CLEFT LIP AND PALATE.pptx

CLEFT LIP AND PALATE

1. NAVODAYA DENTAL COLLEGE DEPARTMENT OF PEDODONTICS STAFF NAME – Dr K M PARVEEN REDDY Associate Professor TOPIC NAME – CLEFT LIP AND PALATE

2. DAVIS & RITCHIE (1922) They classified congenital clefts based on the position of the cleft in relation to the alveolar process GP I : PRE ALVEOLAR –(LIP ONLY) GP II : POST ALVEOLAR(HARD AND SOFT PALATE) GP III : COMPLETE ALVEOLAR (LIP ALVEOLUS, PALATE) CLASSIFICATION

3. 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 .

4. Group III - Complete unilateral cleft of soft and hard palate, lip and alveolar ridge Group IV - Complete bilateral cleft of soft and hard palate, lip and alveolar ridge on both sides.

5. Kernahans classification In this classification the incisive foramen is taken as the reference point 1,4 – LIP 2,5 – ALVEOLUS 3,6 – PALATE ANT TO INCISIVE FORAMEN 7,8 – PALATE POST. TO INCISIVE FORAMEN 9 – SOFT PALATE

6. V 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. L- lip A- Alveolus H- hard palate S– soft palate

7. LAHSHAL - OKREINS (1987) L – LIP A – ALVEOLUS H – HARD PLALTE S – SOFT PALATE

8. SCHUCHARDT & PFEIFERS

9. age orthodontics surgery After birth external elastics over protruding premaxilla – no obturator 3–4 weeks 6 months Lip adhesion Millard Forked Flap von Langenbecka (simultaneous closure of the hard and soft palate 18–30 months 4–5 years Correction of buccal crossbite only using a fixed quad helix palatal expander 5–7 years Fixed palatal retention 7–8 years Align anterior teeth prior to secondary alveolar cranial bone graft ( SABG) Secondary bone graft using iliac crest bone 9–13 years Full banded treatment with or without maxillary protraction (Delaire faciai mask) Nasal tip revision 13–17 years Full orthodontics. Evaluate need for surgicaiorthodontics (Distraction osteogenesis or Lefort I) Maxillo-mandibular surgery Nasal-lip revision 17–18 years Postsurgical orthodontics followed by prosthetics Nasal-lip revsions

10. Obturator construction Dental problems associated with CLP Maintaining good oral hygiene Application of topical fluorides Recall appointments Observation and review for developmental changes in dentition Motivates parent and child to cooperate with the treatment Role of Pedodontist

11. Feeding Three types of bottles: Mead-Johnson cleft Palate Nurser Haberman feeder Pigeon nipple

12. Mead – Johnson cleft palate nurser: Soft squeezable Short nipple Practice squeezing Stop when child stops breathing Haberman feeder: For premature infants with only cleft palate One-way valve – keeps milk in nipple Milk expressed – when placed against palate Sucking not required Less tiring for mother

13. Obturator for palate + bottle feeding: Pigeon nipple: Can be used with any bottle Works well for slightly older infants Firm side – towards palate Soft side – towards tongue Small notch – at base of nipple: for airflow – should be present below the nose Tightening the nipple: Decreases flow of milk Loosening the nipple: Increases flow of milk

14. Cross-cut nipples: used with compressible bottles, offer the advantage of controlling the flow of liquid when feeding. Slight thickening of liquid should be done

15. ISOLATED CLEFT PALATE: Feeding techniques: a ) breast feeding b) bottle feeding using soft nipple with enlarged outlet. c) commercially used cross cut (juice) nipples. CLEFT OF THE SOFT PALATE Feeding techniques: Correctly shaped, regular nipple. CLEFT LIP ONLY Feeding technique: a) breast feeding b )large nipple size.

16. Breast feeding should be encouraged Feeding by bottle rather than spoon Nostrils – cleaned. Lips- well lubricated with Vaseline If orthopedic splint worn – remove before feeding, clean it , place it , then feed Tapes – checked for dry, cleaned firmly attached to elasto plast base on cheeks Basic Instruction

17. POSITION FOR FEEDING : Regular breast feeding or bottle feeding do not work well Unable to seal their lips, velvopharynx Cannot develop sufficient suction on bottle nipple . A semi-upright position. Feeding the baby in a reclining position - contamination of the middle ear and ear infections. Always the baby’s head – higher than his stomach.

18. CLEFT LIP PALATE: Feeding techniques : Deliver the milk directly into the mouth. A soft bottle is useful. LACT-AIDE DEVICE Used after lip closure. Delivers the milk through a small tube while the infant is placed at mothers breast

19. 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 . 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 , also helps in the development of the jaws and contributes to speech

20. MULTIDISCIPLINARY SEQUENCE OF TREATMENT STAGE I - Maxillary Orthopedic stage ( birth- 18 months) STAGE II - Primary Dentition stage ( 18 months- 5 years) STAGE III - Late primary/ mixed dentition ( 6 -10 \ 11 years) STAGE IV - Permanent dentition stage (12 - 18 years)

21. Management of CLP- immediate attention of new born. Feeding problems- difficult to maintain adequate nutrition . Numerous prosthetic devices. Mc Neil (1950) devised , Intra oral maxillary obturator . STAGE I – MAXILLARY ORTHOPEDIC STAGE ( BIRTH- 18 MONTHS)

22. Clinical presentation Anteriorly positioned premaxilla Laterally positioned premaxilla STAGE I

23. INTRA ORAL MAXILLARY OBTURATOR : Advantages: 1) Provides a false palate, reducing incidence of feeding difficulties in infants 2) Maxillary cross arch stability preventing arch collapse after definitive cheiloplasty . 3) Molding the cleft segments into approximation before primary alveolar bone grafting. 4) Facilitate infants ability to create sufficient –ve pressure, which allow adequate sucking of milk

24. Block out excessive undercuts – wax Apply tinfoil substitute over entire surface of maxillary model – let it dry Pour resin in cleft till the level of palate Place in warm moist environment – cure for 20 min Add resin – on the palate and mucobuccal area Trim and polish PROCEDURES PERFORMED BY - PEDODONTIST STAGE I

25. Management of initial obturator therapy:birth – 3months Appliance positioned in mouth Areas of excessive pressure – reduced Parents instructed: How to wear Cleanliness Initial adjustment : 2 days Follow-up – monthly Serves till lip closure – 3 months Advantage: Enhances nourishment STAGE I

26. PREMAXILLARY ORTHOPEDICS (BIRTH-4/5 MONTHS) In some cases BCLP ,premaxillary segment is anteriorly placed or displaced laterally to one side . Hofman (1686): Head cap & premaxillary strap to reposition premaxilla. Useful in antero posterior & vertical repositioning. Soft elastic tape :(micro foam tape)

27. 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 Correction of jaw relationship- Face mask Therapy

28. RULE OF TEN Lip correction – as early as possible Soft palate correction –18-24 mons Hard palate correction – 4-5 years of age