role of orthodontist in Cleft lip and palate management

THE ORTHODONTIST'S ROLE IN A
CLEFT PALATE-CRANIOFACIAL TEAM1112
PRESENTED BY-
Dr.Sita Niure
PG resident

CONTENTS
• Introduction
• Epidemiology
• Embryology
• Etiology
• Classification of clefts
• Management of cleft lip and palate:
- Infant orthopedics-nasoalveolar molding
- Treatment in mixed dentition
- Treatment in permanent dentition
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• Surgical orthodontics
• Distraction osteogenesis
• Velo pharyngeal Incompetence
• Conclusion
• References
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INTRODUCTION
• Orofacial clefts are among the second most common congenital
anomalies of all kinds. Such anomalies results in several
handicaps such as impaired suckling, defective speech, deafness,
malocclusion, gross facial deformity and severe psychological
problems.
• Cleft of lip and the palate is one such condition, that occurs at
such a strategic place in the orofacial region and at such a crucial
time that it becomes a complex congenital deformity requiring a
multidisciplinary team approach in its management.
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Members in the team approach to patients with craniofacial anomalies 5112

EPIDEMIOLOGY
• Cleft lip and palate is a global problem.(0.28 to 3.74/1000 live births globally)
• Least incidence in negroids(0.021 to 0.41 per 1,000 live births) and maximum
in afghans(4.9%)
• Orientals(esp Japanese)-1.14 to 2.13 per 1000 live births
• In India 1.7 cases are seen in every 1000 individuals.
• In India - CL+CP-1.25/1000
• CP 0.46/1000
• The incidence of oral clefts is seen more in males than in females.
• Cleft lip alone- more in males than female
• Cleft palate- more in females than males
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ETIOLOGY
GENETIC
TERATOGEN
ASSOCIATED WITH
OTHER MEDICAL
CONDITIONS
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Genetics
• Genetic disorders are classified into the following
groups:
1. Chromosomal disorders
2. Monogenic/Single gene disorders
3. Polygenic/Multifactorial disorders
4. Mitochondrial disorders
• The expression of a multifactorial disorder is based on a
threshold model(Melnick 1972), whereby those with more
of the disease causing genes and environmental factors are
likely to exceed the theshold and express the disorder.
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SYNDROMES WITH CLEFT LIPAND PALATE
• Van der woude Syndrome
• Apert syndrome
• Treacher Collins Syndrome Autosomal Dominant
• Cleidocranial Syndrome
• Ectodermal Dysplasia
• Stickler’s Syndrome
• Oro-facial digital syndrome
• Pierre Robin syndrome
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• Roberts Syndrome
• Christian Syndrome Autosomal Recessive
• Meckel Syndrome
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ENVIRONMENTAL FACTORS: TERATOGENS
• The impact of a teratogen is determined by the genotype
of the mother and the child and the timing and the dose of
the drug.
• Usually occurs due to various influences during 1st
trimester.
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• Medications implicated to cleft formation:
1. Diazepam and other benzodiazepines
2. Steroids(0.07% to 1.9%)
3. Amphetamine
4. Diabetes- a medical condition
5. Anti seizure drugs.eg: diphenyl hydantion and
trimethadione.also causes growth retardation,
craniofacial dysmorphism, mental deficiency including
oral cleft.
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Environmental teratogens:
- Ethyl Alcohol- causes FAS (fetal alcohol Syndrome).
- Cigarette smoking- 30% increase in cleft lip and palate and
20% increase in cleft palate in smoking during pregnancy.
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• Nicotine acts synergistically with TGF.
• An important initial step in development of the
primary palate is a forward movement of the lateral
nasal process which positions it so that contact with
the median nasal process is possible.
• The hypoxia associated with smoking probably
interferes with this movement.
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• Hypervitaminosis A: acute maternal exposure to 13-cis
retinoic acid during first trimester causes cell death in the
pharygeal arch leading to facial clefting. Vit A analogue
used as an anti-acne drug-Also proved by animal
experiments.
• Folic Acid: Deficiency of folic acid affects virtually every
organ system. It affect the neural tube- neural crest cell
migration and differentiation.
• Anaemia and anorexia
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INFECTION DURING PREGNANCY:
• Rubella infection during the first 3 months associated
with clefting.
PARENTAL AGE:
• Shaw etal presented evidence that women above the
age of 35 had a doubled risk of having a child with
CLCP. above 39- tripled risk.
• Consanguineous marriages- increased risk of CLCP
in child
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Elevation of palate
• Descent of tongue influenced by the growth of mandible and meckel’s cartilage
• Myoneural activity of tongue
• Mouth opening reflexes 19112

