rub - universiti sains...
TRANSCRIPT
CLEFT PALATE IN CHILDREN AND ADOLESCENT: A STUDY OF ARCH
EXPANSION.
By
Dr. Najeeb Mohammad Abu Rub
A Thesis
Submitted to the School of Dentistry
at
Universiti Sains Malaysia
In fulfilment of the requirements
For the degree of
Master of Science
In
Orthodontics
Department of Orthodontics
USM, Kelantan.
2004
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[96:1-5] Read! In the name of your Lord who created- Created the
human from something which clings. Read! And your Lord is Most
Bountiful - He who taught (the use of) the Pen, Taught the human
that which he knew not.
Chapter 96: AL-ALAQ
Dedication Ul
Dedication
To my parents, whose love, support, eternal dedication and devotion to us inspire me and
design my life.
To my brothers and sisters, Husam, Salah, Ahmad, Manal, Amneh, Maram, Muna, whose
love and support made this possible.
To my in-law Dr. Reyad Al-Shalabi, and my sweet nieces, Rawan and Diana. Your smiles
are all I need for encouragement.
THANK YOU!
Acknowledgment iv
Acknowledgment
Praise is to ALLAH, the Lord, the Almighty ...
There are t~es when words are inadequate. I grant my grateful appreciation and thanks to
all those who have contribute to this work.
My main supervisor Dr. Ahmad Burhanuddin Abdullah, for his unparalleled example,
clinical skills and leadership that gave me a great foundation in orthodontics.
My co-supervisor Prof. Dr. Abd. Rani Samsudin, for his untiring dedication, guideness, ~-
and for his great knowledge of research, support, advice and leadership.
Dr. Nizam Abdullah for her time, efforts, help and contribution to my research.
Dr. Mohd Ayub Sadiq for his expert analytical and mathematical contributions to this
project.
Dr. Rusdi Abdul Rahman for his assistance on this project.
Prof. Dr. Ahmad Sukari for his contribution and support.
My respect and thanks are due to all the staff at Jalan Mahmoud Dental Clinic,
Orthodontic Department, especially Puan Salina, for their help and support.
Acknowledgment
Thanks and gratitude is also due to the head and staff of Dental school, USM, especially
Orthodontic department for their support and homely environment.
I also extend my grateful appreciation and thanks to
My colleagues, classmates, fellow residents and friends, for their friendship and support,
especially Dr. Mohd Sarhan, Dr. Ayman, Dr. Saed Ba'nabilah, Dr. Rajan, Dr. Hamed,
Dr. Rasheed, Dr. Fawaz, Dr. Naser, Dr. Saed Mohd, Anifin, Dr. Siddique, Dr. Zain,
Dr. Ali, Maulood, Rana, Tabitha, Ma'en, Monther, Yazan, Rebhi, Wisam, Zeyad,
Sultan, Majed, Ali Sleet, Ra'fat, Dr. lyad, Dr. Ayed, Mustafa, Moh'd Hamzeh, Dr.
Silwadi, Nael Abu rub, Abu Afif, Dr. Dawabeh, Zaid, Abdullah, Rania, Abu Jaitem,
Samer, Dr. Sanjay, Shahida, Nadia, Omar, Qawi, Abu Salim.
To all named and unnamed helpers and friends, I again extend my thanks.
Table of content: .. · Vt
Table of contents
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[;:;:::~;i~:::::'J~;::,"""::::~::~::::s~:~"":"s::::~:_::J\2~:j! :. -·-· j! Eptdennology ot oral clefts .. .. . .. .. .. .. .. .. .. .. . .. .... .. .. ... .. . .. .. .. .. .. . !i 10 ! ~ ...... ~.~_ ....... ~ ............... ~.~ .............................. ':'. .... :'..'::·: .......................................................................... ~ ;-:·:· ......................... ~."":':':'.':':':":':':""."':":":':"':":":".":'::':"":".":"':.":"'.'":".":":':': .... "'::"':.":':':'::-:::.':"':':":"".":':"':".".".":":":":":':'.':":""."::":".':":"":'.".":":":":".":':":":":"':":.':':"':":"":':':':':":":':":"".".':".':''".::": ... ':.._..._..._ ...... ..._..._..._.._ .. _..._ ... ,._..._..._..._..._..._.._ ... .._'",":":":': ... ":":".":":":':":~ ~':":.":':"':';':.''::':":':":":":'::~ : L 2.3. H Classification of oral clefts . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. .. . .. .. .. ... L 13 L :: ................................................ ..!L ................................................................................................................................................................... JL ............ J: ',•, .. , ............ -~ .. ~.:~.:-~_:_ .. _: ........... JL~-~::.:~-~-~~~~~-~~-~::~.:~~-~~-~: .. ~~~~-~~--:~.:-~:~:.:_:~.:.:.:~:.:.:~_:_:_:_~_:_:_:~_:_:_::_:_:_:: .................. ...1[_~~ .... _ .. ..1
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2.7.3.
· -.7.5. L Velopharyngeal Insufficiency.............................................. If 3_ !';
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l[:::_~:j=:::::::::::::::::::::~:::t::l i 2.8. n Management of cleft lip and palate........................................ !: 35 !\
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········:=========:=================================c===============================================================================';=======================================================================================c=================r (. .. l: 2.8.2.3.1. Surgical aspects .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . !! 45 r' !t.,, .. ;;;;;;;;;;;;;;;;;;;;;,,,,,;,,,,,,,;,;;;;;;:~L::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::;;;;;;;;;;_,;;;;;;;;;;;;;;;;;;;;;,,;,,,,,,,,,,,,,,,;,,;,;;;;;;;;;;;;;;;,,,,,;;;;;:H::;;;;;;;;_,,,,,_j: F n 2.8.2.3.2. Dental aspects .. .. .. .. .. .. .. .. .. .. .. .. . .. .. . .. .. .. .. .. .. .. .. .. .. .. n 48 !
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~' 2.9.2.3. !: Passive expansion .. . . . . . . . . . . . .. . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . .. . . . . i: 54 1: .. !• !" ' E ................................................. L .................................................................................................................................................................... JL ............. J
li=~,=:~~~E:~:==~~=-==:==l~l' L 2.9.3. n Arch expanswn m cleft pattents .. .. .. .. . . . .... .. .. .. .. . .. . .. .. .. .. .. .... .. n 54 !: i ;,._;;;;;;:·.::;;;;';".;·.;;;;;;;;';".:;;;;;:~':'.;;;;;;;·) l.::':'.':'.::::':'.':'.':'.':'.':'.::':'.;~;;;;';".;;';".':'.':'.;;':":';".;;';".':'.::::::::::':'.':'.::':'.':'.':'.;;';".;;;;';".':'.':":;;":":'::';".;;;;;;':'.;;';".':'.~:::::::::':'.':'.::;;;;;·.::':'.':":':'.::;;::':'.::::::::':'.::::':'.':'! \,';"_;·.::':".::':"):.
