Dr. Shruti Singh, Subharti Dental College, SVSU

Dr. Shruti Singh, Subharti Dental College, SVSU

Dr. Shruti Singh Sr. Lecturer Dept. of Pediatric & Preventive Dentistry


Introduction

Embyological aspects

Etiology and Diagnosis

Classification of cleft lip and palate

Types of clefting

Facial growth in unrepaired CLP cases

Orthodontic management of CLP

- Infant orthopedics

- Primary dentition period

- Mixed dentition period

- Permanent dentition period



“ ORO - FACIAL DEFORMITY ”


1 in 600 – 1000 live births




Failure of fusion


HANDICAPPING MALOCCLUSION AND

HANDICAPPING DENTOFACIAL DEFORMITY

- J.A.Salzmann

Definition : conditions that are harmful to the physical,

psychodynamic and social well-being of the person by

adversely affecting the health, function and esthetics

of the facio-oro-dental tissues.

Am . J . Orthodontics, March 1966


The cleft can be diagnosed by high resolution

ultrasound at 18 weeks of gestation.

Diagnosis is otherwise made after delivery.



Defective muscular supply to the area involved

Mechanical disturbance in which the size of the

tongue may prevent the union of the parts

Circulating substances like alcohol and certain drugs

and toxins

Infections

Lack of inherent developmental force


Hereditary/Polygenic Syndromic/Manogenic


MSX 1

TGFA

TGFB 1

TGFB 2

IRF 6

BCL 3

BMP 4

BMP 3

PAX 7

PAX9

Seminars in Orthodontics June 2008



Davis and Ritch classification :

Group I – Pre alveolus clefts (clefts involving only lip)

Unilateral

Bilateral

Median


Group II – Post Alveolar Clefts

- comprises of different degrees of hard and soft

palate clefts that extend upto the alveolar ridge.

Unilateral

Bilateral

Median


Group III – Alveolar clefts :

Complete clefts involving the

- palate

- alveolar ridge

- lip


Group I : Clefts involving only the soft palate

Group II : Clefts of hard and soft palate extending

upto the incisive foramen.


Group III : Complete unilateral cleft involving the

soft palate, hard palate, lip and alveolar

ridge.

Group IV : Complete bilateral clefts affecting the soft

palate, hard palate, lip and alveolar ridge.


Group I Group II Group III

- lip - lip and palate - clefts of

palate

unilateral unilateral

bilateral bilateral


Group I

Clefts of lip only

Group II

Clefts of palate only

(2o)

Group III

Clefts of lip,

alveolus, palate

Group IV

Clefts of lip and

alveolus

(primary cleft

palate and lip) Group V

Miscellaneous


1 and 4 - Lip

2 and 5 - Alveolus

3 and 6 - Hard palate anterior

to incisive foramen

7 and 8 - Hard palate posterior

to incisive foramen

9 - Soft palate Dr. Shruti Singh, Subharti Dental College, SVSU

Clefts of primary palate ( unilateral and bilateral )

Clefts of primary and secondary palate

Clefts of secondary palate



SKELETAL GROWTH :

Facial width :

- Generalised increase in width of facial strucutres

which appears to persist throughout growth.

- Head width is relatively greater than head length.


- Orbits are further apart than in normal.

- Maxilla which was wider in infancy remains wide.


- Palatal shelves are deficient in width.


- Clubbing of the shelf ends suggest that the growth is

being distorted probably by the tongue.

- The buccolingual occlusion of the posterior teeth is

invariably excellent.


- Mild deficiency of maxillary bone if present is

compensated for by an adjustment in the direction of

dental eruption and alveolar apposition.

- Anterior nasal spine is markedly deviated to the non

cleft side.


Facial height :

- Maxillary height in unilateral clefts

slightly less on the cleft side than on non-cleft side.

- Height of nasal cavity may be less in infants but greater

in adults .


Facial depth :

Infants with unilateral CLP or isolated cleft palate

Maxilla is more retrusive

Older children and adults

Maxilla is in a normal position


Pre-maxillary area

rotated forward and laterally in unilateral clefts

advancing the nasal spine maxillary protrusion


Pterygoid process

abnormal in size and direction of growth

adults with cleft palate and unilateral CLP


Growth of Nose :

- Tip of nose retrusive (all types of clefts)


- Nasal bones distorted (infants with UCL)

- Nasal bone flattened on cleft side

- Short columella + nasal tip is slumped and blunted.

bilateral clefts


Musculature :

Bilateral case

severe under-development and atrophy of prolabium

Unilateral cases

upper lip less protrusive

lower lip protrusive


Dental occlusion :

Maxillary buccal teeth

usually in normal buccolingual r/s with mandibular teeth

(in CLP cases)

Maxillary incisors protrusive ( bi CLP)

Mandibular incisors less protrusive

Interincisal angle is normal.


