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On cleft lips and cleft palates

Jean­Jacques Aknin

Journal of Dentofacial Anomalies and Orthodontics / Volume 11 / Issue 04 / December 2008, pp 221 ­ 229© RODF / EDP Sciences Published online by Cambridge University Press: 12 January 2012DOI: 10.1051/odfen/2008045

Link to this article: http://www.jdao­journal.org/10.1051/odfen/2008045

How to cite this article:Jean­Jacques Aknin (2008). On cleft lips and cleft palates. Journal of Dentofacial Anomalies and Orthodontics, 11, pp 221­229 doi:10.1051/odfen/2008045

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Address for correspondence:

J.-J. AKNIN,Faculté,d'Odontologie de Lyon,11, rue Guillaume,Paradin,69372 Lyon Cedex 08.drjjaknin@aol.com

DOI: 10.1051/odfen/2008045 J Dentofacial Anom Orthod 2008;11:221-229© RODF / EDP Sciences

As we approach the end of another year we have the great pleasure of welcom-ing Jean-Jacques Aknin. He is the Director of the Department of Dento-Facial Orthopedics in the Faculty of Odontology of Lyon and a HospitalPractitioner responsible for the Functional Unit of Dento-Facial Ortho-pedics in the Service of Odontology of the Civil Hospices of Lyons. An emi-nent member of the ‘Association of the Revue of the ODF and the newPresident of the SFODF, he has prepared his initial editorial in the form ofa short article in which he presents a synthesis of the responses to a question thatis important but little known to practitioners who do not work in hospital or uni-versity settings, primarily because patients who suffer from cleft lips and cleftpalates do not ordinarily consult private practitioners, remaining instead under thecare of hospital and university services.

Philippe AMAT

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On clef t l ips and clef t palates

Jean-Jacques AKNIN

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2008045

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Children who suffer from clefts oflips, alveoli, and hard and softpalates, phenomena that occur oncein every 700 births, are often obligedto travel great distances to receiveorthodontic treatment. It wouldseem advisable, accordingly, thatmore orthodontists be trained in thisspecial area so that patients withclefts could receive care at facilities

located nearer to their homes.Perceived for many years as seriousdeformities with grave conse-quences, cleft palates can now betreated with remarkable facility andsuccess thanks to new proceduresand surgical techniques and alsobecause of the efficacy of the multi-disciplinary therapeutic approachthat has become increasingly utilized.

1 - EMBRYOLOGY

The eventual configuration of theface derives from the fusion of thefacial buds.

1 - 1 - Formation of the primary Palate

During the 6th week the maxillaryprocesses begin to develop under theembryonic eyes. They come into con-tact with the internal and external nasalprocesses. Next the right and left max-illary processes fuse with the internalnasal process to form a cellular massthat constitutes the primary palate.

1 - 2 - Formation of the secondary Palate

During the 7th week, behind theprimary palate two small horizontal

lamina appear at the level of themaxillary processes. They are thepalatal processes that are going todevelop horizontally on both sides ofthe tongue. Then the tongue movesfrom its position near the nose to aplace within the buccal cavity thusfacilitating closure of the palatal pro-cesses to form the secondarypalate. The joining of the palatal lam-inae proceeds from to rear, from theincisive canal to the uvula. At thesame time, at another level, a verti-cal crest arises in the naso-frontalprocess, becoming the nasal septumthat is going to descend to meet the palatal processes in joining theupper aspect of the secondarypalate, which will define the twodefinitive nasal processes.

3 - 1 - Different anatomo- clinical forms

The deeper the cleft, the wider itappears laterally:

– simple labial clefts;

– labio-nasal clefts (from the lip tothe base of the nose);

– labio-alveolar clefts. All degreesof partial clefts exist. They can be uni-lateral or multiple and confined to lipsand teeth or extended into:

3 - DESCRIPTION OF CLEFTS

Two genetic factors can be distin-guished in the etiology of facial clefts,but extragenetic forces, which can oper-ate separately or in association, in whatis called multifactorial etiology, can alsocontribute to their development.

• The genetic factors:

– Isolated clefts often have a multi-factorial derivation based on both

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2 - ETIOLOGY

genetic factors and environmentalinfluences;

– Very few clefts derive solelyfrom inherited defects such as chro-mosomal aberrations, mutant genes,or of direct teratogenic action.

– palatal clefts. These combineddefects must be separated into twocategories, those that are primarypalatal clefts and those that are sec-ondary palatal clefts.

