cleft lip and palate
TRANSCRIPT
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CLEFT LIP AND PALATE
DEPARTMENT OF ORTHODONTICSSWAMI DEVI DYAL DENTAL COLLEGE
BY ANUBHA TIWARIINTERN
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CLASSIFICATION OF CLEFT LIP AND PALATE
• KERNAHAN AND STARK (1958)A.CLEFTS OF PRIMARY PALATE ONLY1. Unilateral complete incomplete2. Median complete(premaxilla absent) incomplete(premaxilla rudimentary)3. Bilateral complete incomplete
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B. CLEFTS OF SECONDARY PALATE ONLYCompleteIncompleteSubmucosalC.CLEFTS OF PRIMARY AND SECONDARY PALATE1.Unilateral complete or incomplete2.Median complete or incomplete3.Bilateral complete or incomplete
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KERNAHAN’S STRIPED “Y”
1. BLOCK 1 AND 4 – LIP
2. BLOCK 2 AND 5 – ALVEOLUS
3. BLOCK 3 AND 6 – HARD PALATE ANTERIOR TO INCISIVE FORAMEN
4. BLOCK 7 AND 8 – HARD PALATE POSTERIOR TO INCISIVE FORAMEN
5. BLOCK 9 - SOFT PALATE
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MILLARD’S MODIFICATION
• MILLARD added two triangles over the tip of the “y” to denote the nasal floor
1. BLOCK 1 AND 5 – NASAL FLOOR2. BLOCK 2 AND 6 – LIP3. BLOCK 3 AND 7 – ALVEOLUS4. BLOCK 4 AND 8 – HARD PALATE ANTERIOR TO
INCISIVE FORAMEN5. BLOCK 9 AND 10 – HARD PALATE POSTERIOR TO
INCISIVE FORAMEN6. BLOCK 11 - SOFT PALATE
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LAHSHAL’S CLASSIFICATION
• OKRIENS(1987)L - lipA - alveolus bilateralH - hard palateS - soft palate unilateralH - hard palateA - alveolusL - lip
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Iowa Classification
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DEVELOPMENT OF LIP
LOWER LIP – • The mandibular process of the two sides
grows towards each other and fuse in the midline.
• Fused mandibular process gives rise to lower lip and jaw.
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UPPER LIP
• MAXILLARY PROCESS grows medially and fuses first with the lateral nasal process and then with the medial nasal process• Medial and lateral nasal process
also fuses with each other
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• UPPER LIP:A.The mesodermal basis of the
lateral part of the lip is formed from the maxillary process.
B. The mesodermal basis of the median part of the lip is formed fromed FNP
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DEVELOPMENT OF PALATE
• From each MAXILLARY PROCESS a plate – like shelf grows medially . This is called as PALATAL PROCESS.
• Basically there are three components from which the palate will be formed
1. the two palatal processes2. the primitive palate formed from the
frontonasal process
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• The definitive palate is formed by fusion by:a. Each palatal process fuses with the posterior
margin of the primitive palate.b. The two palatal processes fuse with each
other in the midline. - their fusion begins anteriorly and proceedsBackwardsc. The medial edges of the palatal processes fuse
with the free lower edges of the nasal septum thus seperating the two nasal cavities from each other , and from the mouth.
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• At a later stage the mesoderm in the palate undergoes intramembranous ossification to form the hard palate.
• Ossification does not extend into the most posterior portion which remains as the soft palate .
• The part of the palate derived from the frontonasal process forms the premaxilla which caries the incisor teeth.
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PRIMARY PALATE
• PALATAL development begins in week 5 but weeks 6-9 are most critical
• Formation of intermaxillary segment from merged MNP
• Primary palate forms from MNP• Ossifies as premaxillary portion of the maxilla
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• Lateral palatine process• Ingrowth from maxillary process• Eventually project horizontally above the
tongue• Fuse with each other ,primary palate, nasal
septum• Nasal septum• Downgrowth of MNP• Fusion of lateral palatine process starts
anteriorly then moves back
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• Hard palate• Primary palate – premaxilla• Secondary palate – maxillary process
• Soft palate• Unossified portion of the lateral palatine
process
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CLEFT LIP
• DEFINATION – Cleft lip occurs because of failure of fusion between the medial and lateral nasal processes and the maxillary process which occurs during 6th week of development.