• Transition from vertical to horizontal is completed within hours
Mechanisms proposed for this rapid elevation of palatal shelves:
1. Biochemical transformations in the physical consistency
of the connective tissue matrix of the shelves
2.Variations in vasculature and blood flow to these structures
3.Sudden increase in their tissue turgor
4.Rapid differential mitotic growth
5.An intrinsic shelf-elevating force-chiefly generated by
accumulation and hydration of hyaluronic acid
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Prenatal Diagnosis of Cleft Lip/Palate
• Ultrasonography is a noninvasive diagnostic tool now
widely used as a routine component of prenatal care.
• Ultrasonography serves to confirm fetal viability,
determine gestational age, establish the number of fetuses
and their growth, check placental location, and examine
fetal anatomy to detect any malformations.
• Three-dimensional ultrasound imaging is a new
technology that presents views of the fetal face with
greater clarity than the conventional two-dimensional
imaging
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Advantages of prenatal diagnosis
1. Psychological preparation of parents and caregivers.
2. Patient education
3. Preparation for neonatal care and feeding
4. Opportunity to investigate for other structural or
chromosomal abnormalities
5. Possibility for fetal surgery
6. Customized surgical treatment plan by the plastic
surgeon.
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Disadvantage
• An emotional disturbance and high maternal anxiety
after prenatal diagnosis.
• Families choosing to terminate the pregnancy even in
the absence of other malformations.
1. perceived burden,
2. expectation of recurrence,
3. religious and cultural beliefs,
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DAVIS AND RITCHIE CLASSIFICATION (1922):
Group I-Pre alveolar clefts Lip clefts only
with subdivisions for unilateral, median,
bilateral.
Group II-Post alveolar clefts degrees of
involvement of soft and hard palate to be
specified till the alveolar ridge, submucous
clefts included.
Group III-Alveolar clefts is complete clefts
of palate, alveolus ridge and lip with
subdivisions for unilateral, median, bilateral.
They classified congenital clefts based on the position of the
cleft in relation to the alveolar process.
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A) Cleft lip
Class I-unilateral and bilateral cleft of the
Vermillion border not extending into the
lip.
Class II-unilateral and bilateral notching
of Vermillion with cleft extending into the
lip, but not including the floor of the nose.
Class III- unilateral and bilateral cleft of
vermilions border, involving lip and
extending into the floor of the nose.
Class IV-any bilateral cleft of the lip
whether incomplete or complete.
VEAUS CLASSIFICATION - 1931
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B) Cleft palate
• Class I- cleft involving
only soft palate
• Class II- cleft involving
hard and soft palate
extending no further than
the incisive foramen
• Class III- complete
unilateral or bilateral
cleft extending from
uvula to incisive foramen
then deviating to one side
• Class IV- complete
bilateral cleft similar to
class III with two clefts
extending forward from
the incisive foramen into
the alveolus
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KERNAHAN’S STRIPED “Y” CLASSIFICATION
(1971)
• In this classification the incisive
foramen is taken as the reference
point
• “Y” logo are each divided into three
sections, representing the lip, the
alveolus and the hard palate as far
back as the incisive foramen. The
stem of the “Y” is also divided into
three parts, representing varying
degrees of clefting of the hard and
soft palates.
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MILLARD’S CLASSIFICATION (1977):
• A modification of Kernahan’s striped
“Y” classification.
• The inverted triangles represent the
nasal arch the upright triangles
represent the nasal floor.
LAHSHAL CLASSIFICATION:
L- lip
A- Alveolus
H- hard palate
S– soft palate 32112

