Development of Palate and its Anamolies.pptx

Detailed description of growth and development of palate.

1. Dr. Meghul Chadha MDS 1st Year Pediatric and Preventive Dentistry Growth and Development of Palate

2. CONTENTS Introduction Development of Palate Prenatal growth Postnatal growth Facial Malformations Definitions Incidence Etiology

3. Theories of Clefting Associated Syndromes Associated Conditions Factors affecting Development of Palate Anatomy of clefts Classification of Clefts Other types of clefts Management of Cleft Lip and Cleft Palate Treatment Plan References

4. INTRODUCTION The palate anatomically separates the nasal cavity from the oral cavity. Structurally it has a bony (hard) anterior component and a muscular (soft) posterior component ending with the uvula. The oral side of the palate is covered with a squamous stratified epithelium . The surface of the hard palate is further thrown into a series of transversal palatal ridges or rugae palatinae. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

5. 6th to 12th weeks, the palate is formed from 3 primordia: A midline median palatine process and paired lateral palatine processes Beginning of 6th week - merging of paired medial nasal processes forms the inter-maxillary process Later in the sixth week, paired lateral palatine processes arise as medial mesenchymal projections During the seventh and eighth weeks the palatal shelves elevate into a horizontal position above the tongue. A - 7-8 Weeks B - 8-10 weeks C - The lateral palatine processes grow medially and eventually merge in the midline and with the inter-maxillary segment (primitive palate) Som PM, Naidich TP. Illustrated Review of the Embryology and Development of the Facial Region, Part 2: Late Development of the Fetal Face and Changes in the Face from the Newborn to Adulthood. American Journal of Neuroradiology [Internet]. 2013 Mar 14;35(1):10–8. Available from: http://www.ajnr.org/content/35/1/10

6. Neural crest has a major contribution to the palate development. In palate formation there are two main and separate times and events of development. During embryonic period (Formation of primary palate) During early fetal period (Formation of secondary palate) This separation of events into embryonic and fetal periods corresponds closely the classification of associated palate abnormalities. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

7. DEVELOPMENT OF PALATE / OVERVIEW OF PALATE FORMATION Tissue intervening between nasal and oral cavities is known as the palate. By the 6th week the primary palate, formed by the two maxillary and two medial nasal processes, separates the developing oral and nasal cavities. Subsequently, between 6th and 8th weeks, the secondary palate is formed from the two palatal processes (outgrowths of the maxillary processes). Primary and secondary palates together form the definitive palate. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

8. Around the 4th week of intrauterine life, prominent bulge appears on the ventral aspect of the embryo corresponding to the developing brain. Below the bulge a shallow depression which corresponds to the primitive mouth - STOMODAEUM . The floor of the stomodaeum is formed by the buccopharyngeal membrane which separates the stomodeum from the foregut. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

9. PRENATAL GROWTH OF PALATE The Pharyngeal Arches Mesoderm of foregut comes to arranged in the from of 6 bars dorsoventrally in the sidewall of the foregut - pharyngeal arches. The pharyngeal arches are laid down on the lateral and ventral aspect of the cranial most part of the foregut. In humans, 6 pairs of pharyngeal arches. The 5th arch disappears after its formation. 1st arch is known as the mandibular arch, and 2nd arch as hyoid arch. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

10. Each arch has Outer covering of ectoderm An inner covering of endoderm Core of mesoderm Arches are separated from each other by Pharyngeal cleft or groove externally Pharyngeal pouches internally Wilson, Mark, and Margaret Coyle. “Embryology of the Branchial Arches.” Clinical Embryology, 2019, pp. 169–176, https://doi.org/10.1007/978-3-319-26158-4_21. Accessed 26 Mar. 2023.

