not indicated M achos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204. 123

124. Unilateral clefts – 2 piece Le Fort I osteotomy Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14 124

125. Bilateral clefts – 3 piece Le Fort I osteotomy Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14 125

126. INDICES FOR CLEFT To categorise the complexity of malocclusion in purpose of choosing a treatment option 126

127. Oslo protocol A protocol for the management of cleft patients in 1948 was established with the following key elements. No presurgical orthopaedics . Closure of cleft lip in infancy combined with a one-layer vomer flap for the closure of the nasal floor in the region of the alveolus and hard palate at the same operation Closure of the remaining posterior palatal cleft in early childhood by a von Langenbeck palatoplasty . 127

128. 128

129. 129 ‘ Bilateral CLP cases also do not receive any presurgical orthopaedics ’. This approach provides least restraint on the maxillary anteroposterior growth. Lip closure is done first on the wider cleft side at about 3 months of age. Straight line closure is done on the skin and mucosa without the suturing of the orbicularis oris in the midline. The tension of lip closure centralises the premaxilla and then the other side of the lip is closed at 4 months of age Bilateral cleft lip and palate

130. Current Oslo Protocol Unilateral clefts of the lip are closed at the age of 3 months by Millard’s technique. Bilateral complete clefts are closed in two stages with an interval of 4–6 weeks between the operations. The widest cleft in a child with BCLP is closed first and the other side is closed 4–6 weeks later. The anterior part of the palate is closed simultaneously with the lip by means of a single layer vomerplasty 130

131. Clefts of the secondary palate are closed at the age of 12–18 months with a von Langenbeck procedure with reconstruction of the levator muscle sling. The patients are reviewed at the age of 3–4 years when plans are made for further treatment. Functional and cosmetic imperfections are corrected as far as possible before school age 131

132. GOSLON yardstick 5-yr-old’s index Huddart Bodenham system Modified Huddart Bodenham system EUROCRAN. 132

133. GOSLON YARDSTICK INDEX 133 GOSLON (Great Ormond Street, London and Oslo) Yardstick index was developed by Mars et al . and Olav Bergland 1987 A standardized method for categorizing treatment outcomes based on the analysis of dental relationships ( anteroposterior arch, vertical labial segment and transverse relationships) using study models of children born with UCLP in late mixed dentition (10 years of age). This measurement system classifies patients as five groups (from excellent to poor). The Goslon Yardstick:A New system of assessing Dental Arch Relationships in children with Unilateral Clefts of the Lip & Palate (Mars et al Cleft Pal J 1987)

134. GOSLON 1 – Excellent GOSLON 2 – Good GOSLON 3 – Fair GOSLON 4 – Poor GOSLON 5 – Very poor 134

135. I Anteroposterior Arch Relationships: Severe Class III incisor relationships were least satisfactory[group 5] c lass II division 1 relationship in the early permanent dentition , most favorable for subsequent orthodontic correction.[ group 1] Edge-to-edge bite is classified as group 3[fair] and negative overjet of 1–2 mm as group 4 and negative overjet of 3–4 mm is classified as either group 5 depending on dento alveolar inclination. Pre-existing dentoalveolar compensation in the presence of a reverse overjet was not favourable , since it limits the possible orthodontic correction of the incisor relationship 135

136. II Vertical Labial Segment Relationships: Deep overbite is considered favourable , and open bite is unfavourable . 136 III Transverse Relationships: Canine crossbites were considered worse than molar crossbites. The degree of transverese arch constriction , rather than the number of teeth in crossbite, is a critical factor.

137. GOSLON index Groups 1 and 2: Require simple orthodontic treatment or no treatment at all. Group 3: Malocclusion requires complex orthodontic treatment but good result can be anticipated. Group 4: Malocclusion being at the limits of orthodontic treatment without orthognathic surgery to correct skeletal malrelations and if facial growth is unfavourable , orthognathic surgery is required. Group 5: Requires orthognathic surgery. 137

138. Advantage it is simple to use as an outcome measure of primary UCLP surgery. Diasadvantage This index is limited to be used in UCLP children with late mixed and early permanent dentition only. 138

139. 5-YEAR-OLDS’ (5YO) INDEX 5-year-olds’ (5YO) index was developed by Atack et al. in 1997 to overcome the shortcomings of the GOSLON Yardstick this index is applied at 5 years of age that is in the primary dentition in UCLP patients It categorises the dental relationships into 5 groups ranging from 1 to 5 the outcome measure ranging from excellent to very poor based on overjet, incisor inclination, cross-bite, open bite, maxillary arch shape and palatal vault anatomy 139

140. 140 Bilateral cross-bite Poor maxillary arch form and palatal vault anatom

141. Huddart Bodenham system – The original Huddart Bodenham scoring system was developed in 1972 This index scores each maxillary tooth and its opposing tooth based on the presence and degree of cross-bite . These scores are then summed to deduce one overall score. It has five categories for scoring incisors ranging from + 1 to −3 and three categories for scoring canines and molars ranging from 0 to −2. 141

142. The modified Huddart/ Bodenham index The Huddart/ Bodenham system was designed for use in the primary dentition, and it was, therefore, necessary to modify it for use in the mixed dentition. This was undertaken by scoring premolars in the same way as primary molars. At the age of 6 years and after that, the first permanent molars if present, or the midpoint of the maxillary alveolar ridge were scored similarly as in original Huddart/ Bodenham index ensuing maximum range of score from −22 to +2. 142