In unilateral cleft lip and palate:

- maxillary incisors tip towards the cleft

- occasionally an open bite in the incisor region

- maxillary cuspids generally incline towards the cleft

and displaced medially

- posterior occlusion is invariably quite acceptable


Jaw and tooth relations :

Retrusion of maxillary basal bone in CP and uni CLP

balanced by

rotation of the mandible and consequent retrusion of chin

Antero posterior jaw r/s :

- young children : satisfactory

- older children : progressively worsen


MULTIDISCIPLINARY CLEFT MANAGEMENT

Cleft lip and palate

commonest craniofacial anomaly

INTERDISCIPLINARY TEAM OF SPECIALISTS



Pre surgical infant

orthodpedics : 0-4 weeks

Lip closure : 8-12 weeks

Palate closure : 18-24 months

Speech therapy : 6-11 years

Early orthodontics : 7-8 years


Alveolar grafting : 6-10 years

Comprehensive orthodontics : 11-14 years

Pharyngeal flap surgery : 9-19 years

Orthognathic surgery : 17-19 years

Fixed Prosthodontics : 17-19 years


They can be broadly classified as :

a) Dental

b) Esthetic

c) Speech and Hearing

d) Psychologic.


Congenitally missing teeth (upper lateral)

Presence of natal or neonatal teeth

Ectopically erupting teeth

Anomalies of tooth morphology.

Enamel hypoplasia

Microdontia


Fused teeth

Macrodontia

Mobile and early shedding of teeth

( poor periodontal support )

Posterior and anterior cross bite

Protruding premaxilla

Deep bite

Spacing or crowding.


Facial disfigurement

Malformed oro-facial structures

Congenitally missing oro-facial structures

Deformities of nose


CLP

disorders of the middle ear

affect hearing

difficulties in language uptake and speech


CLP

lot of psychological stress

- Due to their abnormal facial appearances

- Put up with staring, curiosities, pity etc.

- Problems in obtaining job and making friends

- Fare badly in academics


Presurgical orthopedics : 0-3 months

Interceptive orthopedics : 6-7 yrs

Alignment of maxillary incisors prior to secondary

alveolar bone grafting


Secondary alveolar bone grafting of the cleft alveolar

process

Conventional orthodontics in the permanent dentition

Prosthodontic or orthognathic surgery : 17-19yrs


By C. Kerr McNeil

Performed on new born before surgical repair of lip.

Rationale...realignment of the collapsed segments

before surgery.


In bilateral CLP – maxillary alveolar segments are

displaced at the time of birth.

In unilateral CLP - premaxillary segment likely to be

displaced facially adjacent to cleft


Displacement of bony segments

separation of the soft tissue segments

lip repair more difficult


To achieve a more normal skeletal base under the lip

and nose

Maxilla becomes more symmetrical.

Lip fissure is narrowed considerably.

There may be slight advancement of the smaller

maxillary segment.


TYPES OF NEONATAL MAXILLARY ORTHOPEDIC

APPLIANCES

Pin-retained active appliances and passive appliances

- Active

- Semi-active

- Passive



Control and modify the postnatal development of the

maxilla

Stimulate palatal shelf growth

Aids the plastic surgeon

Prevents tongue distortions

Prevents nasal septum irritation


Decreases the number of ear infections

Expands the collapsed maxillary segments

Repositioning of pre maxilla

Aids in nursing

Helps the mother psychologically.




http://www.acay.com.au/~gsm/fixomull.jpg

NASOALVEOLAR MOULDING

- Grayson et al,. ( 1993 )

Reduces the severity of the initial cleft alveolar and

nasal deformity.


Improved long term esthetics

A reduced number of nasal surgical procedures

A reduced need for secondary bone grafts

No larger growth disturbance than is found for other

well-established procedures.