E 2.9.3.1. l: Maxillary deficiency and growth impairment............................ l: 54 H n r n ~-~ : ·:::::::::::::::::::::::::::.~::::::::::::::::::.·:::~ :::::::::::::::::::::::.·:.·::::::::::::.·:::::::::::::.~:::::::.~:::::::::::::::::::.~:::::::::::::::::::.~::::::::::::::::.·:::::::::::::::::::::::::::::::::::::::::::::::::~ :::::::::::::::::~: n 2.9.3.2. l! Techniques and appliances in management of maxillary arch deficiency in n 58 E • i· 1 f . L '·
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E ................................................. L ............................................................................................................. ~ ...................................................... L ............ J: ~···················································!!···2:·9-j:-i:i ... R:ajjiCi .. iiiaxi1farv .. eX:iJansi"an:··:·::·:·::·:·:·::·:·:·:·::·:·:·::·:·:·::·:·::·:·:·:·::·:·::·:·:·::··················!:···s9········!; it••n••••••''''"'''''''''"'''''''''''"'"''"''"''"''"'"'jt ...... .,.,, .. ,,,.,,"'"''''"'''""'''"'"''''"••••'-"'"'"'"'''''''':''"""'"'•••"•••oo••••••••••••••••••••'•••••••••"••••••'•"••••••"••••••••••••••'•••"•••••••••"•••"''"'""Jt ..... .,,,.,.,.,..,,.,]j !: · · ll 2.9:3:2:2:r illcticaiioilsfarra!Jict J;laiifi&yexi:lruisiail::.:::.:::.:: lf 60 l: i ;,._,._,, ... _,,,,,~·.:·.:,;;;·:.;;;;;;;;:;;::·.:·;_,~) [. ..... _,._._,._;;·.~·.;;:~·.;;·.:~;;·.;;,·.:·:;:.:~;;:;;:;;;;;;,,-.... _,;;;;;;:·.;;;;;;;;;;;;,;;:;;;;~;;;;;;·:.,;;,;;;;;:·.;;:;;;;;·.;;;;·.;;;;;;:;;;;:;;;;·.::;;:;;:;;;;·.;;;;·:.;;;;;:·.;;·.-!l;-.;;·.::·.;·:_,,,J: F H 2.9.3.2.2.2. Amount of expansion achieved . .. .. .. . ... .. . .. ... . . .. .. i' 61 n ~. l : :: :: i':-:::::::::::::::::::::::::::::::::::::::::::::::::; '::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::::::::::::::::::::::::::.::::::::::::.::::::::::::::::::::::::;=::::::::::::::::!: H n 2.9.3.2.2.3. Types of appliances used in maxillary arch expansion d 61 1:
~ ;~':':':"':':-:':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':.':':':':':':':':':':~ ~':':':':"':':':-:':':":':':-:':':':':':':':':~':~':~~':~':~':~~':~':~':~~~~ ... ~~':~':~~':~':~':~':·':;~~':~~':~':~:;':~':~~':7.~-:~~':~~::~':~':~':~~.;':~':~;~':~.;~"':~':~':~~':~':~'::;':~':~':~~~':":':':':':':':':':':':':':':':':':":':':':':~ ~':':":':':':':':':':':':':':':':l :~ ! r 2.9.3.2.2.3.1. Removable appliances...................... H 61 n ~ t ................................................. j t ..................................................................................................................................................................... ~ t .......... ..... i .l ::··············· ······························!:······································································································································································,:········· ·!: ! 1: 2.9.3.2.2.3.2. Fixed appliances .. .. .. . . . . .. .. .. . . .. .. .. . ... H 61 l E ................................................. L .................................................................................................................................................................... .JL ............. J: = ·i=············ · .. .... · .. ··············· · · ··· ·· ·· :: 6 r L l' 2.9.3.2.3. Slow maxillary expansion .. . .. .. .. .. .. .. .. . . . .. .. .. .... . .. .. ... l' 3 . ::
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lt:,::::J.c::::~:~==~=:=::::,~:=::J~:J., F n 2.9.3.2.4. Dental and Skeletal effects of Rapid and slow expansion..... n 64 !
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IC::~c::::-=-::::::::::::=::~c:J.: :: 1: 2.9.3.2.6. Arch expansion treatment evaluation .. .. . .. .. .. .. .. .. .. .. .. ... ., 65 !:
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IC::~:::::Jt-:::::::::::=::::::::Jr:J1 H 3.4.2. !! Rapid Maxillary Expansion (RME) . . .. .. .. .. .. .. . .. .. .. .. .. .. . . . .. .. . .. .. !j 77 H
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3.7.2. Measurement distances .................................................... .
3. 7.3. Measurement methods ..................................................... .
L 3.7.3.2. l' Inter-tuberositieswidth(T-T) ............................................. ~~ 92 !=
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::::~~8~~~~:~~~~c::::::::l~EJi i 3.7.3.6. n Posteriorarchlength(C-T) ............................................... H 93 L
::·······::::::::::::::::::············:::::·::::::...!~ ........................................................................................................................ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::...1:·:::::::::·····:.1. \ 3.8. n Reproducibility of the measurements . .. . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . .. != 96 \:
ii.,,.,_, .................................................... ..JL .... , ........................ ;;;;;;;;;;;;;;;;;:;;;;;;;;;;;;;;;;;:::::::::::::;;;;;;;;;:::::;:;:::::::::::;;;;;;;;;;:;;;;;;;::;;;:::::::::::::::::::::::::::::::::·::::::----·JL ........ :::::J\ l 3.9. . F Analysis of Data ........................................................ ,._.. E 98 L
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t:·-~=:1~::~~~~~:::::::·::.:::::]~']! : ................... ~.=:~.~ ............... ] [ ........ ~:~:~:~ ... ~:::::.~: .. :~.~:.~.~--.: ... ~ ....... :.:.:.~: .... ~.:.:.:.~------~--:.: .. :_: .... :.:.:.~:.: ... ~------~ ........ J[_~-~--~ ... ...1! : ·~i."3. ····················· ·· ·l :···caiT.eiatiail.iJeiweeil ·aie.aiici"pa1a.ial"cilmiies:·railaWi.fi£irearffieili \viiil. . ... -· :r.. ·:, : n maxillary expansion appliances used . . . . . . . . . . . . . . .. . . . . . . .. . . . . . .. !: 116 !
