Ortho management of clp /certified fixed orthodontic courses by Indian dental academy

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Orthodontic management of cleft lip
and palate.
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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CONTENTS
Introduction
Prevalence & incidence.
Embryology
Etiology
Classification
Management:-
1] Neonatal
2] Mixed dentition
3] Permanent dentition
Recent trends in management
Conclusion

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INTRODUCTION
 It can be defined as “a furrow in the palatal vault” (clp). / A
b r e a c h i n t h e c o n t i n u i t y o f p a l a t e .
 Cleft lip or harelip is most common congenital deformities
s e e n a t t h e t i m e o f b i r t h .
 No group of patients is more profoundly handicapped in a
personal sense than those who are facially disfigured.
Whatever the cause, the high visibility of facial deformity
creates special difficulties related to social identity and
interaction. Initially reaction towards this person are
universally negative even the health professionals initially
h a v e n e g a t i v e r e s p o n s e a s w e l l .

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 To tell simply face is the part of body
with which a person faces the world. So
for the health professionals and us.

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 The management of cleft lip and palate presents a great challenge
not only because it involves face that is the most exposed organ of
the human body but also because of associated various anatomical
and functional problems, which continue to show up with age.
WHY?

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 Facial esthetics
 Feeding difficulties( poor oral seal and nasal reflux)
 Speech problems poor pharyngeal seal and oronasal communication
 Chronic middle ear problems( poor Eustachian tube function)
 Management team:-
Paediatrician
Orthodontist
Surgeon
Otolaryngologist
Audiologist
Speech pathologist
Social worker
Psychiatrist
Geneticist
Prosthodontist
Paediatric dentist
Radiologist
Neurologist
Neurosurgeonwww.indiandentalacademy.com

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AIMS OF TREATMENT.
 Regardless of the type of oral cleft, an inter-disciplinary team of
specialists should provide the care
 There should be a team leader or co-coordinator that facilitates the
function and efficiency of the team and ensures co- ordinate care to the
patient.
 Treatment plan at any stage should be discussed and implemented based
on team recommendations.

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 The principal role of the inter- disciplinary team should be to
provide integrated case management to assure quality and
continuity of patient care and long term follow ups.
 Parents should be provided with written materials on feeding and
all aspects of care and management of the child with craniofacial
deformity such an inter-disciplinary co-ordinate team approach
with defined treatment protocols have shown better treatment
outcome and has reduced the overall burden of care of the child and
parents.

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HISTORY
 Harelip has been reported as back as 1000AD.
 Parea, a French surgeon (in 1561) first used the Obturator.
 Le monnier French dentist [1764] –surgical repair of cleft palate.
 In 1826, DIFFENBACH suggested separation of soft tissue of the
palate from the underlying bone, also recommended use of lateral
relaxation incisions in the soft tissue of the hard palate region to
close clefts of velum & hard palate.
 Fergusson in 1844 & von lagenback in 1862 –laid emphasis on
creating mucoperiosteal flap.
 During First World War Harold gilles and POMFRET KILNER in
London, victor view in Paris also developed skill to repair cleft.

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 “we must strive
for maximum
harmony and
balance as near
to normal as
conditions will
allow”- Tweed.
“To strive, to seek to find,
and not to yield” –
Tennyson
“ The essential goal of cleft care is
restoration of the patient to a
„normal‟ life unhindered by
handicap or disability” – Shaw et
al.

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PREVALENCE & INCIDENCE
 The incidence of cleft lip and/or palate has been reported in
early studies to be as low as 1 in 3000 in Negroids to as high as
4.9/1000 live births in Afghans.
 Studies done in India among such communities reveal an
incidence of 1 in every 600-1000 births.
 The incidence of CLP is highest among the Mongoloids. Cleft
lip is common among males while cleft palate is more common
among females. Unilateral clefts account for 80% of the
incidence while bilateral clefts account for the remaining 20%.
Among the unilateral clefts involving the left side are seen in
70% of the cases.

