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DENTISTRY
SEMINAR OF CLEFT
MANAGEMENT
CONTENTS
Prenatal Diagnosis.
Protocol For Dental Care.
A Multi- Disciplinary Team.
Management
Dentofacial Orthopedics
Management of cleft Lip & Nasal Deformity.
Cleft Palate Repair.
Orthodontic Treatment.
Role of E.N.T. Specialist, Speech Pathologist.
Correction of Maxillary Hypoplasia
Correction of Enamel Hypoplasia.
Role of Prosthodontics
Role of Psychologist
PRENATAL DIAGNOSIS
AND COUNSELING
• Intrauterine diagnosis of orofacial clefts is
possible by ultrasonography.
• Complete clefts are seen easily at 16
weeks gestation.
• Incomplete clefts are seen more readily at
27 weeks.
• Palatal clefts are difficult to visualize by
prenatal ultra sonography.
• The family or obstetrician may request
prenatal consultation with a surgeon.
Protocol For Dental Care of Cleft
Lip and Palate in Children
At Birth
• Predental treatment is provided which comprises feeding
plate, pre surgical orthopedics and helps surgeon in repair
by stimulating palatal bone growth and preventing collapse
of dental arches.
3-5 Month.
• Alignment of the primary teeth and palatal expansion to be
started using a simple fixed appliance like warch & Arnold
expander plastic surgeon to repair the lip.
• Suction myringotomy for “Glue ear”
12 Months.
• Pedodontic review palatal pro sthetic speech.
Appliance may by required to correct velo
pharygeal incompetence.
• Plastic surgeon to repair the cleft palate.
2-6 Years.
• Pedodontic showed review facial growth and development with
regular monitoring one year interval.
• Preventive measures for caries like fissure, sealing, fluoride.
• Restorative
6-7 years.
• Removal of super numerary teeth, correction of cross bite.
• Orthodontic consultation.
8-9 years.
• Suitability about bone grafting.
• Dental bone assessment (OPG, wrist, lateral cephalogram,.
• Review by the plastic surgeon, speech pathologist & ENT
surgeon.
• If needed to relieve crowding and retroclination of the anterior
teeth.
9 years.
• Combined orthodontist and pedodontist
coalescence.
• Bone graft alveolar cleft at half to 1/3 root
development of permanent cuspid.
10-12 years.
• Orthodontic consultation
• Monitoring changing dentition and growth.
12-15 years.
• Orthodontic treatment.
• Speech pathologist to review changing of
the pitch of voice in boys.
A Multi-Disciplinary Team for Cleft
Lip and Palate Patients.
Obstetrician = Refers the child to plastic surgeon
and pediatrician for expert opinion counseling the
parents.
Pediatrician or Neonatology's=Provide medical
care refers the case to the plastic surgeon.
Plastic Surgeon:-Carries out initial lip repair
and palate surgery – performs pharyngoplasty or
reversionary lip & nose surgery.
Oromaxillofacial Surgeon= Usually comes in the
picture of bone grafting – if any final orthopedic
surgery is performed at later stage.
Neurosurgeon= any craniofacial syndrome is
associated.
Pedodontist=
A key member who sees the baby and the parent at
the time of repair of the lip.
Provides pre surgical orthopedic treatment for the
baby.
Pedodontist monitor the growth and development.
To maintain perfect oral health.
To guide the occlusion and facial growth.
Motivates the parent & the child to cooperate with
the treatment.
Orthodontist: Carries out definitive orthodontic
treatment once the full permanent dentition is
erupted.
Speech pathologist: =
• Monitors the speech development to normal.
• Test for an adequate palato pharyngeal closure and guiding
the surgeon as to whether a pharyngeal flap may be
necessary.
Audiologist:- To test hearing in the baby
infants & the young child providing essential
information in hearing loss for both speech
patholigist and otolarynologist.
Otolarynologist: Concerns with the health of
nasopharyngeal tissues including tonsils, adenoids
and middle ear structures.
Blockage of the auditory canal and gluteneous
secretion (glue ear) is very common in these disease.
Psychologist: Plays on important role when the
child’s family is under stress.
MANAGEMENT:
Infancy:
General Consideration:- Patients with C.L.P. requires,
interdisciplinary care from a team of provides including a
geneticist, plastic surgeon, oral and maxillofacial
surgeon, otolaryngologist, dentist, orthodontist, speech
therapic audiologist, psychologist, social worker & nurse.
The role of each specialist depends on the age of the
patient.
During the first days of the infant’s life:-
The infants with a cleft palate cannot generate the negative
intraoral pressure needed to suck from a bottle.
The Nurse on the team or another feeding specialist must
instruct the parents in the use of special feeding device for the
infant eg:- Haberman nipple, catheter & syringe, spoon feeding.
Infants with cleft palate have difficulty ventilating the
eustachian tube. This result in the accumulation of fluid in the
must be treated promptly with antibiotics.
DENTOFACIAL ORTHOPEDICS
In unilateral complete cleft lip and palate (UCCLP) or
bilateral complete cleft lip and palate (BCCLP) with a
protruding premaxilla, labial repair is often
completed with tension on the closure.
Orthopedic appliances bring the dentoalveloar
segments together facilitating a tension free labial
repair that requires undermining of tissues.