11. Each of the 5 arches contain A central cartilage rod that forms the skeleton of the arch Muscular components termed as branchiomere A vascular component Neural element

12. The mesoderm covering the developing forebrain proliferates and forms a downward projection that overlaps the upper part of stomodeum. The downward projection is called “ FRONTONASAL PROCESS (FNP) ”. The FNP gives rise to a pair of medial nasal processes and a pair of lateral nasal processes. The stomodeum is thus overlapped superiorly by the FNP. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

13. 1st pharyngeal arch gives of mandibular arches on both sides. These mandibular arches of both the sides form the lateral walls of the stomodeum. The mandibular arch gives off a bud from its dorsal end called the maxillary process. The mandibular arch is now called the “ MANDIBULAR PROCESS ”. At this stage the primitive mouth or stomodeum is overlapped by from above by frontal process, below by mandibular process and on either side by maxillary process. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

14. The 2 mandibular processes grow medially and fuse to form the lower lip and lower jaw. Maxillary processes grow medially and fuse with the frontonasal prominences forming the upper jaw (maxilla). At the end of the 4th week two ectodermal thickenings : nasal placodes, appear on the FNP. They are the precursors the olfactory epithelium, responsible for the sense of smell. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

15. During the 5th week, lateral nasal and medial nasal swellings that surround the nasal placodes appear on the FNP. These 4 nasal processes grow forward , while nasal placodes “invaginate” but they actually stay behind and come to lie in the nasal pits, surrounded by the nasal processes. This is the first step in the development of the nasal cavities (FNP) Simultaneously, paired maxillary processes develop near from mandibular arch. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

16. They enlarge and grow ventral and medially, surrounding the future oral cavity. The maxillary processes grow rapidly 1st meeting the lateral nasal processes, and then the lower extension of the medial nasal processes. The lower extension is known as the globular or inter maxillary process and will give rise to the midstructure (philtrum) of the upper lip. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

17. Merging Vs. Fusion Of Facial Processes Most facial processes begin as two separate swellings separated by a groove. Merging is the process by which the groove between two facial processes is eliminated. The tissues in the groove “catch up” by proliferating more rapidly than the surrounding tissues, causing the groove to become progressively shallower until it smoothes out. Without it, a deep depression (a facial cleft) remains. Examples of merging are Merging of the two mandibular processes in the midline Merging of the two medial nasal processes in the midline Merging of lateral nasal and maxillary processes Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

18. Fusion is the process by which two facial processes, that were initially separated by a space, grow together. In fusion the epithelium is broken down where the two processes meet. Example of fusion Formation of secondary palate where the two facial processes grow toward each other, touch each other and fuse in the midline. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

19. Development Of Primary / Primitive Palate The primary palate develops at the fifth and sixth weeks. The maxillary processes undergo extensive growth, first coming into contact with the lateral nasal processes and secondly with the globular process of the merged medial processes (philtrum). Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

20. Initially the medial nasal processes and lateral nasal processes come into contact, and secondarily, the medial nasal processes come together (just below and in front of the contact site between the medial and lateral nasal processes) and pinch some epithelium between them. This sheet of epithelium is composed of future nasal epithelium superiorly, and future oral epithelium inferiorly. The two layers of epithelium are then pulled apart, making the mesenchyme between medial nasal processes continuous. This is the core of the primary palate. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

21. Posteriorly, behind the primary palate, the nasal epithelium continues to touch the oral epithelium. The patch of epithelium of called oronasal membrane. Around 6th week of development this membrane is ripped open i.e cells stop undergoing mitosis. The resulting opening is called primitive choanae, one for each nasal cavity. Occasionally the oronasal membrane does not break apart. A choana must then be surgically established at birth. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

22. Development Of Secondary Palate The posterior border of the primary palate is located just posterior (caudal) to the site of the future incisive foramen of the skull. As the face grows forward in an anteroposterior dimension, the primary palate soon is to short to provide adequate separation between the nasal cavities (respiratory function) and the oral cavity (digestive function). A new structure : the secondary palate develops to further separate these cavities. During the 7 th and 8 th weeks the medial walls of of the maxillary processes produce a pair of thin medial extensions, called the palatal processes (shelves). Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