MANAGEMENT OF
CLEFT LIP AND CLEFT
PALATE
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• During different stages of the physical and social
development of the cleft patient, role of one specialist
may be more significant than the other.
• During early days, immediately after birth the feeding
specialist, neonatologist, orthodontist and the cleft
surgeon take the lead role.
• After the first year, issues with hearing, middle ear
infections and speech therapy are more relevant and
important issues to be tackled with.
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• Similarly, later during the late mixed dentition stage
orthodontist would need greater indulgence.
• At adulthood, plastic surgeons, would play a key role
in the correction of secondary deformities of lip and
nose.
• A prosthodontist may be required to rehabilitate
missing teeth and form aesthetic treatment of the
dentition.
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Feeding issues
• Bottle feeding
• Cup & spoon feeding
• Tube feeding
• Posture: Infant must
be held at 30 – 45
degrees or in upright
position in order to aid
in swallowing and
prevent aspiration
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Feeding obturator
• The feeding obturator is a prosthetic aid that is designed to obturate the cleft and
restore the separation between the oral and nasal cavities.
• It creates a rigid platform
• The obturator also prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves.
• reduces nasal regurgitation,
• reduces the incidence of choking,
• also helps in the development of the jaws and
contributes to speech
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• Timing and sequencing of orthodontic care may be
divided into four distinct developmental periods.
• These periods are defined by age and dental
development and should be considered as time frames
in which to accomplish specific objectives.
1. Neonate and Infant (Birth to 2 Years of Age)
2. Primary dentition( 2 to 6 years)
3. Mixed dentition stage
4. Permanent dentition
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Preoperative orthopaedic treatment
• In 1954, Mc Neil advocated the placement of a
prosthesis immediately after birth to help align max
segments in patients, with complete cleft of lip,
alveolus and palate.
• This approach is known as “infant maxillary
orthopaedics”
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• Goal- to move abnormally positioned maxillary
arches and the pre maxilla into a normal
relationship prior to surgery .
intra oral
• Appliances
extra oral
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LIP TAPING
PRESURGICAL ORTHOPEDIC TREATMENT(PSOT)42112

Advantages of lip taping:
• the cosmetic appearance is improved with a minor
initial surgical procedure
• parents are not required to remove or adjust
appliances,
• postoperative care by the parents is minimal.
Disadvantage:
• potential of wound dehiscence and the need for an
additional surgery
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Nasoalveolar molding GRAYSON
• Esthetically pleasing result in the treatment of cleft lip
and palate difficult to achieve due to the actual anatomical
deformity of the nose.
• Abnormal nasal cartilage morphology, deviated nasal
septum and columella, asymmetry of the alar, and a short
or even absent columella, depending on the type of cleft.
• Therefore Dr. Grayson and Dr. Cutting emphasize the
importance of presurgical correction of the nasal cartilage
and soft tissue deformity, which can be achieved by a
combination of nasal and alveolar orthopedic molding.
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UNILATERAL DEFORMITY
• wide nostril base
• separated lip segments on the
cleft side.
• affected lower lateral nasal
cartilage is displaced laterally
and inferiorly -depressed dome
• appearance of an increased alar
rim
• an oblique columella,
• overhanging nostril apex
• If there is a cleft of the palate,