:::: :~=:1!:.::::::~~=~:=:~=~=:::,::::::~:-::j[f!~j : 4.3.2. ti Correlation between age and palatal changes in URA appliance . . . . . . j: 122 i ~ ;:: :::::::::::::::::::::::::::::::::::::::::::::: ::~ ~ ::::::::::::::::::::::::::::::::::::::::::::::::::: ::!::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: J l::: :::::::::: ::J ~
Ji1ble of contents xii
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i L between URA, QH, & UFA expansions appliances . .. . ....... .......... L 146 n
lc:~~:~~;::t:::=::::::::::::::::_-:[-::::Jl:s:Ji (··s·.·f. H Lirnitationsofthestudy··.·:·.................................................. i~ 156 j: . ' ' ~:
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:::~_::::Jt::::;~~~-=::~:::::::::::1;~]1 !... 5.4.1. H Inter-canine width change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... N r. I60 ··I: : ! ~ ! : ! : ! ;·.·-~·.;·_,;;;~·.;~~~~--~s~~~rz-:~·-~~~~~~~~~~~~,~~~1 r--~~~~~~~~fut~;~~~li~~~~lt~~~~Tth:~~h~~~~~~~~~~~~:~~~~~~~~~~~~~~~~~-:·~-:~~:~~~~~~:~~-~~~:~-~~~~:~~:~~~~~~~~~~~~~~~~:~~~~;~;~~~~~~1 r;Ttr-~~~1-! · .................................................................................................... L .......................................................................................................................................................................................................................................................................................................................................... ! l .............................. .r L 5.4.3. li Palatal length change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1: 162 L !' .................................................. ll .............................................. -................................................................................................................... J l. ....... ____ j:
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5 .4.6. · ·.·.·.·.·.·.· j\ Posteriorfiihi a.rC:hfeiliih C:hm1ie :.:.~::::::::::.:··::.:.:::::::::::.:::.::: .·.·.· ll i65 .·.··1·
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li .. ccccccc.cc.•·••·•••••·••••·i I"'~':::~'"'·'·'"·''·''''·"·''"''·"'''''''·'''·''''''·''"'·'"""·"·''·'''·''''"·'''''':·'''''''"·'""'·''·'''''·'''"·'·J''"'·''""'·i i :\ Table.4.8 q Correlation between age and various palatal changes in URA \\ 123 \ n H appliance H l t ................... ·1... ............................................................................................................................................................ 11. ................. 1 ,r--T~bi~:-~nr------:r--·c:;~~1a:t:i0~--t;~;:;~~;:-~:g~--~d--~;i~~;--r;ai~t:a:r~:h~:g~;--i;;:-'Qil _________________________ tr--i2_9 _______ l
L~~--1:~~ ............ ~-~-·-~ .... --~~ .... -~=~ ............ ~- ...... - ... ___ l _ _j
List of tables XJV
t
1--,r~bi~:,~r1o"'"':·r"c~~~i;ti;;,b~t~~~~,~g~";a"~;i~,~~";~~tii"~h;g~~"h;''RMJI"'""""""""'i·r,T3's""'"·l
: 'l appliance ~~ i
., __ .. """"""'"""'"""""'l""'""""""""""""'''"""'""""'"""""""''"'"""""""'"''"'""""'"""'""""'""''"""""""""""'"""'"""""'"""""""·"''"""'""'"'·' rrable.4.11 :! Correlation between age and various palatal changes in UF A :l 141 i ~~ !! appliance lj [
ll""''"""''"''''"""''''"'j'""""'""'""""""'""""''''""''"""""""'"''"'""""""""'"'""''""''"'""""""'"""""""""''"'''"'""""""''"""'""""'"'·'"""'""''""'-1 :i Table.4.12 :\ Comparison of inter-canine width between URA, QH, & UFA ]! 148 i
-l-.:c:c·.:::c·.::::,:;,"""'"""JL""'""'""":"""""""""""""'""""""'""''"""'""""""'"'"""""''"""''"""""""""""""""""""""'--",,,,._,~_,,::-.... _,,,.,,_,·L,,~ ..... ,,, ...... ,,-,_~1 'i Table.4.13 H Comparison of inter-tuberosity width between URA, QH, & UFA :j 149 i
! !...; .. ,_,,,,-,,,,,-,,;,;:::::::::::::~ !,,,,,,,,,,,,,,,,,,,,,,,,::::::::::;:::::::::::::::::::::::;,-,,,,,,,,,,,,,,,,,,,,,"""''''',,,,,,,,-,,·:;::;:;::::::::::::::::::::::::::::::::::::::::;,-;,·::::::;,,,,.,,,,,,,,,,,.,,· L,,-,,,-,:;,,,,, .. ,_.1 ! Table.4.14 n Comparison of palatal length between URA, QH, & FA :1 150 \
\!'""''"'''"''''''''"""'""Jt"'""'""""'"'"""'"""''"""""''"""'""'"""""'""""'""''"'"'"""""'"""'''""""""'""'""''"'"'"'""'"'"""""""'""":;."'"""'"'"""';l :j Table.4.15 H Comparison of palatal depth between URA, QH, & UFA ~~ 151 :\
! !-:::::::::::::::::::::::::::::::::.H-:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:·::::::::::::::::::::::::::::::::::::::::::::::::::!!:::::::::::::::::.1 !\ Table.4.16 [\ Comparison of inter-canine arch length between URA, QH, & !! 152 :1
!I II UFA !I lj
!r''T~bi~:4tt''':i""c~~~~~~"~t;~~~~ri~t~i~h~"~~h,1~~~~h,b~~~~~~t!RX:"C21t''&'"'""""ii"'15'3''"'"·!
11 ...................... 11..~~ .............................................................................................................................................................. 11.. ............... [1 : r--T'~bl~-~~fif'''] f'"co~ari~o·;;:·c;·{post~ri;~-kft-;~h-l~iigthb~t·;~e'ii'ifu:"Qi{''&"~"""""1ris4''""11
iJ.;:::::::::::::::::::.::::::: .. ::::.t::: ...... :.:::::::::::::::::: ... :::::::::::::::.:.::::::::::::::::::::::::: ... ~.::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .. ::.t:::::::::::.:::.::.l
List offi,gures XV
List of figures
. .... rr:~:::::c :. :::::·:' __ ::::~:::::::::.::· :::~:·:J1~:~::! ·~'Fig. 2.1. I OralCleftbreaksdown(Young, 1998) :112 ll :! .. ,:,::,::.::.::::::::.::.::::::::::; :"'""''''''''""'''''"'"''''''"""'''"""'"''"'"''"""''''''""''""'"""'''''''"""'"'''"'''''"'"'"'""'""'''''''""'"""'''"""""'""'~ ;::;;;::::::::;;::::: fFig.2.2. .i Schuchrdt and Pfeifer's symbolic classification !\ 15 
XYJ
IC~:::~:::::::::~:::2:::::::::::~:~JC:] TF"ig.3.7. ;j All acrylic bonded rapid expansion appliance. :l 80 :j
rFig31.==r~~~~ill~~~p~~;,~=~==~~~'~'~=irso'~'l \( .. Fi~· ... t9·: ............... ~[ .... ·6~~~(fi~fu ... ~~-~-li~~-~·:·_. ............. , ............................................................................................................................................................................................................. J .... s.£ ............... :1
: L"'"''"''"'"'"''"''"~ !,:""""'"''"""'"'"''"'''"""'''""'""''"""''"""'"""'"""''""'""'""'"""''"'"'"""""'''""'"'"'"'"'"''"'"''''"'''""""'"~ "'"'""""""'Ji \! Fig.3.10. fl Quad Helix appliance cemented in patient mouth j~ 82 J!
: ~-............ _,,._,, ......... _,,,~·'''"''~ L.,;;,,·.;;·::.:::·.-..... ,,,,,,._,._,;;,,·_,,,,,,,,,._;;,,,,~ ... , ...... ;;,,,,~_,,~.,~.,-.,-.,~ ... ::·.,;;,,,,,,,._,~.,,,,,,".·"··''~·''''.·'""··,··''''''''""""""''"''""'"'''"'"''''\t,~,,"""''''; I !l Fig.3.11. ;! Components of Quad Helix :[ 83 !1
, l., ..... "'""'.""'"'""'"'-: !"""'''"""'"'""""'.""""""""""""""""""''"""""''"'"""""""""""""""""'~'""~"'""""""""'"'"'"""'""""""""~ L"'"""""')l )! Fig.3.12. [! Initial activation of QH before insertion. \~ 83 \!
: !:,,,,,,,,,,,,""""""""': L"'"""'"""""""'"""'""""'"""""""'''"'"'"""'"""""""""''""'""'"'"""""""'""""'''"""""'"'""'""'"""""'"J [,""'""'"'""!I :( Fig.3.13. :\ Upper Removable Appliance with Jack Screw \\ 86 \\
~~. ............................ Jt ........................................................................................................................................................................... Jt ................. ll
l~;~j~~;~==:=:=:JBI n Fig.3.16. d Anatomical and constructed points digitized on the dentulous:~ 91 H 'i ll dental casts ~ H
1 ................. :l .......................... : ...................................................................................................................................... 1 ............. ..!1 ·!-·ri-g·:3·~-T7·----; r··x;;~;:~~~~c;;'d·--·~;~~1~--;;:~~r·p~~;:~----ciigi1~~ci-;;:···;:h~---~-ci~;:1~1~--~;-; !'9·1----·-·-:1
L .. ==JI.::~::=======c=~LJ ! Fig. 3.18. H Measured distances of inter-canines width, inter-tuberosities width H 94 !!