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Cleft Lip
• Complete closure at 35 days postconception:– Lateral nasal, median nasal, and maxillary
mesodermal processes merge.• Failure of closure can produce unilateral,
bilateral, or median lip clefting.• Left side unilateral cleft is the most common.
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UNILATERAL
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• Forms persistent labial groove• Grooves should disappear as maxillary
prominences fuse with merged medial nasal prominence.
• Stretching of epithelium causes tissue breakdown and cleft formation.
• SIMONARD BAND – bridge of tissue spanning the cleft (arrow below)
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BILATERAL
• Similar • Central soft tissue mass that moves freely
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ANTERIOR CLEFT
• Clefting of the alveolar process of the maxilla as well as lip.
• Complete cleft extends to the incisive foramen.
• Complete bilateral anterior cleft isolates the anterior and the posterior parts of the palate
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POSTERIOR CLEFT
• CLEFTS EXTENDING THROUGH BOTH SOFT AND HARD PALATE TO INCISIVE FORAMEN
• Isolates anterior and posterior parts of the palate
• Result from failure of the lateral palatine process to grow medially and fuse to each other
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EtiologyGenes
• Control cell patterning, cell proliferation, extracellular communication, and differentiation
• Clefting usually represents a genetically complex event
• 2 to 20 genes are thought to interact to result in facial clefting
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Etiology• TGF-beta-3 gene – Expressed just prior to palatal fusion. – Results in isolated cleft palate.
• IRF 6. • Identified in -Autosomal dominant vander
woude syndrome
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Etiology• Dlx gene – Direct the destination of the distal skeletogenic
mesenchyme elements to the palate. – Mutations of these genes result in isolated palatal defects.
• Sonic hedgehog gene – Protein that mediates ectodermal functions, might
regulate the outgrowth and fusion of the facial domains.• TGF-alpha variant – Receptor ligand, usually a rare variant of TGF-alpha – Family histories of cleft defects– Additive teratogenic effect with agents such as cigarette
smoking and alcohol
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Etiology• Cigarette smoking – Noted with mothers of children with facial clefting, both
CL/P and CP.– Teratogenesis has been attributed to hypoxia as well as a
component of tobacco (cadmium).• Alcohol – Associated with an increased risk of fetal facial clefting. – Alterations in cell membrane fluidity or reduced activity of
specific enzymes such as superoxide dismutase.• Folate deficiency – Contributes to a range of birth defects. – Evidence is emerging for a similar association with the
development of CL/P.
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Environmental agents• Several agents that are associated with an
increased frequency of midfacial malformation.
• Medications —phenytoin, sodium valproate, methotrexate.
• With corticosteroids there is no evidence of an increase in malformations.– Possible association could not be excluded
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Prenatal Diagnosis• Diagnosed until the soft tissues of the fetal
face can be clearly visualized sonographically (13 to 14 weeks).