In addition, alveolar approximate forms the skeletal
plateform for correction of the nasal deformity and
permits gingivoperiosteoplasty. Alveolar closure
eliminates an around fistula.
The appliance is removed at the time of labial repair
and replaced with a passive appliance to maintain
the alveolar position.
Management of Cleft Lip And Nasal
Deformity
Single stage: repair the unilateral complete cleft lip
and nasal deformity in a single stage.
Two stage repair: First repair unilateral cleft lip &
vermilion deformity.
Proper alignment of white line.
acceptable scar.
1. Straight Line Lip Repair.
Indication:- of incomplete and narrow clefts.
Advantage :- Easy repair
Disadvantage:- Limited Indications.
Tennison Randall Repair
A triangular flap is created on the lateral side
of the cleft to fit into the triangular.
This procedure can be planned exactly after
initial measurements the results can not be
modified once the lip is cut.
The scar is more prominent than in other
procedures.
• Advantage:- Measured techniques
More easily taught.
Can be used for wide dept.
• Disadvantage: Scar interrupts the philtrum
line difficult to modify during
procedure.
VEAU REPAIR
There is only a displacement, deformation and under
development of the muscles and the skeletal tissue.
The surgical procedure should thus aim at returning
there structures to their correct positions.
The naso labial muscles are reconstructed accurately
and within a few weeks, without any form of flap
closure.
This method gives satisfactory results in bilateral
cleft lip.
MILLARD’S Techniques (Rotation advancement
technique) principles of closing bilateral cleft lip.
• Maintain symmetry
• design the prolabium of proper size & shape.
• Ensure primary muscular continuity.
• Construct the median tubercle from lateral labial
elements.
• Peeform primary construction of the columella &
nasal tip.
Procedure :-rotation flap and columella flap are
planned on the medial side of the cleft. after full
thickness of the lip is cut along the marking rotation
gap is produced on the medial side which is filled by
an advancement flap planned on the lateral side of
cleft.
Advantage:- Minimal tissue is discarded
Allows modification during repair
Disadvantage: Difficult for use in wide cleft.
May narrow the nostrial.
CLEFT PALATE REPAIR
Basic goals of palate repair
Separation of oral and nasal cavities.
Construction of watertight and airtight velopharyngeal valve.
Preservation of facial growth.
Development of esthetic dentition.
TIMING OF SURGERY
Early repair leads to a better speech development but severe
balanced result.
Only soft palate are closed by 6-18 months.
TECHNIQUES OF PALATE REPAIR
Single stare technique.
eg:- von langenbeck repair
Ven wardill kilner v-y push back palatoplasty at are
1½ years.
Two stare technique:-
• First stage : soft palate repair before 18 month.
• Second stage hard palate repair at 4-5 years.
eg. Schweckendiek technique.
1) Primary Veloplasty By Schweekendiek.
• First soft palate is closed at an early age 16-12 months)
• Hard palate closed after few years.
• Principle of this techniques is that the soft palate aids in the
speech and is essential to be closed early for velopharyngeal
mechanism.
Disadvantage:- Speech problem (Severe)
Additional surgical procedure.
2) VON LANGENBECK’S PALATO PLASTY.
• Use bipedicled mucoperiosteal flaps of the hard and soft
palate for repair of the defect.
• There interiorly and posteriorly based flaps are advanced
medially closed the palatal defect.
Advantage:- Easy to perform, requires less
dissection. results in decreased denuded palate.
Disadvantage:- Failure to provide additional
palatal length.
- Poor results in large clefts.
- Currently not commonly used.
Veau-Wardill-Kilnar-v-y- Pushback
palatoplasty.
Two mucoperiosteal flaps are raised from a hard
palate and nasal layers are mobilized abnormal
attachment of palatal muscles are divided from the
posterior border of the hard palate to be sutured in
midline to the opposite side the palatal muscle.
Suturing done anterior of the nasal layer and
progressed toward Uvula.
ORTHODONTICS AND MAXILLARY
ORTHOPAEDICS.
Different stages of dentition methods.
A) predental treatment.
B) Deciduous dentition ( 3 to 6 years)
C) Early mixed dentition ( 7 to 9 years)
D) Late mixed and early permanent dentition.
E) Permanent dentition.
A) PRE DENTAL TREATMENT
ROLE OF PSYCHOLOGIST
The psychiatrist and psychologist evaluate the
patient for strength and weakness in cognitive
interpersonal, emotional, behavioural and social
development: emphasis is placed on the patient’s
ability to cope with the emotional and psycheal
stress created by the cleft defect. Consultation with
the parents and schools regarding educational or
behavioural management if carried out when
indicated.
CONCLUSION
The management of cleft lip & palate is
necessary at correct time. If delayed in
the treatment there may be possibility to
developed abnormalities.
So to prevent some problems like speech
problem facial asymmetry, feeding
problem & infection to nasal cavity &
unasthetic appearance. The treatment is
necessary.
REFERENCES
Pediatric Oral & Maxillofacial Surgery by
Leonard B. Kaban , Maria T. Troulis.
Facial cleft and cranio synostosis By
Timothy A. Turvey, Kathorine W L VIG ,
Raymond J. Fansecu.
Clinical Pedodontics By Sidney B. Finn.
Oral & Maxillofacial Surgery by Chitra
Chakravarthy
Clinical Pedodontics By Shobha Tandon.