23. Initially these grow vertically - downward and parallel to the lateral surfaces of the tongue. The beginning of the 8 th week, however, the tongue begins to contract and move out of the way. In addition, the lower jaw drops as it grows downward and forward. By the end of the 8 th week, the palatal processes rotate rapidly upward to a horizontal position and fuse with each other and with the primary palate. The fused palatally processes form the secondary palate - together with the primary palate they form the definitive palate . Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

24. The successful development of the secondary palate depends on extrinsic and intrinsic factors Extrinsic factors Swallowing movements of the tongue , moving the tongue out of the way from in between the two palatal processes and allowing them to move upward. Downward and forward growth of the lower jaw and tongue complex , providing more space above the tongue for the palatal processes. Straightening of the cranial base as the result of growth of the neural mass , establishing the mechanical environment for the palatal processes to swing upward. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

25. Intrinsic factors in palatal processes Mesenchyme cell proliferation Increases volume - ceases hours before palatal processes swing upward Extracellular matrix production - increasing volume Hydration of extracellular matrix - major increase in volume and turgor of palatal processes just before they swing upward Medial edge epithelium (MEE) - covering the free edges of the palatal processes, apoptosis of MEE surface cells immediately prior to fusion and development of temporary glycoprotein coat, enabling adhesion between MEE cells of the opposing palatal processes. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

26. Development Of Soft Palate The soft palate mechanism of closure has not yet been determined, with several existing theories. The recent study of embryos from the late embryonic-early fatal period (54 to 74 days post conception) has identified the timing of soft palate closure. 57 days - Late embryonic epithelial seam present throughout the soft palate 64 days - Early fetal epithelium only persists in the most posterior regions of the soft palate. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers.

27. POSTNATAL GROWTH OF PALATE Head growth continues postnatally near frontenellae to allow early growth. These bony plates remain unfused to allow early growth. These bony plates remain unfused to allow growth - puberty growth of face. The plate also grows postnatally through childhood and becomes more elevated forming the “ palatine vault ”, with different growth between genders. Lang, J., and R. Baumeister. “[Postnatal Development of the Width and Height of the Palate and the Palate Foramina].” Anatomischer Anzeiger, vol. 155, no. 1-5, 1984, pp. 151–167

28. During the postnatal development the anterior width of the palatum durum increases between the 2nd and 5th year more than the posterior palatal width. Also increases the height of the palatum durum and large during the 2nd dentition as to the distance of the foramen palatinum majus from the dens caninus . The size of the foramina palatina enlarges inconstantly during postnatal growth. Lang, J., and R. Baumeister. “[Postnatal Development of the Width and Height of the Palate and the Palate Foramina].” Anatomischer Anzeiger, vol. 155, no. 1-5, 1984, pp. 151–167

29. FACIAL MALFORMATIONS Cleft lip and palate are one of the most common congenital deformities at birth. Various types of cleft lip and cleft palate may be encountered clinically. Complete clefts indicate the maximum degree of clefting of any particular type. (eg a complete cleft of secondary palate, a complete cleft of lip, alveolar process and primary palate, or a combination of these two). Incomplete clefts are found when some merging or fusion has taken place during development. Clefts maybe unilateral or bilateral The important thing to remember clinically is - each site where merging or fusion or occurs during development of face and palate is a potential site for facial / palatal cleft. Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

30. DEFINATIONS Cleft lip and palate can be defined as congenital abnormal gap in the palate that may occur alone or in conjunction with lip and alveolus cleft. Cleft: Split or divided; refers to muscle, skin, bone. Cleft lip: Congenital deformity of the upper lip that varies from a notching to a complete division of the lip; any degree of clefting can exist. Cleft palate: A congenital split of the palate that may extend through the uvula, soft palate, and into the hard palate; the lip may or may not be involved in the cleft of the palate. Submucous cleft palate: A cleft of the muscle layer of the soft palate with an intact layer of mucosa lying over the defect. Velopharyngeal insufficiency (VPI): Inadequate velopharyngeal closure resulting in hypernasality (excessive flow of air through the nose); also called velopharyngeal incompetence. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