• The majority of infants with cleft lip also have palatal involvement:– 85% of bilateral cleft lips – 70% associated with cleft palate. – Cleft palate with an intact lip comprises 27% of
isolated CL/P
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Prenatal Diagnosis• The sensitivity is highest when is associated with
other structural anomalies. • Isolated CL/P in a low risk population, the sensitivity
may only reach 50 percent. • Cleft palate with an intact lip is the most difficult
orofacial malformation to diagnose prenatally.• Detected in only 13 of 198 cases in one large series.• Three-dimensional ultrasound, can provide a clear
image of the malformation
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Prenatal Diagnosis
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PROBLEMS ASSOCIATED
• FEEDING• PSYCHOLOGICAL : Disfigurement caused by the condition causes psychological
stress for the patient and the family
DENTAL: Clefts are associated underdeveloped maxilla 1. Multiple missing teeth 2. Mobile premaxilla3. Impacted teeth
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4. Supernumaries5. Multiple decayed teeth6. Periodontal complication
ESTHETIC : The patients with unrepaired clefts are badly
disfigured due to the nature of the deformity
SPEECH AND HEARING: 1. Definitive speech problems2. Are associated with infections of the middle ear
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TREATMENT
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Principles of ManagementAssessment
Indications: restoring normal morphologic form and functionImportant for normal dentition, mastication, speech, hearing, and breathingContraindications: malnutrition, anemia or other conditions that render infant
unable to tolerate general anesthesia- airway obstruction, otitis media
Work-up
(1) Thorough PE to uncover any associated anomaliesAdditional work-up determined by physical findings that suggest involvement of other organ systems
(2) Weight, oral intake, growth/development are of primary concern and must be followed closely (3) Routine lab studies generally not required; Hgb level before surgery
Clinical Aspects of Cleft Lip/Palate Reconstruction
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Surgical Management
Multidisciplinary approach
Beyond lip repair are other issues:Hearing (otolaryngologists)Speech (speech pathologists)Dental (oromaxillofacial surgeons ,orthodontists)
Psychosocial
Integration with team-based approach
Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her development
Cleft Lip and Palate
Clinical Aspects of Cleft Lip/Palate Reconstruction
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Surgical Management
Staging and Timing of SurgeryDifferent institutions = different practice
Rule of 10’s
Hgb = 10g
Weight of 10lbs
Age 10wks
Cleft Lip Cleft Palate
9-12 months of age
Clinical Aspects of Cleft Lip/Palate Reconstruction
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Surgical ManagementUnilateral Complete Cleft Lip
Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral dimple and ; natural appearing Cupid’s bow; functional muscle repair
Surgical Principle: Lengthen medial side of cleft so that it equals the vertical dimensions of non-cleft side
Flap designs:1) Triangular (Tennison-Randall)
2) Quadrangular
3) Rotation-advancement (Millard*, Mohler)
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Millard Technique
Scar placed in more anatomically correct position along philtral column
“Cut as you go” technique
1) Medial flap rotates downward to achieve necessary lengthening
2) Lateral flap advances into the defect produced by downward displacement of medial flap
3) Small pennant-shaped medial flap can be used to restore nostril
Preserves’ cupid’s bow and philtral dimple
Tension of closure under the alar base; reduces flair and promotes better molding of the underlying alveolar processes
In simple medical student terms:
Clinical Aspects of Cleft Lip/Palate Reconstruction
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Clinical Aspects of Cleft Lip/Palate Reconstruction
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Post-op Management
1) Feedings administered with catheter tip syringe fitted with small red rubber catheter for the first 10 days post-op2) Nipples are avoided to minimize strain on the muscle/skin sutures3) Velcro arm restraints to protect repair from flailing hands/fingers4) Suture line care: cleansing with half strength peroxide followed with polymixin B-bacitracin ointment
Cleft Lip
Clinical Aspects of Cleft Lip/Palate Reconstruction
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Dr. Christine Underhill
Orthodontic treatment:- performed at different stages of development.
• Neonatal maxillary orthopaedics as an infant• Orthodontic-orthopaedics in deciduous dentition.• Orthodontics in the mixed dentition.• Orthodontics alone or in conjunction with
maxillofacial surgery (+/_distraction osteogenesis) in the permanent dentition.
(Patients with cleft of lip only or soft palate only, defect will not effect dentition.)
12th July 2008
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Dr. Christine Underhill
STAGE 1 (Neonatal Orthopaedics)• FROM BIRTH TO 24 MONTHS Performed on new
born before surgical repair of lip.• Rationale...realignment of the collapsed segments before surgery• STRAPPING OF PREMAXILLAFirst collapsed maxillary posterior segments must be expanded
laterally and then pressure against premaxilla can be applied .