II [j and palatal length. ;! II
--: i ... Fig:-~J::"C ........ r·n·is.trib~tio·~--o'f'~i~i!;--~~~-~--i;~-;T~~~~:;ii~·;·K:cccn·c: ...................................... [ l"'i6i ..... 1!
if Ftg 4£ .fc;~;;~~;;Jdi~;~;b';;ti~;; ~fd~ft~ ;;;~~ ;;;~~~~~~~;~ ;;; KCCCDC if 102 ·i =.L .... """""""""""'H"""'"'"""'"'"'"""'"""""'"""""'"""'""""""""'""'""'"'""""""""""""""'"""""""'""'"""""'""'""""'"'"""lL,_"""'"""";J ....
List ojf!gures xvii
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'Fi!;"4.t2"',fca~~~~c~~;;'g~~==·~4='\j F;gA.t3'h~~ti~~~~~'Hwidfu"~d~ii~~=~~ =Fu0i ........................... ·! ................... •.................. .. . . .... · ............ ·. ·.·.• ................................... ?......... . ................... ........ .... . ~ ~ .. :! ·"Fig-:4-:i4······= r··c:c;;:~1~ii0:;-bei-;;;·~;-i~1f1e'llgth:·a;;d-~g~--i'll·URA. .. g~o~p:···························-···: (··izs····--\~
Fig.4.17
--Fig:·4:is·······lr-c:;n:eiati;il·bet;~e;:·I>r::&·a;;d··~i~ .. ~-lfRA-·g~o~'P-:···········································Ti27···· .. :l
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xviii
rr;g::z:;t::::::::::~~~::::::::::~:~:::::"JC:JI friQ.4.24 ! Correlation between PRAL and age in QH group. H 132 H
l.:.cc·.::::·.:c:c:c:c::c:::cc:'L::::::::::::::::::::::::::::::::::::::::::::::::·.:::·.::::·:.:':::·.:·.::·:.::':::·.::::::·.:::::::::·:.::::'··'·:.~.,,, .• ,, .• ,, .• ,,, .• ,,,,, .. ,,, .• ,,,, .• , .• ,,,,,,,,,,,,,,,,"''''''''''''';l,,cc:'::::::cc::'::l
i".Fi2:.4.25 l Correlation between PLAL and age in QH group. [! 133 [\
i F;i4i6 J~~:i~~~~~~=ee~ ~:~~;d,~~~~eh;~~~~~p - ~~~=6 J! ·r·'Fi~~'4:·;x7--··--·:l··-c·~-n:~i~ti0;·b~-t;~~~-f~f-·;i~ith--~ii'd··;g~~~-R.ME-g~~~p~------·--··--·---------·:r--i36··----;!
~-F;;42~J[~=~,i=~~~~:~~~~~J~~~::~~~-===::t~~~J lt:;:~j~~~;~;~;~~~~;~~=l~JI lr~~~~~JI~~~~~~~~~~==J~~I [ Fig.4.33 H Correlation between C-C width and age in UFA group. \\ 142 :1
:~~~~~;:Ji~;~~~;~;~;~~;;~~=l;jl il·F~g~~6 ]1-=~:~i~~:n~~=:~~:n~~~ag~~~~A~=~~- ~ : : ]- -_ :-- .[i4~]1 . r··:p·ig~·4:·3·7--·--··i i"ca·n:~i~tio;·b~-t;~~~-c·~·c .. ;~];--i~~:g-ih .. ~ct--;g~-~-u:F"A·-g;~~P~------~ .... -·--:rT44 ...... 11
i ~ ·:--·fiii:4~·4o:----·--r .. c~illrill:rs·~~-c;Ic~c·;i'd'th'.ctiff~~~~;~~-b~t;~~;·uR:A":·Q!C&.u:FA::-·--·1f--T4·s·------:l
~~F~g~~~ ~~ ~o:~:~:~.~~-~~~dth:~:~~~-~\=~~~~~~·~liF~ -t~~9- ~ = ["':Pig~-4:4·2·:··--·: ~-·-cc;·~-p-ru:isa;·c;I·i~if(i'iff~reii.~~-bet;-e-;ii·m"A:·-Qif:"&-u:PA::··---·--····-·--· .. : r--Tso ....... :\
1""'"'""'""""'"""'[L,""'"'"""'"'"""""'"'""""'"'""'"'""'"'""""""""""""'"""'"""'"""""""'""'""'""""'""'"""'"'"'"""""'""'"LL""'"""'"jj
List o_f(igures XJX
L;~t of abbreviations •• }~ .J XX
List of abbreviations
·········-·································································-···································-·················································· ······················ ... .
r:::-~~:~;::::--~r-----------------------------------------------------------------~i:~--~-;-:~:~:~;:::~~------------------------------------------------------------------:1 . i ~ ~ !:.' 1 ................................. ~ ~. ' .................................................................................................................................................. -........................ -................. ' • j···Kciij5c ................. r·keianta~··co~iJhi~ct-·c1eii .. Lii)··a;d··rai~te .. ail2C<Sanioi~~-i~i·D'eio~t-ies ............... :l
1"""""'"""'"'"=""1:i~=""""=""'"""'"'==cc=c"cc=c=c=ccc=ccccccc=cc=cJ : C- C l Inter-canine's width. H
' : : : : ~
J~~~;~~a; lj fu;~,~~~~'; ~~h~~~ili: • ,, , · , · - jj
!1:~~~-=j~~;~;;~;::::::~~ll ! CASP i Clefts of Anterior Secondary Palate. i
li·c~ -- ~~=[=~:tb:~d~cle:~~~,e===--==~ --~-~-=~-~-] l1
~-cPP ~-~--I~~e~,~~~ ~,=:~~,~~-= -· ·=·: ~~- :~ =- :~~--Ji
ii~~~=--~-~:Jl~:~~~=::~:::.::_:==~~=~~-::=====~:==-:.~] :\ I- H l Palatal length. H
·_L"'""""""'""""""""'""""l""'"'""'""""'"'"'"""'""'"'""'""'""""""'""'""""'"""""""'"""'"'""""""'"""""'"'"'"""""'"'"'"""""":"'"'""""""'"_jl
· '"· h'1 1"·'Vl·.·,tz'/•r" Ll st OJ a._ r. ~- ,_,, ". t., x:<l
·rt"p~~~t""""'"'""""'!fi;'~i~;rp;~t:""""'"""""""'"""""""'"'""""""'""'""""'"'""""""'""""""""""'"'"""""""'"'"""'""'""""""""'f! 'I :· ., :! .:.c .. c·oc.::::;;:;:;:::::::::::.: L::.::;;;;;;;;;:;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;:;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;·;;;;;;;;;;;;;;;;;;:;;;:;;;;;;;;;;;;:;;;:;:;;;;;;;;;;;;·;;;;;;;;;;;;;;;;;;;;;;c;,;:::;;.:;;;,;;;;::J nee I Intra-class Correlation Coefficient. :I ! l !
