Cleft Lip and Palate Treatment Quiz

Cleft Lip and Palate

• Cleft lip and palate are defects in the formation of the lip and/or palate.

• Clefting occurs due to the failure of the lip and/or palate to properly fuse during fetal development. These processes contribute to the formation of the primary palate and secondary palate and are covered with ectoderm on the outside and filled with mesoderm on the inside

• The merging of the medial nasal prominences with the maxillary and lateral nasal prominences is essential, breaking down the tissues connecting them, allowing for underlying tissue fusion.

• If these protrusions don't properly fuse in a soft tissue state, a cleft occurs in the lip and palate.

• Primary palate is formed by the fusion of the lateral nasal process with the medial nasal process and maxillary process.

• Forward movement of the lateral nasal process during primary palate formation keeps it in contact with the medial nasal process, and interference with this movement can lead to a cleft.

• Closure of the secondary palate depends on the tongue being cleared from between the palatal shelves. Its elevation and contact with the shelves is crucial at the correct time. Problems with this process frequently result in cleft palate.

Etiology

• Heredity (family history)
• Consanguineous marriage
• Alcohol consumption and smoking during pregnancy
• Drug use during pregnancy (e.g., Phenobarbital, diphenylhydantoin, diazepam, cortisone)
• Radiation exposure during pregnancy
• Infectious disease during pregnancy (e.g., Rubella)
• Excessive vitamin A consumption or deficiency
• Folic acid deficiency
• Teratogenic drugs
• Physical and emotional stress during pregnancy

Classification

• Veau Classification: This classification system categorizes clefts based on the affected palate components (primary and/or secondary) and laterality (i.e. unilateral or bilateral).

  • Group I: Incomplete clefts of the soft palate and uvula (no involvement of the hard palate)
  • Group II: Clefts of the hard palate, soft palate, AND uvula (no involvement of the lip)
  • Group III: Complete unilateral clefts involving lip, alveolus, soft palate, and uvula
  • Group IV: Complete bilateral clefts involving lip, alveolus, hard palate, AND soft palate

• Davis and Ritchie Classification: This system classifies clefts of the lip, distinguishing those that also include the maxillary alveolus and incorporating bilateral, unilateral, or median clefts.

  • Group I: Clefts of the lip (no maxillary alveolus inclusion); unilateral and bilateral
  • Group II: Clefts of the lip involving the maxilla (from the alveolus to the palate)
  • Group III: Clefts that extend to the alveolus (unilateral or bilateral; median cleft can be complete or incomplete)

Types of Cleft Lip and Palate

• Normal palate anatomy displays intact lip, uvula, hard and soft palate.

• Cleft uvula is a split in the uvula.

• Unilateral cleft of the secondary palate affects only one side of the palate.

• Bilateral cleft of the secondary palate affects both sides of the palate.

• Complete unilateral cleft lip and alveolar process of the maxilla with a unilateral cleft of the primary palate (anterior palate).

• Complete bilateral cleft of the lip and alveolar process of the maxillae with a bilateral cleft of the anterior part of the palate.

• (Additional diagrams and explanations of different types are provided)

Prenatal Diagnosis

• 3D Ultrasonography (typically during the second trimester, with 90% accuracy)
• Magnetic Resonance Imaging (MRI)
• Cleft lip occurs during the 6th week of pregnancy
• Cleft palate appears around the 8th week of pregnancy
  • Allows for early identification enabling better preparation for the family's psychological needs, genetic assessment, and ensuring appropriate delivery circumstances.

Clinical Manifestations of Cleft Lip and Palate Patients

• Difficulty feeding (babies with cleft may find breastfeeding challenging).
• Specialized feeding strategies (e.g., bottle feeding may be needed)
• Speech distortion (potential difficulty pronouncing sounds)
• Hypernasality (nose-like vocal quality)
• Chronic otitis media (middle ear infections).
• Hearing disorders, facial growth disturbances, and psychological consequences may also be seen.

Dental Defects Resulting From Cleft

• Anomalies in number of teeth (missing or extra teeth, particularly lateral incisors)

• Position of lateral incisors is unpredictable

• Abnormal tooth shapes (peg-shaped or malformed maxillary lateral incisors)

• Defects of enamel (hypoplasia and opacities—thinning and discoloration)

• Higher occurrences of caries (tooth decay).

• Deviations in tooth eruption (teeth erupting improperly in relation to cleft area)

• Tear-drop shaped defects impacting tooth eruption and proper root position

• Importance of coordinating alveolar bone grafting with orthodontic tooth movement

• Permanent canine emergence often impacted.

Treatment

• Team Approach (pediatrician, orthodontist, prosthodontist, plastic surgeon, dentist, laryngologist, and speech pathologist)

• Infant Orthopedics (Nasoalveolar Molding (NAM)) - an early technique for molding the nasal structure.

• Early Surgeries (lip and palate closure; typically 3-6 months for lip closure, 6-18 months for palatal closure)

• Orthodontic Treatment (correcting jaw and tooth misalignments)

• Orthognathic Surgery (surgical repositioning of the jaw bones)

• Maxillary Distraction Osteogenesis: used for severe maxilla hypoplasia/scarring necessitating significant advancement of the Le Fort I segment.

Bone Grafting

• Most patients with alveolar bone clefts require bone grafting for future tooth movement and prosthetic restoration.
• Common donor sites are iliac crest and calvarial bone.
• Typically performed during mixed dentition.
• Early alveolar bone grafting is crucial to prevent treatment discontinuities preparing for orthognathic surgery.

Orthodontic Treatment

• Significant discrepancy between maxillary and mandibular growth patterns can worsen with age.
• Orthodontists play a crucial role in prevention, correction, and reducing cleft-related problems.
• Orthodontic movement correction for crowding, congenitally missing/supernumerary teeth, and various relationships may be necessary.
• Advanced cases may require complex treatments like orthopedic alignment or even surgical repositioning of the jawbones.

Orthognathic Surgery

• Maxillary advancement or jaw repositioning surgery occurs in cases where significant jaw misalignment is present or if the previous orthodontic treatment is not successful in achieving the desired results.

Maxillary Distraction Osteogenesis

• This procedure is reserved for cases of severe maxilla development issues and scarring, needing substantial advancement of the Le Fort I segment.

Overall

• Children with cleft lip and/or palate often face considerable social challenges and require empathetic care from dental professionals.

This quiz covers key aspects of NAM therapy and its effects on alveolar bone in patients with cleft lip and palate. You'll learn about the timing, duration, techniques, and advantages of NAM therapy, as well as the procedure of bone grafting. Test your knowledge on these critical components of cleft care.