Cleft Lip and Palate PDF

Cleft Lip and Palate  Cleft Lip and Palate The processes contributing to the formation of the primary palate and secondary palate are covered with ectoderm on t h e o u t s i d e a n d fi l l e d w i t h mesoderm on the inside.  Cleft Lip and Palate The merging of the medial nasal prom...

Cleft Lip and Palate  Cleft Lip and Palate The processes contributing to the formation of the primary palate and secondary palate are covered with ectoderm on t h e o u t s i d e a n d fi l l e d w i t h mesoderm on the inside.  Cleft Lip and Palate The merging of the medial nasal prominences with the maxillary and lateral nasal prominences on both sides involves the breakdown of the surface epithelia (the n a s a l fi n ) t h a t c o n n e c t s them, facilitating the mingling of underlying  Cleft Lip and Palate I f t h e s e p ro t r u s i o n s d o n o t p ro p e r l y f u s e w i t h e a c h o t h e r w h i l e s t i l l i n a s o ft t i s s u e s t a t e , c l e f t i n g o f t h e l i p a n d p a l a t e occurs.  Cleft Lip and Palate Primary palate is formed by the fusion of the lateral nasal process with the medial nasal process and maxillary process.  Cleft Lip and Palate Fo r w a rd m o v e m e n t o f t h e l a t e r a l n a s a l p ro c e s s d u r i n g f o rm a t i o n o f p r i m a r y p a l a t e ke e p s i t i n c o n t a c t w i t h m e d i a l n a s a l p r o c e s s. Interference with this movement can lead to clefting of the palate.  Cleft Lip and Palate Closure of the secondary palate To n g u e depends on removal of the tongue from between the palatal shelves. It is now clear that almost all cases of isolated cleft palate are related to problems in tongue removal, palatal shelf elevation and contact of the shelves at the proper time. Etiology  E tio lo g y  H e r e d i t y ( Fa m i l y h i s t o r y )  Consanguineous marriage  Alcohol consumption and smoking during pregnancy  Drug use during pregnancy (Phenobarbital, diphenylhydantoin, diazepam, cortisone..)  Radiation exposure during pregnancy  E tio lo g y  Infectious disease during pregnancy ( e. g. Ru b e l l a )  E x c e s s i v e c o m s u m p t i o n a n d d e fi c i e n c y o f Vitamin A  Fo l i c a c i d d e fi c i e n c y  Te r a t o g e n i c d r u g s  Physical and emotional stress during pregnancy Classification  Classifi cation  Ve a u C l a s s i fi c a t i o n (secondary a n d / o r p r i m a r y p a l a t e s a r e a ff e c t e d a n d b y laterality)  Group I – Incomplete cleft, Clefts of the soft palate and uvula (no uni-/bilateral)  Group II – Clefts of the hard palate & soft palate& uvula (no uni-/bilateral)  Group III – Complete unilateral cleft (Clefts of the uvula &soft palate& alveolus, usually involving the lip  Group IV – Complete bilateral clefts (Lip & Alveolus &Hard palate & Soft palate)  Classifi cation  Davis a n d R i t c h i e C l a s s i fi c a t i o n  Group I- Clefts of the lip (without the inclusion of the maxillary alveolus),  unilateral,  bilateral  median  Group II- Clefts inclusive from the maxillary alveolus to the palate,  Hard palate  Soft palate  Group III- Cleft including the alveolus,  unilateral,  bilateral, or  median being complete or incomplete Types of Cleft Lip and Palate Normal Cleft uvula Unilateral cleft of the Bilateral cleft of the secondary (posterior) palate posterior part of the palate Complete unilateral cleft Complete bilateral cleft of of the lip and alveolar the lip and alveolar process of the maxilla with processes of the maxillae a unilateral cleft of the with bilateral cleft of the primary (anterior) palate. anterior part of the palate. Complete bilateral cleft of the Complete bilateral cleft of lip and