the nasal septum will deviate
to the noncleft side with an
associated shift of the nasal
base.
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BILATERAL DEFORMITY
• Procumbent and/or rotated
premaxilla.
• Increased alar base width
• lip segments are widely separated
• severely deficient or
absent columella- flattened nasal
tip appears tethered directly to
the prolabium
• lower lateral alar cartilages
are flared and concave where they
should be convex.
Esthetic reconstruction of the deficient or absent columella-biggest challenge
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Pre -Orthodontic treatment After 3 months of Grayson
molding plate application
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Concept-molding the cartilage
• The original research for molding cartilage was
performed by Matsuo.
• Cartilage in the newborn is soft and lacks elasticity.
• High maternal level of estrogen at the time of birth
correlates with an increase in hyaluronic acid, which
inhibits the linking of the cartilage intercellular
matrix.
• necessary to relax the cartilages, the ligaments and
connective tissue- enabling the fetus to pass through
birth canal-estrogen level decline after birth.
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• The primary objective of the treatment is stimulation
and redirection of alveolar growth aiming for the non
surgical approximation of the cleft deformity.
• To achieve this it is planned to treat the patients with
molding appliance in conjunction with a traction force
across the cleft lip followed by a nasal stent later.
• The nasal stent and alveolar molding plate help in
achieving nasal and alveolar symmetry, nasal tip
projection, and contact of the cleft alveolus just before
primary lip, nasal and alveolar surgical repair.
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Procedure
• Timing: immediately after birth
Impressions-heavy body impression material
Infants position-upside down-presence of suregon
important.
cast poured with dental stone-molding plate fabricated
(hard clear acrylic and lined with a thin coat of soft
denture material)
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• Molding plate is fabricated in such a way that there
are no extensions of the plate into the alveolar or
palatal cleft space.
• Full time wear- except for cleaning
• The appliance is secured extraorally to the cheeks,
bilaterally by surgical tapes, which have an
orthodontic elastic band at one end.
• The elastics loop over a retention arm extending from
the anterior flange of the plate.
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45 degrees
Nasal stent is added to the molding plate when
the cleft alveolar gap is reduced to 5mm or less.
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a.As the wire armature of the
nasal stent extends into the nostril, it
is curved back on itself to create a small
loopfor retention of the intranasal
portion of the nasal stent.
b. Hard acrylic(methylmethacrylate)
is applied to the wire armature
and shaped into a bi-lobed form that
resembles a kidney.
c. The hard acrylic nasal stent is
coated with a thin layer of soft denture
liner for comfort.
d The upper lobe of the nasal stent
enters the nose and gently lifts the
dome until a moderate amount of tissue
blanching is evident. The lower lobe of
the nasal stent lifts the nostril apex and
defines the top of the columellaNASAL STENT
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Bilateral complete cleft
4months 1.6 years
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Complications Complications and Solutions in
Presurgical Nasoalveolar Molding Therapy
Daniel Levy-Bercowski, D.D.S., M.S.D., Amara Abreu, D.D.S., M.S.D., Eladio DeLeon, D.M.D., M.S. et al
Cleft Palate–Craniofacial Journal, September 2009, Vol. 46 No. 5
Contact dermatitis
SOFT TISSUE
HARD TISSUE
COMPLIANCE RELATED
Overactivation of the nasal stent
may produce bruising or
petechiae in the dome area. 57112