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EMBRYOLOGY

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EMBRYOLOGY
CLEFT MAY OCCUR DUE TO:
1. FAILURE OF THE PROCESSES TO COME IN CONTACT
2. FAILURE OF EPITHELIAL FUSION AFTER CONTACT
3. FAILURE OF MESENCHYMAL CONSOLIDATION
4. RUPTURE OF THE PRIMARY PALATE SUBSEQUENT TO
FUSION
5. REDUCED FACIAL MESENCHYME
6. INCRESED FACIAL WIDTH
7. DISTORTION OR MALPOSITION OF THE PROCESSES.

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 Formation of the Palate
The palate develops in 2 parts . viz;
1.The primary palate
2.The secondary palate
 Palate is formed by the contribution of the
maxillary processes and frontonasal process. The
medial nasal process forms the small triangular,
median part of the palate called the primary palate.

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PROBABLE REASONS
 Complete tongue obstruction over a time specific period
(Poswillo and Roy and Humphrey).
 Alteration in the shelf force:-
 Due to alterations in mucopolysaccharide synthesis ( Ferguson)
 Administration of certain drugs like phenobarbitone and vit A.
(Smiley and R.Nanda)
 Alteration in the cranial flexure ( Harris)
 Disturbance in the epithelial fusion ( Smiley)
 Alteration in the vascularity of the region ( Cooper)

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CLASSIFICATION
 Davis and Ritchie classifications (1922).
This is a morphological classification based on the location of
the cleft relative to the alveolar process.
Group I – Pre alveolar cleft:-They are clefts involving only the lip and are sub
classified as:
Unilateral
Bilateral
Median
Group II - Post alveolar clefts:- This group comprises of different degrees of hard
and soft palate clefts that extend up to the alveolar ridge
Group III - Alveolar clefts:- They are complete clefts involving palate, alveolar ridge
and the lip. They can be subdivided in to ;
Unilateral
Bilateral
Medianwww.indiandentalacademy.com

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Veau‟s Classification (1931).
 Group –1: They are clefts involving the soft palate only
 Group –2: They are clefts of the hard and soft palate extending up to the
Incisive- foramen.
 Group-3: They are complete unilateral clefts involving the soft palate, the
palate, lip and the alveolar ridge.
 Group -4: They are complete bilateral clefts affecting the soft palate, the
hard palate, lip and alveolar ridge.

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

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Schuchard and Pfeifer‟s symbolic
classification:
 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.
 The inverted triangle represents the soft palate while the rectangles
represent the lip, alveolus and hard palate as we go down.
 The advantage of this classification is its simplicity while the
disadvantages include difficulty in writing, typing and communication.

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Kernahan‟s Stripped „Y‟ classification:
 This classification uses a stripped „Y‟ having numbered blocks. Each block
represents a specific area of the oral cavity. Put forward by kernahan and
stark.
 Block 1 and 4 Lip
 Block 2 and 5 Alveolus
 Block 3 and 6 Hard palate anterior to the incisive foramen
 Block 7 and 8 Hard palate posterior to incisive foramen
 Block 9 Soft palate.

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Lahshal classification:
 Presented by Okriens in 1987
 LAHSHAL is a paraphrase of the anatomic affected by the cleft.
L lip
A alveolus
H hard palate
S soft palate
H hard palate
A alveolus
L lipwww.indiandentalacademy.com

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Iowa system classification:
 Group –I These are defined as clefts of the lip only.
 Group-II These are defined as clefts of the palate only i.e. secondary
palatal clefts.
 Group-III These are defined as clefts of the lip , alveolus and palate
i.e. complete cleft lip and palate.
 Group-IV These are defined as clefts of the lip and alveolus i.e.
primary cleft palate and lip
 Group –V This classification is defined as miscellaneous and includes
clefts which do not fit into any of the above categories.

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INDIAN CLASSIFICATION
 Proposed by Dr. C. Balakrishnan in1975
 Cleft lip only (GP.I)
 Cleft lip and alveolus (gp. 1-a)
 Cleft palate only (gp.2)
 Cleft lip and palate (gp.3)

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ETIOLOGY.
 Hereditary: - Acc. To fogh and Anderson less than 40%, cases are genetic
in origin. Acc. To Drilien 1 in 3 children with clefts had some relatives
with similar congenital defects.
 20% of isolated cleft are genetic in origin.
Acc. to Bhatia main modes of transmission is either by single mutant gene
producing a large effect or by no. of genes [polygenic inheritance] each
producing a small effect together?
 Two types of cleft [recent research]
1] Hereditary-probably polygenic
Acc.to this each and every individual caries some genetic liability for clefting
but since that is less than threshold level it doesn‟t not occur when the
liability reaches the threshold level cleft occurs
2] Monogenic or syndromic- associated with various congenital anomalies-they
are high-risk type.
Frazer realizing The impact of the problem wrote “ No single
factor causes all the clinically observed cases of cleft lip and
palate. Even in the individual cases the etiology is for most
part of the result of multiple factors ”.