alveolar processes of the lip and alveolar processes the maxillae with bilateral of the maxillae with complete cleft of the anterior part of bilateral cleft of the anterior the palate and unilateral cleft and posterior palate. of the posterior part of the palate Infant with a unilateral complete cleft lip and palate Cleft of the lip with or without a palate is seen in approximately 1 in 1000 births M o s t a ff e c t e d i n f a n t s a r e male Diagnosis  Prenatal Diagnosis  3D Ultrasonography  (2nd trimester, 90%)  M a g n e t i c Re s o n a n c e I m a g i n g (MRI)  Prenatal Diagnosis  Cleft lip occurs at the 6 th week of pregnancy, the period when mothers usually are not aware that they are even pregnant.  Cleft palate occurs a p p roxi ma t e l y a t t h e 8 t h w e e k o f t h e p r e g n a n c y.  Prenatal Diagnosis  Diagnosing cleft lip and palate during the p r e n a t a l p e r i o d h o l d s s i g n i fi c a n t importance.  It enables informing the family in advance, preparing them psychologically for the post- birth period, assessing genetic risks, and ensuring the fetus is delivered under suitable conditions.  Prenatal Diagnosis  This early diagnosis facilitates the initiation of orthodontic treatment shortly after birth and allows for the planning of appropriate surgical interventions.  Additionally, it is crucial to determine whether cleft lip and palate serve as indicators for a s y n d r o m e o r n o t ( e. g. t r i s o m y, D i G e o r g e syndrome, Pierre Robin syndrome etc.). Clinical Manifestatio ns  Clinical Manifestations of Cleft Lip and Palate Patients  D i ffi c u l t y w i t h f e e d i n g  Slightly upright position during breast feeding  Specialized feeding strategies  Speech distortion  Hearing disorders  Hypernasality  Facial growth disturbances  Chronic otitis media  Psychological consequences  Dental Defects Resulting From Cleft  A n o m a l i e s i n N u m b e r o f Te e t h  a missing or a supernumerary m a x i l l a r y l a t e r a l i n c i s o r.  The position of the lateral incisor is also unpredictable  A b n o r m a l To o t h S h a p e  peg-shaped, or malformed, maxillary l a t e r a l i n c i s o r.  Dental Defects Resulting From Cleft  Defects of Enamel  Defective enamel (hypoplasia and opacities)  Higher occurrence of caries  Dental Defects Resulting From Cleft  D e v i a t i o n s i n To o t h E r u p t i o n  Te e t h a d j a c e n t t o a l v e o l a r c l e f t s r a r e l y e r u p t i n t o g o o d alignment.  Te a r d r o p s h a p e o f t h e d e f e c t m a y n o t a l l o w t h e t o o t h t o erupt in its normal position and emerge with its roots upright  Important to coordinate the timing of alveolar bone grafting of the cleft defect with orthodontic tooth movement  Dental Defects Resulting From Cleft  D e v i a t i o n s i n To o t h E r u p t i o n  Emergence of the permanent canine is often at risk  Therefore before orthodontic alignment of the canine is initiated, it is important to plan and perform the bone grafting of the alveolar defect to ensure proper tooth eruption. Treatment  Pediatrici an Logopedics and Orthodontis Phoniatrics ts Te a m Laryngologist Prosthodonti cs Plastic Dentist Surgeon s  Tr e a t m e n t  Infant Orthopeadics (Nasoalveolar Molding)  Early Surgeries (Lip and palate closure)  O r t h o d o n t i c Tr e a t m e n t  Orthognatic Surgery  Distraction Osteogenesis (severe cases)  Nasoalveolar Molding (NAM)  The nasoalveolar molding (NAM) technique uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period.  N A M t a ke s t h e a d v a n t a g e o f t h e fl e x i b i l i t y o f t h e c a r t i l a g i n o u s s e p t u m i n t h e fi r s t f e w w e e k s a f t e r b i r t h.  