t:-~ ~:::: r~:~::e.:~::::::~=-=0
:-:_::_::~_:_-_-:-:_- ~~: TpLAL d Posterior left Arch Length. d
:!""""""""; ............. :c;c;c;;c;J!," .. ·""""''"'"'''''''"'"""""'""""""""'"""'''''""''"""'"'""""''''''""'"'''''"'""""''"'"""'''"""""""'''""""""""""""'"""'""\1 [ PRAL 1 Posterior Right Arch Length U
:: __ ,.,_.;;;;;·_,,,,;;-_,,,._,""''""'"''"":L""'""""""""'""""".·"'"""''.·""""'"'""""""""'".·"""""'""'"""'"""""""'"""'-·'""""'".·'""'""'"'""""""""'"'""'""'""""!1 f PRS ! Pierre Robin Sequence \
l .... ;c .• c::::::c;;;,;;;;;;;;;;;;;;;;;;;;;.! L;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;:;;;;;;;;;;;;;;;;;;;;:;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;:;;;;;;·;;;;;;;;;;;;;;;;;;;;;:;:;;;;;;;;;;;;;;;;;;;;;;:;;c;;;;;:;;;;;;;,.,;;;:;; ••• ::;,l : PSOP l Pre-Surgical Orthopedic Plate U
:l,,,,,,""''''''''"''''"'"''''""'"";L"'"''"""""""''':""''''''"''"'""'''""''""""'"'"""""""'"""'"""""""'"'"'""''"""""""''"''"""'""''"''"""'"""'''"""''"''''''''-1 i QH ! Quad Helix :l
·I ..................... )! ........................................................................................................................................................................................ :! r~ Jt~·~id~=~~~=s;an - -- -11
ij-sc~=-~~=J~~=~O=e=~=:~~======~~J~JI r·srss ............................ rs·t:;1i~1i~~fp·;~k~g~·ic;·r-1h~-·sc;~i;rs~i~;;~~·s·---------......................................................................... :i
il~~~- il~;:~~:~~:h~ --~::: :_ :- -=J- JJJ ~JI :[uR:c ---][tl~~~:~~~~~C<;='=~:~i:k-=~=::J-==~--JJI
ll::=··~::~·:·····:::···::·····:·:·::::[~::~t·~=::·::~::·i::g·t:::··:·····:··::··::······:::········:·:·:··::::::::··········::··········:···:·:····: .. ··:·:·:···:·:··:··::·:······:····· .. :·:·:··:·::·ll --~ .................................................................................................................................................................................................................................................................. ~~~~~ .. ~~~ .................... " ....... , .. " .. ~"~'"""""~' ........................................ -................................. ~ .............. ~~ ......... ~ ..................................................................... , ......................... ~ ........... .
~'. ,~ Abstract XX!J
Abstract
Cleft palate in children and adolescent: A study of arch expansion
The use of palatal expansion appliances has been claimed to produce a light, continuous
force, which is capable of expanding the maxilla and correcting dental arch width of cleft
palate patients who have deficient maxilla. The aim of this study is to evaluate the palatal
changes and the effects of expansion practice with different arch expansion appliances in
patients with cleft palate with or without cleft lip (CP/L) that were treated at the Kelantan
Combined Cleft lip & palate and Craniofacial Deformity Clinic (KCCCDC) at different
stages of the long-term management and also to compare these changes among upper
removable appliance with mid-line screw (URA), quadhelix (QH) and upper fixed
appliance (UF A).
This is a retrospective record review study involving forty-nine oral clefts patients who
underwent palatal expansion at KCCCDC, comprising of 12 patients had used Pre-Surgical
Orthopedic Plate (PSOP), 11 patients used URA, 11 patients used QH, 3 patients used
Rapid Maxillary Expansion (RME), and 12 patients used (UFA). All these had orthodontic
study models taken prior to expansion and at the end of the retention period following
expansion. These pre and post treatment study models were analyzed for changes in inter-
tuberosities width, inter-canines width, palatal length, palatal depth, inter-canine arch
length, posterior arch length; using fowler-sliding caliper measuring instrument (Fowler
Ultra- Gold, USA). By analyzing pre and posttreatment dental casts using SPSS statistical
analysis version 11.0, differences in palatal changes in all expansion groups were e·valuated
Abstract XXU!
for statistical significance of the effect of expansion appliances using Two-related sample
analysis and Wilcoxon signed ranks test. The correlation between age and palatal changes
also tested for all expansion groups using Spearman rank correlation. And comparing the
palatal changes and the effect of expansion produced between URA, QH, & UFA were
evaluated for statistical significance using Kruskal Wallis test .
Results of this study suggest that all expansion appliances are clinically capable of
expanding the maxilla. There is a significant increase in maxillary inter-tuberosity width
following treatment with maxillary expansion appliances.
Age does not have influence in explaining the total amount of expansion in all the
appliances except that in RME group, the inter-tuberosity width increase as age increase.
And quite opposite; palatal depth in UFA group decreases as the age increase.
There is no significant difference in palatal change between URA, QH and UF A expansion
appliances, except in inter-tuberosity width; there is significant difference between the
groups and more increase in the URA group tlien QH and UFA.
In conclusion, this study shows that PSOP, URA, QH, RME and UFA are suitable for arch
expansion in all ages of children and adolescent, except that RME produce more lateral
expansion in adolescent and UFA produce more shallow palate in children.
Abstrak XXIV
Abstrak
Sumbing bibir dan lelangit dikalangan kanak-kanak dan remaja: Kajian tentang
pengembangan rahang maksila.
Penggunaan alat untuk mengembangkan lelangit telah dikatakan berkesan dalam
menghasilkan daya ringan yang berpanjangan untuk mengembangkan rahang maksila di
kalangan pesakit-pesakit sumbing bibir dan lelangt yang mempunyai saiz maksila yang
kecil. Tujuan ka:jian ini ialah untuk mengkaji kesan dari pengembangan saiz maksila
dengan menggunakan beberapa jenis alat yang berbeza ke atas pesakit pesakit sumbing
bibir dan lelangit yang dirawat di Klinik bersepadu sumbing bibir dan lelangit di Negeri
Kelari.tan. Ianya juga bertujuan untuk membuat perbandingan perubahan yang dihasilkan
dari sudut kepelbagaian alat-alat dan umur pesakit.
Kajian retrospektif ini melibatkan 49 pesakit sumbing bibir dan lelangit yang telah
menjalani rawatan pengembangan rahang di Klinik Pergigian Kota Bharu. Dua belas orang
pesakit telah menggunakan 'Pre-surgical orthopedic plate' (PSOP), 11 orang pesakit telah
menggunalian aphar boleh tanggal 'Upper Removable Appliance' (URA), 11 orang pesakit
telah rnenggunalian 'Quad Helix', 3 orang pesakit telah menggunalian 'Rapid Maxillary
Expansion' (RME) dan 12 orang pesakit telah menggunalian 'Upper Fixed Appliance' ·
(UFA). Model kajian ortodontik sebelum dan selepas rawatan dikaji dengan mengukur
panjang lelangit, kedalarnan lelangit, lebar antara gigi taring dan lebar antara tuberositi
deugan menggunakan fowler sliding caliper untuk rneugetahui perbezaan di an tara waktu
Abstrak XXV
sebelum dan selepas rawatan bagi setiap jenis alat yang digunakan. Kaitan di antara umur
pesakit dan perbezaan hasil pengembangan yang dihasilkan oleh setiap alat juga dikaji.
Keputusan kajian ini menunjukkan bahawa semua alat pengembangan rahang yang
digunakan berupaya untuk menghasilkan pengembangan rahang maksila yang diperlukan.
Penambahan yang ketara dilihat pada lebar antara tuberositi.