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 Multifactorial threshold hypothesis: - It suggests that many
contributory risk genes interact with one another and the environment
and they collectively determine that threshold of abnormality is breached
resulting in defect. It clearly explains the etiology of isolated cleft lip or
palate.
 Congenital: - Congenital anomaly is which is already present at birth. It
can be hereditary or genetically determined or induced by environment or
teratogens.
 Hereditary anomalies might or may not present at birth and may appear
in due course of time.
 Infections: - Like rubella, influenza, toxoplasmosis etc.to the mother
during pregnancy may cause the defect.

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 Drugs: -
 Aminoptrein [an antifolic drug] is an abortifacient. A foetus
survived of such abortion drugs can become malformed.
 All cytotoxic anticancer drugs such as alkylating agents
can cause the defect.
 Cortisone is suspect teratogens.
 Alcoholic mother may give birth to a child with foetal
alcoholic syndrome, which may be associated with cleft
palate.
 Thalidomide also has a similar effect.

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 Radiation: -
Such as x rays, gamma rays etc. these are ionizing
radiations and are capable of producing either somatic
or genetic effects.
Somatic effects are seen in the exposed individual and
the genetic effects are expressed in the individual
descedents like cleft lip, palate, microcephaly and
neonatal death. These are due to irradiation of the
fetus during the pregnancy
 Diets:
Deficiency of riboflavin folic acid and hypervitaminosis
an act as environmental teratogens.

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GENETIC INFLUENCE
 Monogenic or single gene disorder:
Autosomal dominant inheritance:-
 Clefting-ankyloblepharon filiform
 Adentum syndrome
 Ectrodactyly
 Clefting syndrome
 Vander woude syndrome(asociation of lower lip pits or clp)

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Autosomal recessive syndrome:-
Appert ayndrome
Bixer syndrome
Bowen-armstrong syndrome
Juberg-harward syndrome
Robert syndrome

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Environmental:-
Fetal hydantoin syndrome
Fetal trimethadione syndrome
Clefting ectropion syndrome
Unknown genesis:-
Pilloto syndrome
Yong syndrome
II. Polygeneic or Multifactorial syndrome:-
Here many genes with relatively small effect act in concert
withpoorly defined environmental triggering
mechanisms leading to expression of the abnormalitiy

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CHROMOSOMAL ABBERATIONS
 Cleft lip and palate occurs as a feature of
several syndromes resulting from chromosomal
aberrations. Notable among them being trisomy
D and E syndrome.

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PREDISPOSING FACTORS
 Increased maternal age:
Women who conceive late have an increased risk of having an off
spring with some form of clefting. The cause remains unknown.
 Racial
Some races are more susceptible to clefts than the, Mongoloids
show the greatest percentage of incidence.
 Blood supply:-
Any factor that reduces the blodd supply to the nasomaxillary complex
during the embryological dev. predisposes to cleft.

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Problems associated with clp
 They can be broadly classification as: -
Dental
Esthetic
Speech and hearing
Psychologic

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Dental problems
 The presence of the cleft is associated with division, displacement and
deficiency of oral tissue.
Congenitally mussing teeth (most commonly the upper laterals )
Presence of natal or neonatal teeth
Presence of supernumerary teeth
Ectopically erupting teeth
Anomalies of tooth morphology
Enamel hyperplasia
Microdontia

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 Fused teeth
 Aberrations in crown shape
 Macrodontia
 Mobile and early shedding teeth due to poor
periodontal support.
 Posterior and anterior crossbite
 Protruding premaxilla
 Deep bite
 Spacing /crowding.
 Difficulty in mastication and swallowing.

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Esthetic problems
 The clefts involving the lip can result in facial
disfigurement varying from mild to severe. The oro-
facial structures may be malformed and congenitally
missing.
 Deformities of nose can also occur. Thus esthetics is
greatly affected.