3 - 2 - The secondary palatalcleft

This type of defect is located alongthe trajectory of the median sagittalsuture of the hard palate, between the

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two palatal plates that it divides, andthrough the soft palate up to the uvula.This is a posterior, symmetrical, mid-line anomaly running forward to theanterior palatal canal. Depending uponthe severity of the deformation, it canencompass a splitting of the uvula andthe soft palate as it extends into thehard palate. Because of its being splitinto two halves the soft palate cannotfulfill its physiological role of acting as amobile screen between the cavum andthe oropharynx. The cleft makes itimpossible for the oral cavity to beclosed off from the rhino-pharynx andprevents children from enunciating cor-rectly as they learn to speak.

3 - 3 - The bilateral cleft

Like unilateral clefts, bilateraldefects can run through the entirelength of the palate or only through

part of it. They are characterized bythe median process being isolated asa result of the double dehiscence.Two qualities of the median processcan complicate treatment:

– it is very hypoplastic;– the normal orientation of the total-

ity of the median process having beenseriously disturbed, it may be tilted for-ward as much as 45°.

3 - 4 - Growth of soft tissues

The exterior, cutaneous appear-ance of cleft palate patients reflectsthe underlying skeletal status.Accordingly, children with facial cleftswill have malformed profiles becauseof the basic initial deformity and the subsequent soft tissue defectsthat will vary in response to the typesof surgical treatment they havereceived.

4 - ASSOCIATED DENTAL ANOMALIES

4 - 1 - Anomalies of number

• Congenital absence of upper lateral incisors occurs frequently:

– on the side of the cleft in 40% ofthe adult dentitions and 27% of thetemporary dentitions;

– on the side unaffected by thecleft in 11% of cases.

• DoublingBelow, one lateral incisor on the side

of the smaller fragment and another onthe side of the larger fragment.

Doubling affects lateral incisors onthe side of the cleft in 22% of thecases in the permanent dentition and

in 42,5% of temporary dentitions. Inthese cases lateral incisors appear oneach of the two sides of the cleft.

7 - INITIAL SURGICAL TREATMENT

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7 - 1 - The operatory timetable

Schedules vary from one dentaldepartment to another, but to keepthis presentation uncomplicated we

It is important to emphasize that amulti-disciplinary team should takecharge of the patent's treatmentfrom the earliest possible age untiladulthood.

4 - 2 - Anomalies of position

The poor arrangement of toothbuds results from a disorganizationof basal bone, itself a victim of fail-ure of embryonic segments to fuseproperly.

4 - 3 - Anomalies of form

The tooth most often malformed isthe lateral incisor which presents a riziform or peg-shaped appearanceor be absent entirely.

5 - OCCLUSAL RELATIONSHIPS

• In the sagittal sense: The maxil-lary retrusion and the pseudomandibular protrusion in congenitalcleft palate cases reflect an underly-ing Class III skeletal condition with anarch length discrepancy in the maxillaand a mandible unaffected by malfor-mation.

• In the transverse sense: a retrud-ed maxilla may or may not be accom-panied by a retrusion of the alveolar

process. The upper mid-line is deviated.A small sized maxilla may or may notbe accompanied by an alveolar pro-cess reduced in bulk. The incisal mid-line is deviated. The difference in sizebetween the large and the small max-illary fragment, which is tilted towardthe median, is marked. The mal-posi-tion of this smaller portion causesmajor deviations in tooth alignmentand occlusal relationships.

6 - HEARING AND SPEECH

The hearing of cleft palate patientsis adversely affected in 75% of thecases because of the intrusion of air intothe middle ear, which modifies breathingcapacity and tympanic pressures.

6 - 1 - Impact on patients'phonics

Because of the open communi-cation between the oral and nasal

cavities, air can escape readily. Thetypes of soft palate insufficiencyleading to loss of function are:divided palate, excessively shortpalate, and inert palate. In all threeinstances, compensatory function-ing may be established, but if thatdoes not occur, dentists should pro-vide patients with obturators.

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shall offer Psaume and Maleck tech-nique that the team from Lyons isusing the clinic Val d'Ouest:

• Isolated labio-alveolar cleftLip + nose: 2 months (+ nasal con-

formator).– Total unilateral labio-palatal clefts

Soft palate correction: 3 months(staphyloraphy).

Lip+nose+hardpalate (Uranoplasty):5 months (+ nasal conformator).

Pharyngoplasty before 6 years(before beginning kindergarten).

• Total bilateral labio-palatal cleftsSoft neo-natal obturator: 3 months.Veloplasty: 3 months.1st on the side of the lip, hard palate,

nose: 5 months.2nd on the side of the lip: 7 months.

• Soft palate-hard palate cleftsClefts affecting only the soft palate:

3months.Soft palate + Hard palate: in two

stages: 3 months and 5 months.

Orthodontists can begin treatingcleft palate patients with orthopedicdevices when they are still in the tem-porary dentition stage to establish func-tional equilibrium as soon as possible soas to encourage harmonious growthand development of facial structures.