Overstretching of the columella in a patient
with bilateral cleft, as a result of the
pressure exerted by the prolabium tape
and the nasal stents.
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HARD TISSUE COMPLICATIONS
Figure: A)Patient with complete unilateral cleft lip and palate with a
severe nasal deformity (pretreatment with NAM).
B)After 18 weeks of NAM treatment, nasal morphology
improved significantly. However, a T-shaped maxillary arch was created.
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FIGURE. A) Premature eruption of primary maxillary incisors due to the pressure
exerted by the molding plate in a patient with bilateral cleft lip and palate.
B)Patient continues with NAM treatment after the extraction of the primary incisor.
Figure: NAM modification to permit the eruption
of primary incisor
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Compliance related problems
•Eight (39%) of the patients had at least one broken appointment.
•The NAM appliance was removed with the tongue in seven patients
(26%) and with the hands in three (11%)
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Cleft lip repair
Goal: goal of all repairs is a normal looking lip and nose
which will not be distorted by the growth or aging.
Criteria for satisfactory repair:
• Accurate skin, muscle & mucous membrane union.
• Symmetrical nostril floors
• Symmetrical vermilion border
• Slight eversion of the lip
• Minimum scars
• Preservation of cupids bow & vermilion cutaneous ridge.
• Production of symmetrical nostrils as well as symmetrical
nasal floors.
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Timing :
• Rule of “over ten” – 10 weeks, 10 pounds, 10 gm
of Hb.
• Preferably 3 – 6 months.
• Techniques used:
1. Tennison's triangular flap procedure
2. Millard's rotation flap
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Cleft Palate repair
• Aim – speech, chewing & aesthetics.
• Timing : previously the surgeons involved in cleft
palate treatment usually performed surgical
procedures whose sole purpose was to close the
defect as early as possible without considering the
ultimate effect on surgery on palatal, facial or
speech development.
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• The timing of closure is controversial. Can be done early
at 18-24 months or at 9-12year
• At 18-24 month-
• Development of normal speech
• Tendency towards maxillary underdevelopment
• At 9-12year-
• Normal growth of maxilla with unrepaired cleft
• Reduces surgical morbidity and infection
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• Latest suggestion-
• Closure of soft palate –age of 12 month
• Help in development of Speech
• No growth retardation with early soft palate closure
• Closure of hard palate –age of 5-6year
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Primary Dentition Stage
(2 to 6 Years of Age)
• Establishment of primary dentitions-enables to predict the
developing malocclusion
• Facial soft tissues may mask the underlying skeletal
deficiency of the midface in young children.
7 years 9 years
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• Treatment priorities are:
1. To correct crossbite by using removal plates or
lingual arch.
2. To control or eliminate oral habits, functional shift
or space loss after premature loss of primary teeth
3. After the first phase, a removable retainer (at least
night time) is worn till the next phase is begun.
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Mixed Dentition Stage
(7 to 12 Years of Age)
•A tentative decision on extraction of
supernumerary teeth and overretained teeth.
•Correction of cross bite- jack screw, RME,
quad helix, Niti expanders
•Maintain space for proper eruption of teeth.
•Expand collapsed segment to improve
surgical access to the graft site.
• Traumatic occlusion is eliminated in
preparation of alveolar graft. (By aligning
offending tooth)
• Correction of jaw relationship- Face
mask Therapy
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Because deficiency of tissue is an inevitable consequence of facial
clefting, not only are the teeth missing but also the supporting
alveolar bone at the cleft site is compromised.
Bone defect before
grafting
7 months 4 years after alveolar
bone grafting
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Alveolar bone grafting
• Primary alveolar bone grafting: done at the time of
lip closure at around 10-12 weeks. Common in 1950s.
Causes hinderance in maxillary growth.
• Secondary alveolar bone grafting: Boyne and Sands in 1972
• done after lip closure at later stage. This is can be
divided into three:
• Early (2-5 years): performed in primary dentition.
Rationale is to allow eruption of the lateral incisor if
present. Can affect growth of midface.
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• Intermediate (6-15years): performed in late mixed
dentition time to allow the eruption of the permanent
canine in the graft. There is minimal interference in
growth.
• Late secondary alveolar bone grafting (adolescence
to adulthood):
• Aids in replacement of missing teeth with implants
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Rationale for bone grafting
1. To restore physiologic continuity of arch for esthetic and
hygenic replacement
2. To provide bone for stability of dental arch and the
premaxillary segment
3. Bone is provided into which unerupted teeth may erupt.
4. At the time of placement of graft, patent oronasal fistulas can
be closed
5. To allow orthodontic alignment of teeth
6. To provide support for the lip and the alar base and the nasal
tip.
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• Bergland and coworkers have given an index to
evaluate success of the grafted bone based on the
height of the interdental septum on IOPA X-ray films
• Type I—normal
• Type II—75% of normal bone height
• Type III—less than 75%
• Type IV—no bony ridge.
Post bone graft follow up
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THREE CONTEMPORARY CONTROVERSIES ARE:
1) Timing of grafting
2) The type of bone for alveolar grafting and donor site
3) Sequencing of orthodontic expansion.
Favor of 8-10 year of age (when canines about to erupt-one
quarter to two thirds of root complete)- Bergland etal
• Erupting tooth is a potent stimulus for bone formation.
• After tooth eruption is complete, it can be very difficult to
induce the formation of new bone.
• Prevents eruption into cleft-periodontal defect
• If placed after eruption of permanent teeth then chances
of damaging roots and resorption 75112