31. Fistula: Abnormal opening from the mouth to the nasal cavity remaining after surgical closure of the original cleft. Cheiloplasty: Surgical repair of cleft lip. Cleft palate team : Craniofacial team: Group of professionals involved in the care and treatment of patients having cleft lip/palate and other craniofacial malformations; consists of representatives from some of the following specialties: pediatrics, plastic surgery, otolaryngology, audiology, speech- language pathology, pedodontics, psychiatry, orthodontics, prosthodontics, psychology, social service, nursing, radiology, genetics and oral surgery. Maxillary orthopedics: The movement of palatal segments by the use of appliances (also called dentofacialorthopedics). Obturator: A plastic (acrylic) appliance, usually removable, used to cover a cleft or a fistula in the hard palate, or to help achieve velopharyngeal closure in order to promote clear speech. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd. Obturator Fistula

32. INCIDENCE Affects approximately 1:1000 Caucasian, 1:500 Asians, and 1:2000 African Americans. Majority of patients with cleft lip and palate are but approximately 25 percent have associated birth defects/chromosomal abnormality, or a genetic syndrome. More than 400 syndromes reported in association with cleft lip or cleft palate Overall incidence varies from 0.3 to 6.5 per 1000 live births Negroid race has least incidence while mongoloid have the maximum Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

33. Cleft lip is more common in males Cleft palate is more in females Unilateral clefts are more common as compared to bilateral Left side has more predisposition for clefts Incidence is increased with increase in parental age More chances of cleft in patients with family history of the same and in consanguine marriages. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

34. ETIOLOGY OF CLEFT Heredity Environment: Teratogens like rubella virus, thalidomide. Mutant genes: Some syndromes follow Mendelian inheritance, e.g. lobster defect-cleft with ectodermal dysplasia Chromosomal aberrations Increased maternal age Decreased blood supply in nasomaxillary region Deficiency of folic acid and vitamin A Multifactorial inheritance Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

35. THEORIES OF CLEFTING Dursy–His hypothesis: Failure of fusion between median nasal and maxillary process Veau’s hypothesis: Failure of in-growth of mesoderm between the two palatal shelves Alternations in intrinsic palatal forces Excessive head width or diminutive palatal shelves Excessive tongue resistance Nonfusion of shelves Fusion of shelves with subsequent breakdown Failure of tongue to drop down as in case of Pierre Robin syndrome Inclusion cyst pathology. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

36. ASSOCIATED SYNDROMES Autosomal dominant Van der Woude syndrome (lip pits with cleft lip/palate) EEC syndrome (ectrodactyl, ectodermal dysplasia and clefting) Larsen syndrome (originally thought to be recessive) Autosomal recessive Chondrodysplasia punctata (Conradi syndrome) Meckel syndrome Orofaciodigital syndrome, type II Fryns syndrome Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd. Orofaciodigital syndrome, type II Van der Woude syndrome EEC syndrome

37. X-linked Orofaciodigital syndrome, type I (dominant, lethal in male) Isolated X-linked cleft palate with ankyloglossia Chromosomal Trisomy 13 also known as Patau Syndrome Trisomy 18 Non-mendelian Pierre Robin sequence Clefting with congenital heart disease Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd. Trisomy 13 Orofaciodigital syndrome, type I Pierre Robin sequence

38. ASSOCIATED CONDITIONS Presence of middle ear infections Attendant hearing loss in children Otitis media develops quite early in most (within the 1st month of life) Speech problems - retardation of consonant sounds (p, b, t, d, k, g) Language activity is omitted Columella of the nose pulled to the non cleft side Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