This movement can be accomplished by light elastic strap
• Definitely makes lip and anterior palate surgery easier at the time
12th July 2008
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• Fabrication of a feeding plate or a obturator
OBTURATOR – is a passive prosthetic appliance which aids in sucking
Prevents maxillary arch from collapsing further
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Dr. Christine Underhill
Pre surgical plates, moulding plates, feeding plates…….
12th July 2008
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Dr. Christine Underhill
Feeding plates to assist in early feeding
• Obturator plate
12th July 2008
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NAM
• NAM(nasoalveolar moulding) :Is a nonsurgical method of
reshaping the gums lip and nostrils before cleft lip and palate surgery lessening the severity of the cleft .
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To start NAM, parents work with an orthodontist. Within the first couple of weeks after birth, babies are fitted with a custom-made molding plate that looks like an orthodontic retainer.
The device is attached with a small orthodontic rubberband that is taped to the baby's face.
Unlike some older techniques, the molding plate does not push or stretch the delicate tissues; it only helps gently direct the growth of the gums
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• Adjustment of the molding plate is done by the orthodontist weekly or every other week depending on progress. Each appointment takes 40-60 minutes.
•Once the cleft gap in the gums is small enough (around one quarter-inch), a post is attached to the molding plate and is inserted in the nostril. This post is then slowly adjusted to lift up the nose and open the nostril.
•By the time of the surgery, the nose has been lifted and narrowed, the gap in the gums is smaller and the lips are closer together.
• A smaller gap means less tension when the surgeon closes the cleft.
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Dr. Christine Underhill
NAM Nasoalveolar moulding
12th July 2008
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STAGE 2 (FROM 24 MONTHS TO 6YRS)
• ORTHODONTISTS basically observe• Bring about changes in the obturator plate to
incorporate the deciduous teeth• CROSS BITES can be corrected at this stage
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Dr. Christine Underhill
Orthodontic orthopaedic treatment in the deciduous dentition
• STAGE 3 - (6 YRS TO 12 YEARS In vicinity of cleft alveolus ….delayed eruption, malformation or absence of deciduous lateral incisor
• Unilateral or bilateral cross bites often present.
• soft tissue drape often disguises skeletal defect at this stage.
12th July 2008
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ARCH EXPANSION Arch expansion can be done using a quad
helix
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Dr. Christine Underhill
Mixed dentition…common since event of alveolar bone grafts (ABG)
• Requires careful assessment of problem, risks and benefits
• Timing of treatment closely related to timing of planed bone graft.. either before lateral incisor erupts (argued can effect maxillary growth), or before canine erupts
• When root of canine 1/3 to ½ developed.• Orthodontic treatment involves expansion to
develop favourable arch form, alignment ..care not to move roots into cleft defect.. correct root angulation post grafting
12th July 2008
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Dr. Christine Underhill
Repaired cleft palate in 8 year old
12th July 2008
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Dr. Christine Underhill
Brackets to keep roots away from cleft
12th July 2008
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Dr. Christine Underhill12th July 2008
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Dr. Christine Underhill
Alveolar bone grafting (ABG)
• Provides continuity of alveolar ridge…• Provides bone for canine to erupt • Osseous support for adjacent teeth• Majority of canines erupt spontaneously…others
require surgical exposure often in combination with orthodontics.
• The erupting teeth often appear to then stimulate the formation of new alveolar bone
12th July 2008
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Feedings• Infants with CL/P have few feeding problems. • If the cleft involves the hard palate, the infant
is usually not able to suck efficiently. – Experiment (special nipples or alternate feeding
positions)• The infant should be held in a nearly sitting
position during feeding– Prevents flowing to the back into the nose.
• Should be burped frequently, (q 3-4min).
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Haberman Feeder
• Activated by tongue and gum pressure.
• Milk cannot flow back.• Replenished continuously
as the baby feeds.• Prevents the baby from
being overwhelmed with milk.
• A gentle pumping action to the body of the nipple will increase flow.
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THANK YOU