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Hearing and speech: -
 The first two years of the child are very crucial from the point of
speech development and it is the same time when the 1ry surgeries
are done. Physiological integrity of the structure involved in speech
and adequate neuro – sensory – motor functions are essential for
development of the normal speech.
 Receptive language problem may arise in children with cleft plate
because of the fluid in the middle ear.
 Hearing loss may also occur is these patients due to ossicular
malformations and /or improper aeration of the Eustachian tube.

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 Clinically an operated cleft palate child usually presents with short palate
or decreased mobility of soft palate due to Scarring and oronasal fistula,
 Thus causing velo- pharyngeal insufficiency, hypernasality, nasal escape
of air, mis-articulations and poor intelligibility of speech. High nasality
could be due to oronasal fistula or inadequate velo-pharyngeal seal.
 Acrylic or chrome cobalt obturators, which are still very
popular in India, were given to prevent nasal escape of air.
The modified obturator called speech bulb appliance is useful
in cases where palatal lift or soft palate closure is needed to
improve velo-pharyngeal seal.

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PSYHCOLOGICAL PROBLEMS
 They are under lot of psychological stress due to their abnormal
facial appearance they have to put up with staring, curiosity, pity
etc.
 They also face problems in obtaining jobs and making friends.
 Studies have shown that these patients are badly in academics.
 This is usually as a result of hearing impairment, speech problems
and frequent absence from school.

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MANAGEMENT
 The cleft child has a lot of dentoalveolar and maxillo mandibular
problems, which are quite different from the routine orthodontic
patient
 The maxilla is more often seen to be retruded, and this effect is
primarily seen as a post surgical problem. Further more, there is a
progressive decline of the maxillary prominence in both UCLP and
BCLP patients as the child grows through adolescence
 There are postural adaptations to the dentoalveolar and basilar
discrepencies and a lower jaw position in over closure is a common
feature.

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In addition to the sagittal discrepancies getting accumulated by
the surgery, transverse relations are also severely compromised.
Two common types of maxillary transverse collapse
patterns mostly related to the palatal repair surgery are seen.
1)The unilateral collapse frequently seen in UCLP presents with
the lesser segment caught behind under the greater segment.
2)The bilateral collapse, typically seen in BCLP has equal
transverse constriction of the maxillae.
The arch deficiency and dentoalveolar mutilation is further
complicated by congenitally missing lateral incisors,
supernumerary and fissural teeth adjoining the cleft site,
ectopically erupting maxillary canines and a general hypoplasia of
the maxillary incisors.
Anchorage planning and management of tooth movement is thus
complicated.

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NEONATAL( Birth to 18 months)
 Early contact and counseling of the parents
should be done to reassure them and prevent
inaccurate information being provided by
other professionals who are not involved in
cleft treatment.
 The optimum time for the first contact by the
professionals with the family and evaluation
of the child soon after the birth .

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 Feeding a child with cleft palate is a very
challenging job. Making the parents
understand about the normal physiology and
altered anatomy can guide towards a
successful feeding.
 The normal process of feeding involves two
basic tasks, suckling and swallowing. In
patients with cleft lip and alveolus , breast
feeding is not a problem and can be achieved
with slight adjustmentswww.indiandentalacademy.com

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NEONATAL
 Placing the finger over the cleft assist in creating negative pressure
inside the oral cavity and thus making swallowing effective.
 However , in cleft palate patients breast feeding is usually not
successful. The patient cannot build up pressure inside the oral
cavity because the air is drawn through the nose.
 For this variety of nipples and feeding devices are available. Two of
them are inexpensive and readily available.
 Enlarged (1/4 inch) cross cut regular nipple and the Mead
Johnson cleft palate nursing bottle.