39. Chief Complaints Deformity of face Unable to feed Nasal regurgitation of fluids Dental Problems Congenital missing teeth Neonatal teeth Ectopic eruption Supernumerary teeth Anomalies of tooth size and shapes Micro and macrodontia Fused teeth Enamel hypoplasia Deep bite Cross bite Crowding or spacing of teeth Esthetic Concerns Loss of facial morphology Missing structure Hearing and Speech Pathology Disorder of middle ear Nasal twang in voice Difficulty in articulation Psycological Effects Due to the defect the patients are object of curiosity, pity and are often separated from their normal counterparts in society. This can result in life long trauma be it social, mental or recreational Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

40. FACTORS AFFECTING DEVLOPMENT OF PALATE 2. INADEQUECY OF PALATAL PROCESS - TOO SMALL OR TOO LATE STRUCTURAL 1. TONGUE POSITION TIMING, SPATIAL 3. CRANIAL FACTOR CLEFT LIP AND PALATE FUNCTIONAL 4. SECONDARY RUPTURE - EPITHELAIAL PEARLS CONNECTING BANDS OF TISSUE IN THE LINE OF CLEFT 6. FAILURE OF EPITHEILAL DEGENERATION - EPITHELIAL CYSTS, MESODERMA GROWTH FAILURE 5. INADEQUETE SHELF FORCE Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

41. ANATOMY OF CLEFTS Cleft lip is associated with typical deformities caused by a symmetrical forces on the premaxilla during facial growth. The presence of Simonart’s band may reduce the extent of facial deformity with growth by exerting restorative force. There is rotation and distortion of the vermillion with the loss of cupid’s bow and philtrum and marks on the cleft side. Orbicularis iris muscle fibres are asymmetrically oriented along the cleft margins and maybe continuous across Simonart’s bands in milder forms. The typical nasal deformity is displacement of the lateral crus of the alar cartilage laterally, inferiorly and posteriorly. Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

42. The tip is flattened and deflected to the non cleft side. The ipsilateral nostril is oriented horizontally rather than vertically. The columella is significantly shortened and deviates to the non cleft side along with the caudal septum. The nasal cartilages may or may not be deficient. Clefts of the palate are associated with bony as well as soft tissues abnormalities. Clefts of the secondary palate may be isolated or associated with clefts of the primary palate, those involving the primary palate are usually asymmetric, with the vomer attached to the non cleft side. The dental arch on the non cleft side usually splays outward due to the lack of restraining force from the lip, and the p[alate his foreshortened in the anteroposterior direction. Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

43. In the case of complete bilateral clefts, the entire premaxilla protrudes from the adjacent ridges. Because of the collapse of the palatine shelves posterior to the premaxilla and its possible rotation, the premaxilla is prevented from rejoining the arch and is left attached solely to the vomer. Soft tissue defects of cleft palate include hypoplasia of the velar musculature in addition to anomalous insertions of its muscular components. Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

44. CLASSIFICATION OF CLEFTS We classify as follows - Is it combined (cl+cp) or isolated (cl or cp) cleft ? Is it unilateral or bilateral ? Is it complete (if it cross the nasal philtrum) or incomplete (if it does not cross the nasal philtrum) Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

45. David and Ritchie (1922) - (On Anatomical Basis) Group 1 - Pre Alveolar Clefts Unilateral Bilateral Median Group 2 - Post Alveolar Clefts Soft palate only Soft and hard palates Sub-mucous Cleft Group 3 - Alveolar Clefts Unilateral Bilateral Median Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

46. Veau (1931) Cleft of soft palate only Cleft of soft and hard palate extending no further than incisive foramen, thus involving secondary palate alone. Complete unilateral cleft, extending from the uvula to the incisive foramen in the midline, then deviating to one side and usually extending through alveolus at the position of the future lateral incisor. Complete bilateral cleft, resembling Group 3 with two clefts extending forwards from the incisive foramen through the alveolus. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

