BDS7122 Cleft Lip and Palate PDF

 Cleft lip and palate (CLP) is the most common craniofacial malformation, comprising 65 per cent of all anomalies affecting the head and neck. Non Syndromic syndromic In combination with other physical an...

 Cleft lip and palate (CLP) is the most common craniofacial malformation, comprising 65 per cent of all anomalies affecting the head and neck. Non Syndromic syndromic In combination with other physical and developmental anomalies.  The prevalence of cleft lip and palate varies geographically and between different racial groups. Amongst Caucasians, this anomaly occurs in approximately 1 in every 700 live births. 0.42/1000 live births  A family history can be found in around 40 per cent of cases of cleft lip with or without cleft palate. Cleft lip and palate 2 1 Isolated cleft palate 1 2  In normal development, fusion of the maxillary and medial nasal processes occurs around the sixth week of intra-uterine life.  ‘Flip-up’ of the palatal shelves from a vertical to a horizontal position followed by fusion to form the secondary palate occurs around the eighth week. Before fusion can take place, the embryological processes must grow until they come into contact.  May be complete or incomplete  Feeding The problems associated with cleft lip and/or Hearing Speech palate depend on the type and severity of the cleft and whether both Features lip and palate are involved. of CLP Dental Dental anomalies arch Others Potential problems associated with feeding difficulties include; Fatigue due to excessive energy exerted during feeding; Poor weight gain due to inadequate nutritional intake; Excessive air intake Nasal regurgitation  Speech development is adversely affected by velopharyngeal insufficiency, where the soft palate is not able to make an adequate contact with the back of the pharynx to close off the nasal airway  A cleft involving the posterior part of the hard and soft palate will also involve the tensor palati muscles, which act on the Eustachian tube. This predisposes the patient to hearing difficulties which will also retard a child’s speech development.  Cleft lip only is usually associated with minimal problems. Unilateral Cleft lip and palate is associated with segmentation of the dental arch into lesser and greater segments.  In bilateral clefts both lateral segments are often collapsed behind a prominent premaxilla  Cleft lip with or without cleft palate, and isolated cleft palate are associated with other congenital abnormalities. The prevalence is greater in babies with isolated cleft palate. The most common anomalies affect the heart and extremities.  Delayed eruption Hypodontia “especially the maxillary lateral incisor” or supernumerary teeth. Microdontia and abnormalities of tooth shape Enamel defects  Individuals with unoperated clefts do not experience a significant restriction of facial growth. In contrast, individuals who have undergone surgical repair of a cleft lip and palate exhibit marked restriction of mid-face growth antero-posteriorly “causing a Class III relation” and transversely “causing posterior crossbites” due to the restraining effect of the scar tissue, which results from surgical intervention.  Management: Psychologist Nurse It is a long term, Cleft/ Maxillofacial surgeon plastic complex multidisciplinary CLP surgeon management that GDP & patient prosthodontist Orthodontist starts from birth and extends to over 20 Speech years of age ENT therapist  The clinical nurse from the cleft team provides initial support, help and advice as soon as possible after diagnosis. Education of the mother for feeding the cleft babies is the responsibility of the specialized nurse.  A period of active presurgical orthopaedic alignment of the cleft alveolar segments is occasionally carried out in the neonate to reduce the size of the cleft defect and facilitate surgical repair.  Nasal stents can be added to improve the alar support “naso-alveolar molding”.  Surgical repair of cleft lip is usually carried out between 3 and 6 months of age as a single procedure.  Currently, repair of cleft palate is normally undertaken between 6-9 months or 9 and 12 months of age. In some European centres closure of the hard palate is delayed until 5 years of age to try to reduce the restriction effects of early surgery upon growth, however adverse effects on speech were reported.  Speech assessment starts by the age of 2 years. A pharyngeal surgery ”pharyngoplasty” may be needed to improve the velo-pharyngeal insufficiency which is usually performed by the age of 4-5 years.  Mixed dentition stage Secondary Correction of grafting crossbites During this stage, the restraining Management effect of surgery upon growth Orthodontic of maxillary preparation becomes more apparent, retrusion transversely and antero-posteriorly.  Alveolar or secondary bone grafting involves placing cancellous bone, usually harvested from the iliac crest, directly into the maxillary alveolar defect. This procedure is normally carried out at around 8–10 years of age, before the eruption of the permanent canine, when root formation of this tooth is around two-thirds complete.  Provision of bone through which the permanent canine (or lateral incisor) can erupt into the arch Providing an intact arch; Improved alar base support;  A period of orthodontic treatment is usually required prior to graft placement to expand the collapsed maxillary arch and create surgical access, maximizing the amount of bone that can be placed. This expansion is often achieved with a W arch or a quadhelix appliance, followed by a period of retention.  During this phase of orthodontic treatment, some alignment of the maxillary incisors can be achieved but care needs to be taken not to move any teeth into the cleft site where there is no bone.  Facemask with maxillary expansion plate could be used for maxillary protraction to try to correct the skeletal Class III relationship Permanent dentition stage Orthodontics Orthodontics & orthognathic alone surgery Fixed appliances are used. 25 per cent of CLP patients require orthognathic surgery. Prosthetic replacement It should be deferred until the might be required to growth has been completed. replace missing teeth Surgeries include maxillary “mainly lateral incisors” advancement with/without mandibular setback.  Permanent dentition stage After orthognathic surgery and post surgical orthodontics are finished, plastic surgeons evaluate for revision surgeries to improve aesthetics of the lip and/or nose  The most important thing in management of CLP is being able to audit the treatment progress among the different disciplines involved in care provision. Concentration of expertise and experience at certain centres of excellence produces superior results to those obtained by discrete practitioners. Standardised treatment protocols for management of CLP have been set in many countries in Europe and the Americas. Careful standardised records should be taken before and after any intervention (surgical or orthodontic).  Currently, management of CLP in Egypt is through decentralised care in large numbers of local hospitals and most surgeons work in isolation. There are no constitutional protocols for management and studies showed a wide variation of the surgical techniques and timing. Patients’ registration systems are still lacking in most of the centres. The initiatives for establishment of a standardised national protocol have been already taken to achieve a more efficient care of cleft patients.  Cleft lip and palate is the most common craniofacial malformation affecting the head and neck. Management is complex and requires a co-ordinated multidisciplinary team approach Management starts since birth and continues to mid-twenties. The orthodontist plays an integral role for management of CLP patients. The setting of CLP care in Egypt requires the development of cleft teams of the concerned specialties that follow a standardized protocol. Students are advised to read relevant sections of the following texts: Mitchell L. An introduction to orthodontics; 4th edition, Oxford University Press Cobourne M. DiBiase A. Handbook of Orthodontics; 2nd edition, Elsievier