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 During feeding following guide lines should be
followed:
1. The infant is held upright in the lap at about 45o to 60o
angle to decrease nasal regurgitation.
2. Direct the nipple to intact part of the palate.
3. Burping the infant after ½ of feed is necessary because
excessive air is swallowed.
4. Adjust the flow of the milk dropping in the mouth to the
ability of the child to swallow and limit the feeding to
maximum ½ an hr.
5. Observe the child for choking , cyanosis or abdominal
distention. During feeding , widened eyes or choking
indicate too rapid flow of liquid and needs to be adjustedwww.indiandentalacademy.com

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FEEDING APPLIANCE
 The feeding appliance assists in feeding by sealing the oro-
nasal fistula and thus enables the child to suck by negative
intra- oral pressure.
 Feeding appliance should be considered to assist with feeding
only if other methods of feeding are not successful in the first
one or two weeks.
 Infants up - to 6 months of age are require 115 to 120 cal
/kg. of body weight and they are fed every 2-4 hrs.
 If oral feeding is not useful, naso–gastric feeding many be
used temporarily.

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 The orthodontist has been involved in some centers in providing
feeding plates and the use of plates to remove the influence of
tongue on cleft width.
 The speech and language pathologist recommends such plates
during the 1st year of development until the palate closure is done.
The appliance provides the cleft child with an intra-oral
environment as normal as possible during the early critical and
active phase of articulation development.
 Burstone pioneered and introduced neonatal maxillary orthopedics
in the 1950 s

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RATIONALE FOR TREATMENT
 Reposition the severely displaced maxillary
segments.
 Reduction in width of wide clefts.
 Improved symmetry of nose and cleft maxilla.

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Passive maxillary obturator
 It is an intra oral prosthetic device that fills the palatal cleft.
 Provides a false roofing against which chid can suckle.
 Reduces feeding difficulties viz; insufficient sucking,excessive air
intake,choking.
 Provides maxillary cross arch stability preventing the arch from collapse.

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DECIDUOUS DENTITION(18months to 5
years)
 No orthodontic intervention is done in the early deciduous dentition.
 Treatment at this stage can produce only ephemeral results and such
results would be poor temporary compensations for deeper skeletal
abnormalities which become increasingly manifest later.
 Patient are seen regularly at six month intervals for review, keeping the
motivation of the family, generating early rapport with the child,
constant monitoring of the caries and oral hygiene status, and diet
consulting.
 In certain cases, equilibration of deciduous canine is done to avoid
encouraging lateral shifts of the mandible.
 Towards the end of the deciduous dentition, the 5 year old child
becomes a candidate for early dentofacial orthopedic intervention by face
mask therapy if indicated.

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MIXED DENTITION(sixth year to
11nth year.)
 The aim of the treatment :-
1. Symmetry within the upper dentition and related to the facial
midline.
2. Normally functioning occlusion with.
3. Correct position of upper incisor teeth and
4. Favorable transverse and sagittal posterior occlusion

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Orthodontic evaluation at 6 yrs of age: -
1 Soft tissue facial appearance: full face and profile
2 Types of the face: Prognathic, orthognathic or retrognathic.
3 Basal jaw configuration: sagittal vertical or transverse
4 Dental occlusion: Frontal (overjet, overbite) or lateral (Angle
classification)
5 Dental space conditions.
6 Disturbances of dental development and occlusion.
7 Orofacial dysfunction
8 Vestibular, periodontal and mucosal abnormalities.

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 Retroclination or cross bite is corrected. The correction of lateral
incisor cross bite, which is usually present in cleft, is postponed until
the permanent dentition.
 Before correcting the rotation and cross bite of teeth one should
confirm the adequate bone support of the tooth on a radiograph. (IOPA
OR OCCLUSAL)
 If insufficient bone support is available, de rotation may
result in root exposure in the cleft and devitalization.
 If adequate bone support ,de rotation and cross bite
correction are usually performed before the patient is
considered for alveolar bone grating.
 But if the adequate bone support is not there then these
procedures are performed after the alveolar bonr grafting.
Pre surgical orthodontics

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 If the cross bite or edge to edge bite causes functional shift of the
mandible, then attempts should be done to relieve it by selective
grinding or orthodontic treatment .
 Maxillary arch expansion is needed and this procedure if required
should be performed before secondary alveolar bone grafting. The
correction of maxillary arch collapse helps to prevent
1. Lateral shifts of the mandible
2. Improve sagittal mandibular position by cricumventing the
adaptive mandibular prognathism
3. Provide area for the tongue
4. Promote normal maxillo mandibular developement and prepare
the arch for secondary bone grafting as a part of prebone graft
orthodontics.