47. Fogh Andersons (1942) Group 1 - Cleft Lip Unilateral Bilateral Group 2 - Cleft Lip and Palate Unilateral Bilateral Group 3 - Cleft of Palate up-to incisive foramen Fog Anderson added group 4 to capture the median cleft lip, which was previously regarded only as a rare defect rather than as an atypical but distinct category of cleft lip. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

48. American cleft palate - craniofacial association classification (Harkins et al, 1962) Clefts of prepalate (Cleft of lip and embryological primary palate) Cleft lip (Cheiloschisis) Cleft alveolus (Alveoloschisis) Cleft lip, alveolus, and primary palate (Cheiloalveoloschisis) Clefts of palate (Cleft of embryological secondary palate) Cleft of hard palate (Uranoschisis) Cleft of soft palate (Staphyloschisis or Veloschisis) Cleft of hard and soft palate (Uranostaphyloschisis) Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review. Bilateral alveolar cleft

49. Clefts of prepalate and soft palate (alveolocheilopalatoschisis) Facial clefts other than pre palatal and palatal Cleft of mandibular process Oro-ocular clefts Oroaural clefts Naso-ocular clefts  Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review. Cleft of mandibular process Naso-ocular clefts 

50. International classification (Broadbent et al.) Classification of the lip, alveolus and palate (based on embryological principals) - Clefts of anterior (primary) palate Clefts of anterior (primary) and posterior (secondary) palates Clefts of posterior (secondary) palate Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review. Cleft of Secondary Palate Cleft of primary and secondary palate Cleft of primary palate

51. Classification of rare facial clefts (based on topographical findings) - Median clefts of upper lip, with / without hypoplasia or aplasia of the premaxilla Oblique clefts (Oro-orbital) Transverse clefts (Oroauricular) Clefts of the lower lip, nose, and other very rare clefts Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review. Cleft of lower lip and bifid tongue Oblique Cleft

52. Kernhan’s and Starks Classification of Clefts 1971 (Kernhan’s striped “Y” Classification) Clefts of primary palate Unilateral (r/l) Complete Incomplete Bilateral Complete (premaxilla absent) Incomplete (premaxilla rudimentary) Median Complete Incomplete 1,4 - Lip 2,5 - Alveolus 3,6 - Palate anterior to incisive foramen 7,8 - Palate anterior to incisive foramen 9- Soft palate Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

53. Clefts of secondary palate only Complete Incomplete Sub mucous 1,4 - Lip 2,5 - Alveolus 3,6 - Palate anterior to incisive foramen 7,8 - Palate anterior to incisive foramen 9- Soft palate Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

54. Clefts of secondary and primary palate Unilateral (r/l) Complete Incomplete Bilateral Complete Incomplete Median Complete Incomplete 1,4 - Lip 2,5 - Alveolus 3,6 - Palate anterior to incisive foramen 7,8 - Palate anterior to incisive foramen 9- Soft palate Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

55. Millard’s Modification of Kernhan’s Classification Millard added another parameter to kernhan’s classification and that was the addition of the nasal floor. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

56. Friedman’s classification - 1991 To indicate the severity of the deformity a number is placed in each diagrammatic segment to represent. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

57. Pfeifers Morphogenic Classification 1 - Generalised malformations 2 - Malformations in frontonasal region 3 - Malformation in diacephalic border 4 - Malformation in posterior lateral region 5 - Malformation in the neck Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

58. Kriens “LAHSHAL” Classification - 1969 L - Lip (Right) A - Alveolus (Right) H - Hard Palate (Right) S - Soft Palate (Median) H - Hard Palate (Left) A - Alveolus (Left) L - Lip (Left) Uppercase letter - Complete cleft Lowercase letter - Incomplete Cleft “.” Or “_” - Normal Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

59. Paul Tessier Classification - 1976 All clefts are numbered from 0-14 Midline clefts are number 0 Facial clefts are numbered out laterally from 1-7 inferior to the orbit Cranial clefts are numbered in medially from 8-14 superior to the orbit. Facial and Cranial clefts can be connected. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