Savings in cost


Intra oral moulding plate

with nasal stents

to mould the alveolar ridge and nasal cartilage concurrently





Reduce the severity of the original cleft deformity

better repair of the alveolus, lip and nose

( by the surgeon )

better and more predictable surgical results


NAM technique

also eliminated surgical columella reconstruction

resultant scar tissue in bilateral cleft lip and palate







Orthodontic management of CLP

- Primary dentition period

- Mixed dentition period

- Permanent dentition period

Goslon yardstick

Stem cell therapy for CLP

Conclusion


2-3 yrs

classification of the type of developing malocclusion

DIAGNOSTIC REGIMEN

skeletal and dental components

IDENTIFIED




primary incisors more upright

anterior crossbite unilateral / bilateral

with / without functional shift

of mandible


To eliminate mandibular shifts

ORTHODONTIC TREATMENT

maxillary anteriors ( anterior crossbite ) /

expansion of posterior segments

to eliminate posterior crossbite


If dental crossbite a continuing problem

reflects underlying skeletal discrepancy

Growth modification and redirection

“FACIAL MASK”




Orthopedic forces for maxillary protraction

350-500 gm per side over 10-12 hr/day

average of 12-15 months


Stability…….(Questionable)

Because of two reasons

Counter pressure of a tight lip on the maxilla

which inhibits its growth

Scarring in the pterygo maxillary region after

extensive tissue mobilization for palatal closure




Child co-operation

Severity of the malocclusion

Timing of secondary bone grafts

Need for future orthodontic treatment in early mixed

or permanent dentitions


Transition to mixed dentition : 6 to 7 yrs

Further growth of the craniofacial complex

accentuates

previously mild skeletal discrepancy








Elimination of the residual cleft

ALVEOLAR BONE GRAFTING

major advance in contemporary management

cleft maxilla


PRIMARY ALVEOLAR BONE GRAFTING

at the time of lip closure

10-12 weeks ( in 1950’s )

- Causes hinderance in maxillary growth


Performed after primary lip repair

- Early secondary bone grafting ( 2-5 yrs )

- Intermediate or secondary bone grafting ( 6-15 yrs)

- Late secondary bone grafting ( adolescene to adulthood)


Provides bone support for unerupted teeth and those

teeth adjacent to the cleft

Closure of the oronasal fistulae


Support and elevation of the alar base on the cleft side

Construction of a continuous arch form and alveolar

ridge

Achieve stabilization and some repositioning of the

premaxilla in those patients with a bilateral cleft


TIMING

depends on dental development than on

chronological age

Ideally : permanent canine root should be half to

two thirds formed at the time graft is placed



SEQUENCING

Most appropriate time for grafting

INTERMEDIATE PERIOD ( 6-15 yrs)

greatest benefits and least risk for interfering with

Midfacial and skeletodental growth and development


Decayed teeth adjacent to the cleft to be restored

Good oral hygiene practices

Reposition maxillary teeth that are in traumatic

occlusion

Expand a severely constricted maxilla

Erupted teeth adjacent to cleft with poor periodontal or

endodontal prognosis to be extracted atleast 2 months

in advance Dr. Shruti Singh, Subharti Dental College, SVSU

Transverse dimension

Incisor alignment

Eruption of maxillary canines


- Transverse dimension

Retention of corrected crossbite

orthodontic appliances post-surgically

Because bone graft is unlikely to stabilize the expansion


- Incisor alignment

- If appliances have been placed presurgically

orthodontic tooth movements delayed until

3-6 weeks following bone grafting


- Eruption of the maxillary canine

orthodontic tooth movement

space is created in the arch

canine erupts successfully


AUTOGENOUS GRAFTS :

- Iliac

- Tibia

- Rib

- Cranial bone

ALLOGENOUS GRAFTS :

- Freeze dried bone


With eruption of canines and premolars

Permanent dentition is established

Adolescent growth spurt and onset of puberty occur


Skeletal discrepancy

accentuated

Facial appearance +

occlusal relationships

deteriorate


Medial displacement of the maxillary segment giving

buccal cross bite

Relative maxillary retrognathism, giving 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


Full fixed appliance

GOALS :

- Achieve alignment and arch form

- Resolve anterior and or posterior cross-bite tendencies


Expansion appliance

Quad Helix Rapid Maxillary Expansion (RME)


Close the lateral incisor space by substituting canines

brings the posterior segments into a class II r/s

or make compensatory extractions in madibular arch


Maintain or create space for prosthetic build up or

replacement of the missing lateral incisor

Class I molar r/s and a non extraction approach

to the lower arch


If growth deficiency is mild

orthodontic treatment

If growth deficiency is severe

orthognathic surgery at the end of growth


Due to severe skeletal discrepancy

deterioration of esthetics and occlusion

Orthodontic and Orthognathic approach


Size and position of maxilla is often a problem

Thus maxillary advancement and occasional grafting

needs to be performed.