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 The Quad Helix appliance in .036 Blue Elgiloy provides controlled force
application to correct severe segmental dislocation. The typical expansion
period lasts for 3 months with 2 activations at 6weeks intervals. The rate of
the transverse expansion is 3mm/month. The optimal force is 200gm. on
each side.
 Advantages are: -
1.Easy to construct at the chair- side using ordinary laboratory
pliers and minimal inventory
2.It offers the unique advantages of providing four sites of activation.
3 It exerts 3-diamensional control on the molars
4 It provides controlled force
5 Relatively less patient co-operation
6 Provides powerful anchorage preservation mechanismwww.indiandentalacademy.com

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PROTRACTION FACE MASK
 Used between 5 and 8 years
 AIMS OF THE TREATMENT
1. Correct midface skeletal deficiency
2. Eliminate anterior and / or posterior crossbite
3. Provide optimal space for spontaneous incisor eruption
4. Improve the soft tissue profile.
 The introduction of the facial mask for early protraction by heavy
forces to the maxillary complex in CLP patients was reported by
Delaire and Colleagues.www.indiandentalacademy.com

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 The Quad –Helix appliance is used as anchorage for the facial mask.
 No other fixation of the mask is needed than the two intra oral elastic
bands from the hooks in the canine regoins to a bar on the mask.
 The force used for facial protraction is about 350gm. on each side (Total
700gm.) .The facemask is used mainly at night for 10- 12 hrs. for 6 to
12months.
 RAPID SAGGITAL CORRECTION IS ACHIEVED:-
1.Maxillary base protraction
2.Canting of the maxillary plane upward
3.Remodelling changes in the anterior maxilla
4.Backward rotation of the mandible

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RETENTION
 Fixed palatal arch
 A Function corrector III (FR-3 )- active
retainer only when unfavourable
growth pattern is seen.

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PERMANENT DENTITION
 Aims of the Treatment in the Permanent
Dentition: -
1. Improving the dentofacial relationship.
2. Balancing the relationship between dental and skeletal components
3. Establishing favourable maxillo mandibular balance and proportion
4. Establishing normal incisal and buccal occlusion.
5. Establishing harmonious dental arches in both jaws.
6. Correcting axial inclination of teeth.
7. Correcting midlines.
8. Avoiding prosthetic replacement of teeth when possible.
9. Establishing functional occlusion in centric relation.
10. Establishing optimal lip contour and contact

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Special precautions during orthodontic
tooth movement.
 Avoid overzealous tooth movement into the
cleft sites
 Mechanics should be gently placed.
 Orthodontic treatment is a prolonged
procedure in CLP patients than the routine
patients.
 The orthodontist should abstain from
proclining the upper anteriors into the tight
scarred upper lip.

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 The decision of orthodontics versus orthognathic
surgery should be judiciously made.
 Long term retention after treatment should be
advocated.
 Follow up should be advised on a 6 month basis till at
least 21 years of age and the original and post treatment
records should be reviewed at every such visit.
 Strict monitoring excellent performance of the child on
personal oral hygiene and caries control efforts.

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Arndt Nickel Titanium Expander
 In mixed dentition. put forward by
Micheal O. Abdoney in 1995.
 It is temperature activated xpander
which creates tranverse xpansion,
uprights and roataes the maxillay
molars and allows a smooth transition
to fixed retention with no patient
compliance required.

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CONCLUSION
 The course of the individual CLP patients rehabilitation
depends not only on the quality of the individual components
of the treatment, but also on organization and co-ordination
to ensure the right timing, sequence and balance during the
often protracted course of treatment. For this reason, a well
adapted CLP protocol, with a collectively operating
interdisciplinary approach to provide integrated cleft care
seems to be absolutely imperative .

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 Our responsibilities go beyond
orthodontics.
 We can always go further, we can
always work harder, we can always
find newer possibilities; but for that, we
must keep going and doing.

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Pierre Robin Syndrome
 Has a very high recurrence risk.
 The anomalad includes cleft palate,
micrognathia, glossoptosis.
 Primary defect lies in arrested dev. &
ensuing hypoplasia of the mandible”
bird facies”

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Kallmann Syndrome:
 Clefts plus Endocrine Pituatary
Problems, often Median Facial Clefts,
Sex Organ Problems

100www.indiandentalacademy.com

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