60. Craniofacial clefts can be groups based on their location. There are 4 main groups.   Oral-nasal clefts are Tessier Clefts 0-3 between the midline and cupid's bow. This results in clefts involving the midline structures (lips and nose). Oral-Ocular clefts are Tessier Clefts 4-6 that occur between oral and orbital cavities without disrupting the nose. Lateral Facial clefts are Tessier Clefts 7-9, resulting in Treacher Collins Syndrome, hemifacial microsomal, and necrotic facial dysplasia. Cranial Clefts are Tessier clefts 10-14 that occur in the frontal and cranial vault. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

61. OTHER TYPES OF CLEFTS Microform Cleft May look like A dent in the red part of the lip Scar from the lip unto the nostril Muscle tissue underneath the cleft can be affected and may require surgery. Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

62. Submucous cleft palate Midline deficiency or lack of muscular tissue Often a submucous cleft palate is associated with a bifid or cleft uvula Posterior nasal spine is almost always missing Speech problems are common Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review.

63. MANAGEMENT OF CLEFT LIP AND CLEFT PALATE Copper ——> Clinicians providing treatment to the child can act as a team ——> Association would result in better understanding of the problem. Fundamentals of cleft palate team Requires an interdisciplinary team of specialists with experience in CLCP Team must see sufficient numbers to maintain expertise Optimal time for team evaluation is in first few days or weeks of life Team should adhere to principles of informed consent, form partnership with parents, and allow participation of the child in decision making. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

64. Care is coordinated by the team, and is provided locally if possible and appropriate Team should be sensitive to cultural, psychosocial and other contextual factors Team is responsible for monitoring short- and long-term outcomes, including quality management and revision of clinical practices, when appropriate Treatment outcomes include psychosocial well-being, and effects on growth, function and appearance. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

65. Cleft Palate Team A cleft palate team consists of Patient care coordinator Obstetrician Paediatrician Plastic surgeon Surgeon Oral surgeon Neurologist Pedodontist Orthodontist Speech therapist Psychologist Prosthodontist ENT Specialist Social Worker Parents Genetic counsellor Audiologist Nurse Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

66. Management of a Neonate Medical and nursing attendants do face two types of problems Neonatal respiratory obstruction Seen in syndromes like Pierre Robin Syndrome Infants born with a very small and posteriorly displaced mandible and tongue which falls back causes severe obstruction to the airway Difficulty in feeding Breastfeeding should be encouraged Nostrils must be cleaned Lips should be well lubricated Folds of neck should be carefully be washed and dried Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

67. Parental Counselling Parents - most important people associated at this stage and need the most support and information regarding the treatment. Should be told the hold the child / infant - to increase bonding The mother plays a major part in the form of a nurse as well as mother. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

68. Nursing management The mother acts as a very important nurse at this time. After the obturator has been fitted the mother will take care of this appliance. After each feed the plate is removed and cleaned with running water and soaked once a day for 20 minutes in hibitane solution. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

69. Feeding Management For those with a cleft lip only - Should be able to eat normally using standard techniques. They can be even breastfeed. For those infants with a cleft palate, with or without a cleft lip - The infant with a cleft palate will require specific bottles and a special feeding technique. Breastfeeding and use of a regular bottle are rarely possible. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

70. FEEDING BOTTLES The first is the cleft palate nurser made by the Mead- Johnson Company. It is a soft-sided bottle that is squeezed in coordination with the infant’s sucking efforts, and thus milk is delivered into the mouth The second is the HabermanTM feeder available from the Medela Company. This feeder consists of a large, compressible nipple with a one-way valve at its base that keeps the nipple full of milk. The infant’s effort to compress the soft nipple is often sufficient to dispense the milk into the infant’s mouth The third option is the pigeon cleft palate nurser distributed by children’s medical ventures. This system also makes use of a one-way valve at the base of the nipple. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

