Management Of Cleft Lip And Palate Question And Answers

Management Of Cleft Lip And Palate

• Group 1: These are the clef which involve soft palate only.
• Group 2: They are the clefts of hard and soft palate extending up to incisive foramen.
• Group 3: They are complete unilateral cleft which involve soft palate, hard palate, lip and alveolar ridge.
• Group 4: They are complete bilateral cleft affecting the soft palate, the hard palate, the lip and alveolar ridge.

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• Clef palate
• Cardiac defects
• Characteristic facial appearance
• Learning problems and speech
• Feeding problems.

• Recent studies have shown that environmental factors play a significant contributory role at the critical time of embryo- genic development when lip and palatal shelves are fusing.
• A number of environmental factors have been suggested as causative factors including:
  • A defective vascular supply to the area involved during critical time of embryonic development.
  • A mechanical disturbance in which size of the tongue may prevent union of parts.
  • Excessive concentration of circulating substances such as alcohol, certain drugs i.e. teratogens (antibiotics, steroids, insulin) and toxins.
  • Viral infections.
  • Exposure to radiation.
  • Hypoxia.
  • Vitamin deficiencies.
  • Stress.

• Every parent has approximately 1 in 700 risk of having a child with a cleft
• Parents having a child with a clef have increased risk of having the 2nd child affected 2-5%.
• If more than one person in immediate family has a cleft risk rises to 10-12%.
• A parent having a cleft has 2-5% chance of having a child with a cleft
• If a syndrome is involved, the risk for recurrence within a family can be as high as 50%.
• Maternal age-increased risk of clefting is observed when age of conceiving is late.

• Predental treatment/pre-surgical orthopedics:
• Pre-surgical orthopedic appliances:
  • The aim of pre-surgical orthopedic is to align the displaced clef segments.
  • Lip repair is carried out at about 3 months and clef palate is carried out at 9-18 months.
  • A passive feeding appliance incorporated with acrylic or wire wings.
  • Duyzing plate is used for patients with cleft of hard and soft palates. Hard palate is blocked and a soft acrylic extension is used to cover the sof palate defects.
  • Extraoral strapping: The main objective of the extraoral strapping is to reposition the premaxillary portion of jaw by means of pressure from extraoral strapping when an appliance is worn in the mouth.
    • Feeding plates are used which assist in feeding by closing oronasal fitula. These are removable appliances.

• Orthodontic treatment should not be undertaken because of its limited advantage at this stage.
• Permanent incisors erupts rotated and are in crossbite. This is corrected by using removable appliances.

• Treatment of cleft lip and cleft palate during early mixed dentition: Permanent incisors may erupt into linguo-occlusion. This should be corrected if feasible but may be delayed until the next phase of development.
• Treatment of cleft lip and cleft palate during mid-mixed dentition: If an alveolar clef is evident, secondary alveolar bone graft is routinely performed at age of 9–10 years.

• Fixed orthodontic treatment is started at this era.
• In the missing tooth areas space closing is done by bone grafting.

• Preadjusted edgewise appliances should be used for positioning of teeth.
• Impacted teeth should be brought in the arch.
• For redirecting mandibular regrowth chin cup is employed.

• Stage 1: It comprises of the treatment done from birth to 18 months of age.
• Stage 2: It is from 18th month to 5th year of life. This corresponds to primary dentition stage.
• Stage 3: It includes treatment which is carried out during mixed dentition stage. It spans usually from 6th to 11th year of life.
• Stage 4: It includes the treatment done at permanent dentition stage i.e. 12 to 18 years of age.

• Fabrication of passive maxillary obturator
• Presurgical orthopedics
• Surgical management of clef lip
• Surgical management of clef palate

• This is an intraoral prosthetic device fabricated using cold cure acrylic.
• Clasp may aid in retention. If there is insuffient retention, wings made of thick wire can be embedded in acrylic and can be stabilized against cheeks using micropore adhesive tape.
• This fils palatal clef and provides false roofig against which the child can suckle.
• This decreases incidence of feeding diffilties such as insufficient suction, excessive air intake and choking.
• This also provides maxillary cross arch stability, thus preventing arch from collapsing.