Umur pesakit didapati tiada berkaitan dengan jumlah penambahan pengembangan kecuali
dalam kumpulan yang menggunakan RME yang mana lebar antara tuberositinya bertambah
bila umur bertambah. Disebaliknya, kedalaman rahang untuk kumpulan UF A berkurang
bila umur bertambah.
Tiada perbezaan pada rahang didapati dian tara penggunaan alat URA, QH dan UF A,
kecuali pada Iebar antara tuberositi yang telah didapati berbeza antara kumpulan.
Penambahan yang ketara didapati pada kumpulan URA berbanding dengan QH dan UF A.
Sebagai kesimpulan, kajian ini menunjukkan bahawa alat-alat PSOP, URA, QH, RME dan
UF A adalah sesuai digunakan untuk pengembangan rahang maksila untuk pesakit pada
semua peringkat umur. Walaubagaimanapun alat RME didapati mengahasilkan
pengembangan lateral yang lebih pada pesakit remaja dan alat UF A didapati menghasilkan
lelangit yang cetek pada pesakit kanak-kanak.
Introduction 1
,-,,.
Chapter One
Introduction
Introduction
1.1. Background
Chapter One
Introduction
2
Cleft lip or/and palate (CLIP) in children has drawn the attention of many researchers to
study this most frequent congenital oro-facial deformity, occurring approximately in 1:700
life births (Barden et al., 1989). Cleft lip and palate is usually not a terminal illness unless it
is associated with some syndrome having other systemic complications that could include
cardiac, central nervous system. renal, and skeletal defects. These are associated with 10-
20% of cleft palate cases which often require complicated management (Sphrintzen et al.,
1985).
The face is formed by fusion of a number of embryonic processes, which form around the
primitive oral cavity (stomoqeum). The palate is formed by the fusion of the maxillary
shelves with each other (maxillary process) and with the frontonasal process. Failure of
fusion of these processes results in clefts of the palate. Cleft lip is caused by inadequate
proliferation and fusion of the maxillary process and medial nasal process. Cleft lip could
occur either unilaterally or bilaterally with varying degree,. of severity. The condition is
more prevalent in males and if it occurs unilaterally, it is usually on the left side (Young,
1998). From about the third month of pregnancy; it is usually possible to diagnose a cleft
using high tech ultrasonic scanner.
The development of cleft lip was found to be of genetic mechanism different from· that of
cleft palate. The lip develops between the 5th and 7th week of intrauterine life while the
Introduction
palate at about 9th week. The mechanism altering the former could interfere with the later,
but the palate closure might also be affected independent of lip formation (Rani, 1997).
Oral clefts are believed to occur due to genetic and environmental factors. Recent studies
have shown· that the etiology of cleft lip and palate is an interaction of multi-factorial
etiology; hence it cannot be attributed solely to either genetic or environmental factors. It is
argued that unless the patient is genetically susceptible; the environmental factors may not
by them selves cause clefts (Habel et al., 1996).
A cleft lip or/and palate patient (CLIP) is afflicted by a number of problems, which could
broadly be classified under dental deformities, aesthetics, speech and hearing, psychosocial,
and systemic. The complexity Gf the problem requires that a team cooperate to ensure
comprehensive care of the patient. This led to the concept of mu!~idisciplinary cleft lip and
palate team which include pediatricians, pedodontists, orthodontists, oral and maxillofacial
surgeons, general dentists, plastic surgeons, prosthodontists, psychiatrists, ENT specialists,
genetic counselors, speech therapists, social workers, and cleft supporting organizations.
Cleft lip and palate patients developed defective dental occlusion and midface concavity
due to collapse and insufficient growth of the maxilla. The orthodontist's has played a great
role in the correction of the dentoalveolar and maxillomandibular relationship by applying
a combination or a solitary use of orthodontic and orthopedic forces. Orthodontists usually
have to start this part of treatment early in the neonatal period and follow up as the child's
growth eventually into the adulthood. By the end of the treatment, the middle and lower
1 n troducti on 4
third of the face have been assisted to develop both functionally and aesthetically. Even in
severe oral cleft near normalcy can achieve.
Cleft palate cases often have narrow upper dental arch. As such attempts are made to
correct the segmental displacement and expand the maxilla by means of rapid .or slow
palatal expansion, which will often open and identify an occult defect in the alveolar bone.
For this reason, it is carried out before bone grafting procedures.
In mixed and permanent dentition, maxillary arch expansion appliances are widely
incorporated to allow maxillary expansion in order to achieve proper dental alignment and
correct maxillomandibular relationship. The most common rapid maxillary appliances used
for expansion are Derichsweiler type, Hass type, IsaacSon type, and Hyrax type. These
appliances produce a skeletal as well as dentoalveolar expansion (Bhalajhi, 1998). While
the most common slow maxillary appliances used for expansion are Jack screws, Coffm
springs, and Quad helix. These appliances bring about a slow dentoalveolar expansion.
When the slow maxillary appliances are used during the deciduous and early mixed
dentition stage, skeletal mid-palatal splittlifg can be achieved. An apE.arently complex yet
relatively simple procedure in orthodontics is maxillary arch expansion; its versatility is
unique despite many controversies surrounding it. Desirable results could be achieved
when used in appropriate situation, adequate time, cooperative patient and skilled clinician.
The issue of arch expansion as part of management of cleft lip and palate patients will be
the focus of this study.
Introduction 5
1.2. Statement of the problem
The palatal expansion appliances is claimed to produce a light, continuous force which is
capable of expanding the maxilla and correcting dental arch width of cleft palate patients
who have deficient maxilla. The skeletal and dental effects of the palatal expansion
appliances on the maxilla have not been reported in the practice of Kelantan Combined
Cleft lip & palate and Craniofacial Deformity Clinic (KCCCDC). Hence, we carried this
research to find an evidence based practice of which expander to be used or which
expander was more efficient and also to evaluate the benefit of each expander.
1.3. Hypothesis
1. There are changes in maxillary inter-canine width, maxillary inter-tuberosity width,
palatal length, palatal depth, inter-canine arch length and posterior arch length following
treatment with maxillary expansion appliances in cleft palate with or without cleft lip
patients.(CPIL) at the KCCCDC.
2. There is correlation between age and. palatal changes m following treatment with
maxillary expansion appliances in CP/L patients.
3. There is difference in palatal changes between different expansions appliances used.
Introduction 6
. I
. ~-• 1.4. Objectives .. ~;: c
1.4.1. General objectives
The purpose of this study is to investigate the epidemiology of oral clefts at the KCCCDC
and the practice of arch expansion using various arch expansion appliances for management
CPIL patients at KCCCDC.
1.4.2. Specific objective
To study and describe the palatal changes and the effects of expansion produced by various
expansion appliances used in management of CPIL patients at KCCCDC.
To correlate between age and palatal changes following treatment with maxillary expansion
appliances.
To compare the palatal changes and the effect of expansion produced between URA, QH
and UF A expansions appliances.
1.5. Significance of the study
The results of this study will provide information on the skeletal and dental effects
produced by various palatal expander appliances used in KCCCDC. This information will
aid clinicians in selecting the appropriate appliance for maxillary expansion in CPIL
patients.
Introduction 7
1.6. Assumptions
It is assumed that all diagnostic materials utilized such as alginate impressions, and study
models were taken and prepared in a consistent manner according to professional standards
but there are still effects of errors such as impression distortion, dental cast trimming and
polishing which may take place for all groups and not possible to be measured. It is also
assumed that all rapid expansion appliances whether banded or bonded produce comparable
amounts of lateral expansion to each other and that any differences are insignificant, this is
also applicable to upper fixed appliances. Also, since multiple operators are involved in the
placement of the expansion appliances, it is assumed that the appliances are inserted and
activated in a consistent manner.