NAM (Grayson &Cutting, 1990s)  Presurgical preparation with NAM also  changes the rotation of the incisal bone and therefore the alveolar bone shape becomes less triangular, more natural  the cleft gap spontaneously reduces  NAM (Grayson &Cutting, 1990s)  Also with the help of lip massage and lip taping, the skin is forced to close over the alveolar bone.  NAM  Fo r N A M t h e r a p y t o b e s u c c e s s f u l , t r e a t m e n t m u s t b e g i n s o o n a f t e r b i r t h ( w i t h i n t h e fi r s t 2 w e e k s ).  NAM (Grayson &Cutting, 1990s)  T h e o v e r a l l t re a t m e n t t i m e f o r a n infant with  Unilateral cleft lip and palate is about 3 months (including 10–12 visits)  Bilateral cleft lip and palate is 4-5 months (including 18–20 visits).  Advantages of NAM Therapy  Cleft width is narrowed, alveolar segments a re approx imated  Alveolar repair is facilitated by narrowing the cleft.  The proper alignment and a pprox imation of the a lv eolar segments allow for tension-free gingival closure across the cleft d u r i n g s u r g e r y.  Advantages of NAM Therapy  Corrects the nasal cartilage and soft tissue deformity  Re d u c e s t h e m a g n i t u d e o f t h e s u r g i c a l challenge and improving outcomes.  Nasal correction performed at the same stage as the primary lip repair also reduces the need for subsequent revision surgeries  Lip & Palate Closure Surgeries  In 3–6 months for lip and 6–18 months for palatal closure.  Bone Grafting  Most of the patients with cleft of the alveolar bone need bone grafting to restore the shape of the bone for the future teeth movement and prosthetic restoration.  Most common donor site is iliac crest or calvarial bone.  Bone Grafting  The bone grafting is usually performed at the m i xe d d e n t i t i o n s t a g e  It is very important to have the upper jaws prepared for orthognathic surgery without any discontinuity; for this, alveolar bone grafting in early age is crucial; if it was not done previously bone graft is performed 1 year b e f o r e t h e o r t h o g n a t h i c s u r g e r y.  Orthodontic Treatment  S i g n i fi c a n t d i s c r e p a n c y i n t h e maxillary and mandibular growth patterns will worsen with age.  The orthodontist plays an important role in the prevention, correction, and reduction of the consequences of cleft lip and cleft palate.  Orthodontic Treatment  In more severe cases, good occlusion achievement may require quite complex treatment by the orthodontist, extensive orthopedics, or even surgical repositioning of the jaws through o r t h o g n a t h i c s u r g e r y.  Orthodontic Treatment CLP patients are usually presented  V- s h a p e d a rc h f o r m w i t h c ro w d i n g with  Supernumerary and/or  Class III relationship congenitally missing teeth etc.  Tr a n s v e r s e m a x i l l a r y d e fi c i e n c y  Ve r t i c a l d e fi c i e n c y o f m a x i l l a  Orthodontic Treatment With orthodontic treatment, arches (presurgical orthodontics)  Develop the arch shape & align the teeth  Extract/Open space for supernumerary teeth  Expansion of the upper arch  Tr a c t i o n o f i m p a c t e d t e e t h (especially canines)  Coordinate the upper & lower  Orthognatic Surgery  Maxillary advancement or  Double jaw surgery  Maxillary Distraction Osteogenesis Maxillary distraction is indicated in severe hypoplastic and/or s c a r r e d m a x i l l a n e e d i n g s i g n i fi c a n t a d v a n c e m e n t o f t h e L e Fo r t I s e g m e n t. T h e c h i l d w i t h a c l e ft o ft e n f a c e s c o n s i d e r a b l e social challenges and deserves the most e m p a t h e t i c c a re f ro m t h e d e n t i s t. Thank you for your attention..