• Aim of pre-surgical orthopedics is to achieve upper arch form that conforms to the lower arch.
• Absence of variable amount of the lip tissue and division in alveolus and palate leads to outward displacement of premaxilla.
• An orthodontist should always try to correct the displacement such as outward displacement of premaxilla (in bilateral cleft and displacement of greatest segment (in unilateral cleft) by extra-oral strapping across the premaxilla which is attched directly to face or some form of the head cap.
• A micropore adhesive tape can also be strapped across the premaxilla.
• If there is narrow, collapsed maxillary arch, expansion can be achieved by a suitable appliance incorporating screws or springs.

• Early school thought: According to them surgery should be performed under 45 days of the birth. Early surgery improves the facial appearance and so improves the child acceptance and decreases the parent apprehension.
• Late school thought: According to them surgery should be postponed at the time of completion of dentition. Here the reason suggested is that the tissue would be able to grow and mature, giving the surgeon more muscle mass to work over.
• Millard suggested rule of 10: Surgery should not be carried out less than 10 weeks of age, body weight not less than 10 pounds and blood hemoglobin not less than l0 g%.

• Palatal repair should be attempted between l2 and 24 months of age which facilitates normal speech, hearing and improves swallowing.
• Palatal repair is carried out using bone transplants which are taken from rib, iliac bone, mandibular symphysis, tibial bone or outer table of parietal bone.

• This stage of treatment is carried out during deciduous dentition period.
• The procedures done during this stage are:
  • Adjustments in the intraoral obturator to accommodate the erupting deciduous teeth
  • To maintain a check on eruption pattrn and timing
  • Oral hygiene instructions
  • Restoration of decayed teeth
• Orthodontic treatment should not be initiated during this phase until it damages the underlying permanent dentition follicles.
• In patients with moderately underdeveloped maxilla and no Class 3 hereditary defect, reverse headgear treatment is given at the age of 4 to 7 years.

• Correction of anterior crossbite with the removable or fixed appliances. E.g. Removable appliance with Z spring for treatment of anterior crossbite.
• Buccal segment crossbites are treated using quad helix or expansion screws.
• Secondary alveolar bone grafting is done commonly during mixed dentition period. Successful grafting produces osseous environment to permit the spontaneous eruption of canine tooth inside the graftd area. Iliac crest is the preferred donor site

• It consists of treatment during permanent dentition along with fied orthodontic appliance.
• All of the local irregularities such as crowding, spacing, crossbites and overjet lover bite problems are corrected.
• Patients having hypoplastic maxilla should be given face mask to advance the maxilla.
• Patients with missing teeth should be given prosthesis aftr completion of orthodontic treatment.
• Following completion of orthodontic treatment long retention phase is required in these patients.

• Natal or neonatal teeth are present.
• Supernumerary or missing teeth are present.
• Presence of ectopically erupting teeth.
• Presence of enamel hypoplasia.
• Presence of microdontia, macrodontia and fused teeth.
• Spacing between the teeth or crowding of teeth is present.
• Mobile teeth are present along with poor periodontal support.
• Presence of posterior and anterior crossbite.
• Malalignment of alveolar arches is present.

• Development of concave profile with midface deficiency.
• Maxilla is hypoplastic over the clef side.
• Shortening of columella over the clef side.
• There is free communication of flor of nose with oral cavity.
• Wide and flat nasal tip is present.
• Muscles of soft palate are hypoplastic.
• Grossly deficient premaxilla in bone with bilateral cleft

• Problem of articulation is common in clef palate patients mainly those involving affricates and fricatives.
• Velopharyngeal mechanism cannot function. The soft palate cannot elevate to make contact with pharyngeal wall and this leads to escape of air in nasal cavity producing hypernasal speech.
• Retardation of consonant sounds is most common problem

• Clef palate is associated with Eustachian tube dysfunction and leads to hearing loss.
• Otitis media is commonly present.