– In the transverse sense theappliance of choice is a Quad Helix to

expand the constrained maxillatoward normal dimensions.

– In the sagittal sense use of themask of Delaire can be used to com-pensate for skeletal defects by mov-ing the maxilla forward while holdingback mandibular growth. TraditionalClass III mechanics can supplementthis extra-oral force.

8 - ORTHOPEDIC TREATMENT

In the mixed dentition, the objec-tives of treatment are to:

– solidify disparate osseous frag-ments;

– correct the malpositions of theincisors while preserving space forthe missing or deformed lateralincisor, which will most often bereplaced with an implant after place-ment of an initial bone graft and theend of the growth period;

– restore the premolars and thecanines to normal occlusion;

– restore the maxillary arch to anormal contour;

– correct any cross bite relation-ships.

After this mixed dentition stage oftreatment, a palatal acrylic retainercan be used to maintain the correc-tions.

• The time for a bone graft variesin accordance with the age of patientsand their motivation, according to the stage of eruption, which is often chaotic in cleft palate patients,

9 - ORTHODONTIC TREATMENT

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according to stage of root maturation,and according to the positions andlong axes of the unerupted perma-nent teeth.

Clinical researchers are currentlyactively trying to determine what isthe most desirable moment for theplacement of bone grafts; precise tim-ing varies with different teams but,generally speaking, grafts can beplaced on children between theages of 8 and ten. Before the erup-tion of the canines or after the erup-tion of the canine in the small fragment when patients are about 12 years old in the adolescent denti-tion. A dentoscan can help the clini-cian to visualize the extent of the cleftand its location in 3D.

• In Class I skeletal cases,orthodontists can prepare the teeth,correcting alignment and restoring idealarch form and, above all: Reducing thesize of the cleft by individualizedmechanics to bring the large and thesmall fragments into as closeapproximation as possible (fig. 1).

This orthodontic preparation shouldtake into account the absence of anupper lateral incisor or the presence ofone that is deformed that will, in mostcases, have to be removed.

• In Class III skeletal cases, com-bined surgical-orthodontic treatmentshould be undertaken as soon the grafthas been placed and become wellestablished. Orthodontic preparatorytreatment, if it has not already beencompleted, will have restoration ofideal arch form as its goal.

Individualized orthodontic reduc-tion of the cleft, Osseous graft, at theage of 14.

Individualized orthodontic reduc-tion of the size of the cleft, Bone graft(14 years). Compensatory orthodonticcorrective treatment, Orthognathicsurgery: Lefort 1 advancement and needfor pharyngoplasty to be evaluated.When these procedures are completed,a six month fine detail orthodontic finish-ing treatment should include root paral-leling in the implant zones where miss-ing lateral incisors will have been

Figure 1Individualized orthodontic reduction of the size of the bilateral cleft.

This space closing procedure is accomplished with a contraction arch capable of approximatingthe three fragments before the graft is set in place. The orthodontic force is 22 bis. Becausesupernumeray teeth are endowed with a certain quantity of bone in the cleft area, they shouldnever be extracted at too eary a stage for fear of causing the loss of precious osseous material.

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replaced. Finally fixed retention is useduntil the implant can be placed.

• Surgery of the lip or nose (sep-tum nasal, at the end of the growthperiod) this can take place once thedento-alveolar rampart has beenreconstituted.

• Retention: unless a transpalatalarch is used there is always the risk ofrelapse of the palatal expansionachieved. This fixed retention has tobe quasi-permanent.

The multi-disciplinary team evalu-ates the proper time for beginningsurgical orthodontic treatment ofclefts based on the interferences thedefect is exerting on normal facialgrowth.

The sequence of the therapeuticstages is complex; every variation inprotocol has its advantages and dis-advantages.

The difficulty in making treatmentchoices derives from the compromiseseach requires, as explained by Talmant,"We must find the best possible balancebetween the most perfect anatomicrestoration and the lowest possible ran-som paid in post-operative scarring."

The therapeutic calendar, especiallyas it is affected by the reciprocal

understanding and cooperation oforthodontists and surgeons, will influ-ence the quality of the resultsobtained.

At the present time, we can safelyassert that the treatment of palatalclefts has greatly improved, thanks, ofcourse, to definite improvement in sur-gical techniques, but also, in a moreimportant global fashion, because ofthe increasingly effective multi-disci-plinary coordination of the efforts ofpediatric surgeons, maxillo-facial sur-geons, implantologists, general den-tists, and the guiding interventions oforthodontists at every stage of treat-ment, which is enormously demandingbut provides even more enormous div-idends for the patients it serves.

10 - CONCLUSIONS