GRAFTING MATERIAL
Autogeous Advantages
• Iliac crest adequate quantity easily condensed &
placed, little donor site morbidity
• Tibia adequate volume
quality similar to iliac crest
• Rib for infants.
• Cranial bone inadequate quantity, less resorption,
rapid vascularization, predictable quality
Allogenic grafts: it acts a scaffold into which new bone develops. Freeze
dried bone( increased chances of immune reaction, HIV infection, longer post
operative phase) REVASCULARISATION OF GRAFT IS SLOW.
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EXPANSION should be done before grafting, as after the graft
mature and sutures fuse it is difficult to expand maxilla later. Also
Expanding the arch before grafting increases the size of cleft and
thus more area for placement of bone. But increased amount of
bone is required and requires more soft tissue dissection for
closure.
Expansion can also be done 6wks after grafting. It has a potential
of stimulating immature bone which may enhance graft survival 77112

Protraction of maxilla-Face mask therapy
•Used in mild maxillary deficient cleft patient
•Orthopedic forces for maxillary protraction
-350-500 gm per side over 10-12 hr / day
for an average of 12-15 months.
• Stability is questionable Because of two reasons
1.Counter pressure of a tight lip on the maxilla,
which inhibits its growth
2.Scarring in pterygo maxillary region
after extensive tissue mobilization for palatal
closure
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•Protraction face mask-
mid facial orthopedic
forces applied
– increase growth at the
circum maxillary sutures.
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PERMANENT DENTITION :
Clinical feature of this stage :
• Medial displacement of the maxillary segment-buccal cross
bite
• Relative maxillary retrognathism-reversed incisal overjet.
• Deficiency of vertical growth of the upper jaw – REDUCED
FACIAL HEIGHT
• Rotation, malposition and hypodontia of teeth.
• Supernumerary teeth
• Accentuated curve of spee in maxilla
• Collapsed arch forms
• Poor oral hygiene and caries
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ALIGNMENT OF INCISOR TEETH
– Incisors usually rotated and in crossbite. Corrected by means of fixed
orthodontic appliance.
CORRECTION OF LATERAL DIMENSION
– Lack of bony union between two sides of the maxilla, correction in
lateral dimension is relatively straight forward.
– By expansion appliance
Quad Helix Rapid Maxillary Expansion (RME)
Patients with CLP have class III malocclusion because of maxillary deficiency
(A-P and Vertically), coupled with mandibular overclosure. In such cases use of
class III elastics after leveling and aligning will result in upper molar extrusion
and favorable downward and backward rotation of mandible.
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Orthognathic Surgery combined with
Orthodontics
•Due to severe skeletal discrepancy, there is deterioration of esthetics
and occlusion, psychological implications leading to low self esteem,
defective speech, oronasal fistulas. Such cases require a combined
orthodontic and orthognathic approach.
•Size and position of maxilla is often a problem, thus maxillary
advancement and occasional down grafting needs to be performed. To
correct the transverse problem multiple segment LeFort I osteotomies
may be required. For a bilateral CLCP three-piece maxillary surgery
(allows rotation of segments also) required while for unilateral CLCP a
two piece is sufficient.(Vlachos 1996)
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Decompensation:
•Usually requires 12 months.
•Multiple segment maxillary osteotomies requires segmental
treatment. The bracket positions are altered for teeth adjacent to the
osteotomy site.
•Dental compensations in the lower arch also should be addressed
i.e, alleviation of crowding and proclination.
•Gaps present in the arches due to the missing teeth must be either
closed- stable result and prevents reopening of oronasal fistula.
Pre-surgical orthodontics
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• Proffit recommends overcorrecting the anterior crossbite
in excess of positive overjet- compensate for post surgical
relapse.
• In cases with an overjet(reverse) of more than 8mm
mandibular surgery (BSSO) also must be considered. If
not then over advancement of maxilla – unstable and
speech defects.
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TIMING
• Never indicated in active facial growth
• Ideal time : age 18-19
•Post surgical orthodontics: involves detailing of occlusion,
closure of residual spaces and maintenance of transverse
dimension (overlay arches). Lasts for 4-6 months.
•Retention: After removal of appliance retainers should be
placed immediately.
Temporary vacuum filled retainers to be avoided-transverse
control inadequate. Soldered lingual arch preferred.
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Decompensation
Age-16 years
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Patient at 17 years of age following maxillary advancement and mandibular setback
surgery and undergoing postsurgical orthodontic treatment
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DISTRACTION OSTEOGENESIS
• With the advent of distraction osteogenesis, correction of
severe maxillary hypoplasia solely by advancing the
maxilla may be possible.
1903 . Dr. Gavril of Russia-Bone lengthening of leg.
• It is a procedure that moves two segment of bone slowly
apart in such a way that new bone fills the gap.
• In distraction osteogenesis, a surgeon makes an
osteotomy in an bone and attaches a device known as
distractor to both sides of osteotomy.
• The distractor is gradually adjust over a period of days
or week to stretch the osteotomy so new tissue fills it.
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Maxillary surgery required in 25-60% of cases with clcp. (Ross and Subtenly)
Distraction osteogenesis allows soft tissue adaptation, including
scar tissue. Therefore doesn’t cause a problem with
velopharyngeal insufficiency thus good results. Distraction Of
maxilla first proposed by Molina & Oritz-Monasterio(1998)
EXTERNAL DISTRACTORS
Advantage:
•Direction of force is well
controlled
Disadvantage:
•Cranial surgery is required
•Esthetics are compromised 90112