1.7. Delimitations
All patients used in this study are cleft palate patients with or without cleft lip, and require
palatal expansion as part of their orthodontic treatment and range from infant to adolescent
with no previou~ history of orthodontic expansion with pre and post dental casts available.
All patients are free from any medical condition that could affect their normal growth and
development.
8
Chapter Two
Literature Review
Literature revie>v
2.1. Introduction
Chapter Two
Literature Review
9
Clefts of the lip and palate usually affect the child's dental development. Teeth in the area
of the cleft may be missing, and other teeth may be improperly positioned. Because
problems with the dentition affect not only the child's appearance, but also his or her
speech development and chewing ability, attention to the child's dental development is
important. Vigilant prevention practices and regular visits to the pediatric dentist will help
ensure the best dental outcome for the child. Most children with such conditions will
require orthodontic treatment at various ages, even as early as four years. The orthodontist,
in conjunction with the rest of the cleft palate team, will devise treatment plans for the best
dental and jaws growth.
2.1.1. Definition
Cleft lip and palate are congenital abnormalities (present at birth) that affect the upper lip
and the hard and soft palate of the mouth Features range from a small notch in the lip to a
complete fissure (groove) extending into the roof of the mouth and nose. These features
may occur separately or together (Reviewed by Molmenti, 2002)
Literature revie>v
2.1.2. History
Hippocrates (400 BC) and Galen (150 AD) mentioned cleft lip, but not cleft palate in their
writings. For centuries, perforations of the palate were considered to be secondary to
syphilis, anti cleft palate was not recognized as a congenital disorder until 1556, by Fanco.
The frrst successful closure of a soft palate defect was reported in 1764 by LeMonnier, a
French dentist. Dieffenbach performed the first closure of the hard palate in 1834. In the
1930's, Kilner and Wardill independently developed the "pushback" procedure (Stewart,
1991).
2.2. Epidemiology of oral clefts
Clefts involving lip and/or palate are the most common congenital deformities that occur at
the time of birth. The incidence of the oral clefts has been the subject of many studies.
These studies have shown that there are variations in the incidence among different races.
The incidence of cleft deformities reported in many comers of the worlds varies from 0. 79
to 3.62 per 1000 (Vanderas, 1987). Mean value of the studies conducted in the world
among different races was 1:700 live births (Barden et al., 1989).
The incidence of cleft deformities in Malaysia, reported by National Oral Health Survey of
School Children, Ministry of Health (1997) is 1: 941. While incidence in Kelantan state in
Malaysia shown that the ratio of cleft was 1:700 live births (Halim & Singh, 2000).
Literature review H'
The mongoloid (Asian descent) has the highest incidence while the Negroid (Africans) has
the least incidence; (1.00 per 1000 live births in Caucasians, 0.4 per 1000 live births in
Negroid, and 2.1 per 1000 live births in mongoloids (Berryman, 1999).
Most of tlie epidemiological studies categorize oral clefts into cleft lip, cleft lip and palate,
and cleft palate only. As shown in Fig. 2.1 combined cleft lip and palate (CLP) represents
approximately 50% of incidents, cleft palate alone (CP) 30%, and cleft lip alone (CL) 20%
(Young, 1998).
Clefts of the lip and combined lip and palate are twice as common in males. Isolated cleft
palates are twice as common in females. This may be explained by the fact that the
secondary palate closes one-week later in females (Young, 1998). The left side was
affected twice as commonly as the right side with majority of cases being unilaterally.
The incidence of oral clefts is generally increasing. Studies in Denmark (Jensen et al.,
1988) have shown a rise from 1:667 to 1:529 between 1942 and 1981. A report from The
European registration of congenital anomalies and twins showed an increase of 1.45/1000
to 1.57/1000 from 1980 to 1988 (EUROCAT, 1995). The increase in incidence is thought
to be multifactorial. However there have been reports associated with older age maternal
and/or paternal of oral clefts offspring (Slavkin, 1992).
Literature review
CL 20%
CLP 50%
30%
Fig. 2.1. Oral Cleft breaks down (Young, 1998)
locLPI I•CP ' !oCL I
,, !..:.
g:
~··. Literature review ~· ;;_·
2.3. Classification of oral clefts
Clefts of the lip and palate can vary considerably from one individual to the next. Some
have both cleft lip and palate; some have only a cleft of the lip; others have only a cleft of
the palate. Clefts may be unilateral or bilateral. Oral clefts are generally grouped on the
basis of clefting of the lip or palate or both. Various authors have put many classifications
for clefts.
2.3.1. Davis and Ritchie classification (1922)
It is based on location of the cleft in relation to the alveolar process (Table. 2.1.).
Table. 2.1. Davis and Ritchie classification.
Group 1 Group 2 Group 3 Pre alveolar clefts Post alveolar clefts Complete clefts, involving (Clefts of the lip) (Clefts ofhard and soft the palate, alveolar ridge,
palate extend up to the and lip. alveolar ridge).
Unilateral Unilateral Unilateral
Bilateral Bilateral Bilateral
Median Median Median
Uterawre n:vie>v 14
2.3.2. Veau's clssification (1931)
Veau has classified cleft lip and palate into four groups (Table 2.2).
Table. 2.2. Veau's classification.
Group Description
1 Involving soft palate only.
2 Involving hard and soft palate, extending up to incisive foramen.
3 Complete unilateral clefts of soft palate, hard palate, lip and alveolar ridge.
4 Complete bilateral clefts affecting soft palate, hard palate, lip, alveolar ridge.
2.3.3. Classification by Fogh Amlrsen (1942)
Fogh Andersen classified clefts into three groups: clefts of the lip, clefts of the palate and
clefts of lip and palate (Table.2.3).
Table. 2. 3. Fogh Andersen classification.
Group 1 Group 2 Group3 Clefts of the lip Clefts of lip and palate. Clefts of palate, extending
u_p to the incisive foramen. Unilateral or Median Unilateral Unilateral or median
Bilateral Bilateral Bilateral
Literat'.lre review
2.3.4. LAHSHAL classification
1n 1987 Okrien had classified cleft lip and palate by paraphrase LAHSHAL, which is the
anatomic areas, affected by clefts.
L: Lip. A: Alveolus. H: Hard palate. ~: Soft palate. H: Hard palate. A: Alveolus. L: Lip. -Areas involve<i in the clefts are denoted by specifically indicated alphabets standing for it
for example: L - - S - - - I stands for clefts of right lip and soft palate
2.3.5. Schuchrdt and Pfeifer's symbolic classification (1966)
This classification makes use of a chart made up of a vertical block of three pairs of
rectangles with an inverted triangle at the bottom (Fig. 2.2). These are representing clefts of
lip, alveolus, hard palate, and soft palate respectively. Areas affected by clefts are shaded in
the chart, the advantage of this classification is the simplicity but the disadvantage is the
difficulty in writing or communication
Ri2:ht Left
Lip
Alveolus
Hard plate
Fig. 2.2. Schuchrdt and Pfeifer's symbolic classification
Literature revie-.,v l6
2J.6. Kernahan's stripped "Y" classification by Kernahan and Stark (1958)
Tllis is another symbolic classification; a stripped "Y" having numbered blocks, which
represent a specific area of the oral cavity (Fig. 2.3).
-Blocks 1 and 4 represent the lip.