71. The regular bottles can also be supplemented with special teats namely Newborn Teat, Orthodontic shaped teat, MAM soft sipper spout, NUK cleft palate teat, MAM vented teat size 2, tapered teat. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

72. TREATMENT PLAN The comprehensive treatment of cleft patients can be divided into 4 stages: Stage 1: Maxillary Orthopedic Stage Stage II: Primary Dentition Stage Stage III: Mixed Dentition Stage Stage IV: Permanent Dentition Stage Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

73. Stage 1: Maxillary Orthopedic Stage Lasts from birth to 18 months. Treatment modalities in this stage Management of feeding problems Fabrication of feeding obturators Pre-surgical orthopedics Surgical management of cleft lip and cleft palate. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

74. Initial obturator therapy D one from birth to 3 months. The appliance is fabricated (made of acrylic) Should be cleaned before and after each feed. Pre-surgical orthopedics (birth to 5 months) - Aim of this is to achieve an upper arch from that conforms to lower arch. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

75. Surgical lip closure (3 to 9 months) - Best time for lip repair (lip is not much developed and the vermilion border is not very conspicuous) ‘Rule of Ten’ is an important criterion for lip repair. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

76. Surgical plate repair (8 to 10 months) - The time of palatal repair is very vital for further growth and esthetics. If the repair is done too early then we will establish good esthetics but growth will be hampered and if we repair too late facial growth will be better but esthetics will be compromised. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

77. There are two types of palatal repair: 1. Single stage: Von Langenbeck repair and V-Y pushback palatoplasty. This is carried out at 11⁄2 year. The disadvantages include midfacial growth retardation. 2. Two-stage repair: Soft palate is repaired around 18 months and then hard palate is repaired at 4 years by Schweckendiek procedure. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

78. Stage II: Primary Dentition Stage 18 months to 5 years of age Treatments include Adjustments to obturators Restorations of decayed teeth Maintenance of oral hygiene Evaluating the erupting dentition Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

79. Stage III: Mixed Dentition Stage The main problems encountered during this stage are due to ectopic eruption of teeth and malalignments. The procedures in this are: Correction of cross bites Maxillary expansion Secondary grafting. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

80. Stage IV: Permanent Dentition Stage During this stage the patients can be treated in conventional manner. Mainly the treatments undertaken during this phase are fixed orthodontic treatments. All types of dental and skeletal irregularities are corrected during this period. Cosmetic repair is also carried out during this phase but is probably the last treatment to be undertaken. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.

81. REFERANCES Liao YF, Mars M. Hard Palate Repair Timing and Facial Growth in Cleft Lip and Palate: A Systematic Review. ​de Souza Freitas JA, de Almeida ALPF, Soares S.das Neves LT, Garib DG, Trindade-Suedam IK, et al. Rehabilitative treatment of cleft lip and palate: Experience of the hospital for rehabilitation of craniofacial anomalies/USP (HRAC/USP) - part 4: Oral rehabilitation. Journal of Applied Oral Science. 2013;21(3):284–92.   ​Shkoukani MA, Chen M, Vong A. Cleft lip - A comprehensive review. Vol. 1, Frontiers in Pediatrics. Frontiers Media S.A.; 2013.   Textbook of management of of cleft lip and palate : A.C.H Watson, P. Grunwell Wilson, Mark, and Margaret Coyle. “Embryology of the Branchial Arches.” Clinical Embryology, 2019, pp. 169–176, https://doi.org/10.1007/978-3-319-26158-4_21. Accessed 26 Mar. 2023 Lang, J., and R. Baumeister. “[Postnatal Development of the Width and Height of the Palate and the Palate Foramina].” Anatomischer Anzeiger, vol. 155, no. 1-5, 1984, pp. 151–167

82. Inderbir Singh (2014). Human embryology. New Delhi: Jaypee Brothers Medical Publishers. Nikhil Marwah (2019). Textbook of Pediatric Dentistry. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.