A, Frontal view of 19-year-
old man with repaired
bilateral complete cleft lip
and palate, with rigid
external distractor
(RED)apparatus in place.
B, Profile view with
distraction osteogenesis
appliance for advancement of
the maxilla.
C, Profile view before
distraction osteogenesis.
severe maxillary deficiency
present.
D, Profile view after
distraction osteogenesis.
improved position of maxilla
relative to mandible.
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INTERNAL DISTRACTORS
Advantage:
•Esthetics
•Psychological relilef
Disadvantage:
•Difficult to control the direction of force
92112

VELOPHARYNGEAL INSUFFICIENCY
Velopharyngeal insufficiency is a
disorder resulting in the improper
closing of the velopharyngeal
sphincter (soft palate muscle in the
mouth)during speech, allowing air to
escape through the nose instead of the
mouth.
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• VPD is of 3 types:
a)Velopharyngeal Mislearning: due to
articulation difficulties
b)Velopharyngeal Incompetence: Due to
functional abnormalities.(paresis, dysarthia)
c)Velopharyngeal Insufficiency: Structural
problems like cleft or bifid uvula etc
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VPI may be found in children who have:
• Cleft palate (about 20-30 percent of children who have
cleft palate will still have VPI after the palate repair)
• Submucous cleft palate
• Certain syndromes, such a velocardiofacial syndrome
• Had previous adenoid removal
• Weak throat muscle
• Too much space between the palate and the throat
Some children have VPI from an unknown cause.
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• The main speech symptoms of velopharyngeal
insufficiency are:
1. Hypernasality and
2. Nasal air emission.
3. Misarticulations of certain words
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Treatment of VPI
Speech Therapy
• Some speech problems linked with VPI, such as
mispronouncing words, can be treated by speech therapy.
Treatment focuses on teaching the child the correct
manner and place of articulation
Non-surgical management:
• Sometimes an obturator is recommended to treat VPI.
• An obturator is like a modified dental retainer with a
speech bulb or palatal lift attached to the back. Each
obturator is shaped uniquely to fit the patient’s muscle
movements.
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•An obturator can be a short-
term or long-term option for
children with VPI.
•It can be used before or
instead of surgery.
•The child may start with an
obturator and have surgery
when he is older or they may
continue to use an obturator
as an adult.
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Surgical intervention:
1. Palatoplasty
2. Sphincter pharyngeoplasty
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Different protocols for the management of CLP
Nether lands protocol
• Presurgical orthopedic treatment appliance(PSOT) –
birth to 1 1/2 years.
• Lip closure – 5-6months
• 2 stage palatal closure – soft palate-12-18months,hard
palate-6-9 years of age.
• Bone grafting of alveolar cleft.
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Oslo protocol
• Evolved at the Oslo Cleft Centre.
• does NOT follow preoperative orthopedics
• Millard lip repair at age of 3 months
• In cases with an associated cleft of the alveolus and
palate, a cranial base single layer vomer flap is
sutured under the alveolus palate periosteum at the
time of lip closure.
112 101