-Blocks 2 and 5 represent the alveolus.
-Blocks 3 and 6 represent hard palate anterior to the incisive foramen.
-Blocks 7 and 8 represent hard palate posterior to incisive foramen.
-Blocks 9 represent the soft palate.
The boxes, which will be shaded, are the places where clefts have occurred ..
Fig .2.3. Kernahan's stripped "Y" classification
Literature revie1-v 17
2.3.7. Classification given by International confederation for plastic and
reconstructive surgery in 1968
Intemational confederation for plastic and reconstructive surgery classified oral clefts into --three groups: Clefts of anterior primary palate, Clefts of posterior palate and Clefts of
anterior and posterior palate (Table. 2.4).
Table. 2.4. International confederation for plastic and reconstructive surgery classification.
Types Area affected sides
Lip: -Right side. -Left side.
Group 1 -Both. Clefts of anterior primary palate. Alveolus: -Right side.
-Left side. -Both.
Lip: -Right side. -Left side. -Both.
Group 2 Alveolus: -Right side. Clefts of anterior and -Left side. posterior palate. -Both.
Hard palate: -Right side. -Left side. -Both.
Hard palate: -Right side. Group 3 -Left side. Clefts of posterior -Both. palate.
Soft palate:
-
Literature revinv 18
2.3.8. IOWA classification
IOWA has classified Cleft Lip and Palate into five groups as shown in Fig 2.4.
It should be noted here that all the classifications apply equally to unilateral and bilateral
clefting.
Group 1: Clefts ofthe lip only
.. · ·'
Group 3: Clefts of the lip, alveolus and palate. (Complete cleft lip and palate)
Group V
Group 2: Clefts of the palate only (secondary palatal clefts)
Group 4: Clefts of lip and alveolus. (Primary cleft palate and lip).
This classification is defined as miscellaneous and includes clefts, which do not fit into any of the above categories.
Fig. 2.4. IOWA classification of Cleft Lip and Palate.
Literature revieH' i9
2.4. Embryology background
To manage a case of cleft lip or/and palate it is necessary to grasp the normal development
of lip and palate. Normal embryological development of the oral cavity has been described
by Sperber (1976).
The face is formed by the fusion of a number of embryonic processes that form around the
primitive oral cavity or stomodeum By the fourth week of intra ute~ine life, five branchial
arches develop at the site of the future neck, which play a vital role in the human body
development. The first branchial arch, called the mandibular arch, is resp.onsible for the
development of nasomaxillary complex.
The embryonic precwsor of the face appears as a large frontal prominence that forms the
upper boundary of the stomodeum (primitive oral cavity). The primary mouth is divided
from the foregut by the buccopharyngeal membrane. On either side of the stomodeum is the
developing mandibular arch, the dorsal end of which gives off a bud called (maxillary
process), with the formation of the nasal pits. The frontonasal process gets divided into
medial nasal process and two lateral nasal processes (Fig. 2.5).
Literature reviev;
2.4.1. Development of the primary palate
In the 5th and 6th week of intra uterine life, the maxillary process undergoes rapid growth.
By the ?th and 7th week, the maxillary process merges with the medial and lateral nasal
processes to form the intermaxillary segment (Fig. 2.6). This intermaxillary segment has a
labial component, which form the philtrum of the upper lip, and a triangular palatal
component, which include the four maxillary incisors and extends backward to the incisive
foramen. The upper lip and the pre-maxilla is thus formed. Inadequate proliferation of the
maxillary and medial nasal processes would cause cleft lip.
2.4.2. Development of the secondary palate
Secondary palate that makes up the rest of the palate forms both hard and soft palate; i.e.
about 90% of the palate.
By the 6th week of intra uterine life the medial surface of the maxillary process gives off
palatal shelves, which grow medially and downward, lateral to the tongue. Elevation of the
palatal shelves begins in week 7th, and more.marked in the anterior region, adjacent to the
primary palate. Elevation of shelves accompanies forward and lateral growth of the
mandible. The forces prompting this elevation have been labeled "intrinsic shelf force".
The tongue plays a vital role in the initial prevention of palatal shelves union, thus the
shelves grows vertically down.
Lftemture revie>v 21
By the 8th week of intra uterine life the tongue descends and palatal shei.-...-es become more
horizontal and approxlln.ate. When the palatal shelves touch; the epithelium has thinned and
degenerated, allowing mesenchyme from both sides to join in the rniJ line. Fusion 1s
completed b);' the lOth week. Final closure by fusion occurs later in female than males.
Failure of fusion of the maxillary shelves with each other and with the fr0ntonasal process
results in cleft palate.
The soft palate is formed from secondary growth centers by successive merging rather than
fusion. The mandibular process gives rise to the lower lip and jaw.
Defective fusion or incomplete fusion between various processes leads to different types of
clefts. It should be noted that during normal development, primary palate has no cleft
unlike the secondary palate development.
Many heW.th workers have put forward theolOiies and investigated the possible reasons for
failure of the fusion process.
Literature review
Frontal Prominence
~ Stomodeum ---- . r··
. \' -r _-
_____ Olfactory Pit
Fig. 2.5. Face of 5 week old embryo.
(Adapted from CLAPAI. Available at http://www.cleft.ie)
.... ··.:~~~~ . · Fused --~ ,.
· ... .,_. :-:-:--------- Primarr;..r -~ '"::! -- Palate "' ':. ---. -'r~:J:~.~,---- Palatal Shelf
Fig. 2.6. Secondary Palate in 7 week old embryo.
(Adapted from-EtAPAI. Available at http://www.cleft.ie)
21
Literature revie1<v
2.5. Etiology of cleft palate
2.5.1. Introduction.
When researchers look at oral clefts, they begin to wonder whether the cleft represents a
deficiency of tissue, displacement of what tissue are present and I or presence of division of
tissue, resulting in an opening. Several studies have been undertaken on cleft youngsters.
Cast studies and radiographic studies. It was ascertained that deficiency and /or
displacement could be present (Coup & Subtelny, 1960).
Cleft lip is considered to arise from inadequate mesodermal proliferation of the maxillary
process and medial nasal process. This causes a weakening and eventual breakdown of the
epithelial bridge between these structures, thereby producing cleft. Another theory says that
the epithelium covering the mesenchyme doesn't undergo apoptosis thus producing a
physical barrier to fusion.
The theories put forward to explain Cleft palate include failure of adequate mandibular
growth, which may inhibit elevation of the .palatal shelves. Another is that the tongue
become wedged and does not descend clear of the palatal shelves, thus physically
obstructing them It is generally considered that the most likely causes are either hypoplasia
of the shelves or delay in timing of shelf elevation.
~,;
t
re review 24
lip and palate either complete or incomplete is more common than either one in
lation. Cleft palate only is more common in females than males. It is proposed that this
is caused by the later elevation of the palatal shelves in females, thus leaving open longer
time period for a potential environmental insult. However, males over all are more likely to
exhibit oral clefting.
;, The development of cleft lip was found to be of different genetic mechanism from that of
cleft palate; since the lip develop between the 5th - 8th week of intra uterine life and the
palate at 9th - 1Oth week, the mechanism altering the former could interfere with the later;
but the palate closure might also be affected independent of the lip.
2.5.2. Factors contributed in Oral clefts
Oral clefts are believed to occur due to genetic and environmental factors.
2.5.2.1. Genetic factor
Three types of genetic risk groups are present. They are the syndromic group, which is
niost easily identified by examination, the familial group, and the isolated defect group,
which is identified by history.