To correct the transverse problem multiple segment

Lefort I osteotomies may be required.


For bilateral CLP

three-piece maxillary surgery

( allows rotation of segments also )

For unilateral CLP

two-piece maxillary surgery

( Vlachos 1996 )


Usually requires 12 months

Multiple segment maxillary osteotomies requires

segmental treatment.

The bracket positions are altered for teeth adjacent

to the osteotomy site.


Proffit recommends overcorrecting the anterior

crossbite - compensate for post surgical relapse.

Cases with overjet of more than 8mm - Mandibular

surgery (BSSO) also must be considered.

If not , over advancement of maxilla – unstable and

speech defects.


Post surgical orthodontics:

- Detailing of occlusion

- Closure of residual spaces

- Maintenance of transverse dimension

- Lasts for 4-6 months.


RETENTION :

Retainers to be placed immediately after removal of

appliance

Soldered lingual arch preferred


TIMING :

Never indicated in active facial growth

Ideal time : 18-19 yrs


Dr. Gavril ( 1903 )

Types :

- external distractors

- internal distractors


Advantage : direction of force is well controlled

Disadvantage : cranial surgery is required

esthetics are compromised


Advantage:

• Esthetics

• Psychological relief

Disadvantage:

• Difficult to control the

direction of force


Replacement of missing teeth

Removable or fixed appliances

improves speech and esthetics


A new system of assessing dental arch relationships

in children with unilateral clefts of lip and palate

The GOSLON ( Great Ormond Street London and

Oslo ) Yardstick is a clinical tool that allows

categorization of the dental arch relationships in the

late mixed and or early permanent dentition stage into

five discrete categories


Cases are allocated to these categories on a value

judgement basis by reference to the anchor groups of

the Goslon yardstick

The clinical features that are considered most

important in characterizing malocclusions in the early

permanent dentition stages of children with unilateral

clefts of lip and palate are :


Anteroposterior arch relationships

Vertical labial segment relationships

Transverse relationships


Severe class III incisor relationship - least satisfactory

Class II division 1 relationship - most favourable

Pre-existing dentoalveolar compensation in the

presence of a reverse overjet - not favourable


Deep overbite preferable to a reduced overbite

which, in turn , was considered a better situation

than an open bite.


Canine cross-bites of the smaller segment were

considered worse than molar cross-bites

The degree of transverse arch narrowness, rather

than the number of teeth in crossbite, is the critical

factor


Anteroposterior relationships

greatest clinical importance

Generalised crowding and irregularity

relatively unimportant


GROUP 1 - Excellent

GROUP 2 - Good

GROUP 3 - Fair

GROUP 4 - Poor

GROUP 5 - Very poor


Groups 1 and 2 - Orthodontic treatment/ none

Group 1 - Complex orthodontic treatment with

good results

Group 4 - limitations of orthodontic treatment

without orthognathic surgery

Group 5 - Orthognathic surgery


Highly reliable

Capable of discriminating among the quality of

results at different centres


Platelet-rich-plasma (PRP) extracted from autologous

whole blood is known to have a number of different

growth factors in high concentration

PRP is a safe and a cost-effective source of growth

factors .

Enhance osteogenesis of alveolar bone grafting in CLP

patients


Muscle derived stem cells have potential for alveolar

bone reconstruction in CLP patients :

Study has shown that cells from orbicularis oris

muscle have phenotypic and behavior characteristics

similar to other adult stem cells, both in vitro and in

vivo.



• CRANIOFACIAL DEVELOPMENT- Sperber

• Surgical orthodontic treatment- Proffit and White

• Grayson etal, Pre surgical naso alveolar molding, cleftliip- craniofacial journal 1999:35

• Cleft Lip and Palate, Diagnosis and Management – Samuel Berkowitz 2nd edition

• Graber. Vanarsdall . Vig – Current Principles and Techniques 4th editionAdvances in management of cleft palate: Edwards and Watson

• Cleft lip and palate, Seminars in Orthodontics

• Baik et al. surgical orthodontic treatment in patients with clcp: conventional surgery vs maxillary distraction, world J Orthod;2:331-40



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Dr. Shruti Singh, Subharti Dental College, SVSU