Zurich concept
• Aim – to maximize palatal growth.
• Passive plates used in conjunction with delayed
surgical procedures were introduced in zurich ,
Switzerland in 1960.zurich appliance is a
combination of both soft & hard acrylic.
• It is worn continuously for 16 – 18 months & is
replaced every 6 months.
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Zurich protocol
• Passive plates worn for 16 – 18 months
• Plate changed every 6 months
• Reduction of gingival side of the plate every 3-8 weeks.
• Lip closure - 6months of age
• Soft palate – 18 months
• Hard palate – 4-5 years.
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A Modified Surgical Schedule for Primary Management
of Cleft Lip and Palate in Developing Countries
Karoon Agrawal, M.S., M.Ch., Kasinath Panda, M.S.
Cleft Palate–Craniofacial Journal, January 2011, Vol. 48 No. 1
• Introduction: In developing countries cleft lip and
palate (CLP) patients arrive late, and there is a risk of
drop out for functionally important palatoplasty after
lip repair. Patients may be underweight, anemic, and
prone to recurrent infections.
• Objective: To repair cleft palate at an appropriate
time and secondly to avoid the drop out after the first
surgery.
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• Modified Protocol: A new surgical protocol has been
designed for patients with CLP in whom the cleft palate is
first repaired at 6 to 9 months of age or whenever the
patient presents at the clinic. The cleft lip is repaired 3 to
6 months after the first surgery.
• Advantages of the modified protocol
1. Cleft palate is repaired at the most accepted time
schedule for palatoplasty at 6–9 months for good speech
result.
2. Compliance for second surgery for cleft lip repair
improved.
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• In presence of unrepaired cleft lip, the mouth opening is
better and hence the visibility of the palate, so the cleft
palate repair is technically easier.
• During cleft lip repair, the anterior palate repair is done
under good vision; hence, incidence of anterior palatal
fistula is very low.
• While performing the cleft lip repair, there is an opportunity
to examine the palate under GA for any abnormality.
• Cleft palate fistula if identified can be repaired along with
the lip repair.
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Treatment of CLCP: A brief Overview 108112

CONCLUSION
• The management of a patient with cleft lip and palate
deformity definitely requires a multidisciplinary
approach and the orthodontist has proven to be an
essential member in the cleft palate team. The
orthodontist is not only responsible for the active
orthodontic treatment but also and facial orthopedic
treatment of the child with a cleft. The ultimate outcome
for team-based care is to have a fully rehabilitated patient
who is satisfied with the treatment outcomes in terms of
speech, occlusion, facial and dental aesthetics, and
function.
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Past Questions
1. You are a member of CLP team.
Q. What is the best time for cleft lip repair?
A. 3 to 6 months
Q. When do you recommend for secondary alveolar
bone grafting?
A. Ideally, the permanent canine root should be half to two thirds
formed at the time the graft is placed. Permanent canine root
formation generally occurs between the ages of 8 and 11
years. Occasionally the graft may be placed at an earlier age
to improve the prognosis of a lateral incisor.
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Q. What is the most commonly used orthopedic
appliance in CLP cases?
A. Face mask
Q. At what age is usually pre-surgical orthodontics
preferred for this kind of patients?
A. Presurgical orthodontics or neonatal maxillary
orthopedics is initiated during the first or second
week following birth unless complications arise from
other congenital anomalies or medical problems
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REFERENCES
• CRANIOFACIAL DEVELOPMENT- Sperber
• Samuel Berkowitz-Cleft Lip and Palate: Diagnosis and management-
2nd Edition
• Thomas M. Graber, Katherine W. L. Vig, Robert L. Vanarsdall Jr.
Orthodontics: Current Principles and Techniques.
• WR Profitt:Contemporary orthodontics-5th edition
• OP Kharbanda; Orthodontics-Diagnosis and management of malocclusions
and dentofacial deformities;First edition
• Cleft lip and palate, Seminars in Orthodontics
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• Grayson et al, Pre surgical naso alveolar molding, cleftliip- craniofacial
journal 1999:35
• B. H. Grayson and C. B. Cutting, “Presurgical Nasoalveolar Orthopedic
Molding in Primary Correction of the Nose, Lip, and Alveolus of Infants
Born with Unilateral and Bilateral Clefts,” The Cleft Palate-Craniofacial
Journal, Vol. 38, No. 3, 2001, pp. 193-198.
• Advances in management of cleft palate: Edwards and Watson
• Baik et al. surgical orthodontic treatment in patients with clcp: conventional
surgery v/s maxillary distraction, world J Orthod;2:331-40
113112

role of orthodontist in Cleft lip and palate management

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role of orthodontist in Cleft lip and palate management