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8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 161
DR RANJITHA S
PG STUDENT
DEPT OF ORTHODONTI
craniofacial anomalies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 261
contents
Introduction
Definition of craniofacial anomalies(CFA)
Types of anomalies
Etiology
Role of an orthodontist in CFA
Cleft lip and palate
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 361
INTRODUCTION The birth of a child with a facial deformity is a devastating
event for most parents who often have never seen orheard about similar malformations For some parents it isvery difficult to accept the deformity of the child becauseit involves the face making the child appear completelydifferent from all the others Feelings of rejection guiltand anxiety gradually develop
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 461
Three-quarters of the malformations diagnosed at birth fall in the category ldquocraniofacialrdquo The most commonfacial malformations are cleft lip and cleft palate
Less frequent are the syndromes of the I and II branchialarches such as hemifacial microsomia (Oto-mandibularSyndrome) or Franceschetti syndrome (Treacher Collins)
Even more rare are the forms that primarily involve themidface and the skull called cranio-facial-synostosissuch as Apert Syndrome (1 born in 100000) or Crouzon
syndrome (1 in 25000)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 561
Craniofacial anomalies (CFA) are a diverse group ofdeformities in the growth of the head and facial bones
Anomaly is a medical term meaning irregularity or
different from normal These abnormalities arecongenital (present at birth) and there are numerousvariations - some are mild and some are severe andrequire surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 661
Types of Anomaliesbull Malformations
ndash Occur during formation of structures
bull Complete or partial absencebull Alterations of its normal configuration
bull Disruptions
ndash Morphological alterations of structures after formation
bull Due to destructive processes
bull Deformations
ndash Due to mechanical forces that mold a part of fetus over aprolonged period of time
bull Clubfeet due to compression in the amniotic cavity
bull Syndromes
ndash Group of anomalies occuring together with a specific
common etiologybull Dia nosis made amp risk of recurrence is known
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 261
contents
Introduction
Definition of craniofacial anomalies(CFA)
Types of anomalies
Etiology
Role of an orthodontist in CFA
Cleft lip and palate
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 361
INTRODUCTION The birth of a child with a facial deformity is a devastating
event for most parents who often have never seen orheard about similar malformations For some parents it isvery difficult to accept the deformity of the child becauseit involves the face making the child appear completelydifferent from all the others Feelings of rejection guiltand anxiety gradually develop
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 461
Three-quarters of the malformations diagnosed at birth fall in the category ldquocraniofacialrdquo The most commonfacial malformations are cleft lip and cleft palate
Less frequent are the syndromes of the I and II branchialarches such as hemifacial microsomia (Oto-mandibularSyndrome) or Franceschetti syndrome (Treacher Collins)
Even more rare are the forms that primarily involve themidface and the skull called cranio-facial-synostosissuch as Apert Syndrome (1 born in 100000) or Crouzon
syndrome (1 in 25000)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 561
Craniofacial anomalies (CFA) are a diverse group ofdeformities in the growth of the head and facial bones
Anomaly is a medical term meaning irregularity or
different from normal These abnormalities arecongenital (present at birth) and there are numerousvariations - some are mild and some are severe andrequire surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 661
Types of Anomaliesbull Malformations
ndash Occur during formation of structures
bull Complete or partial absencebull Alterations of its normal configuration
bull Disruptions
ndash Morphological alterations of structures after formation
bull Due to destructive processes
bull Deformations
ndash Due to mechanical forces that mold a part of fetus over aprolonged period of time
bull Clubfeet due to compression in the amniotic cavity
bull Syndromes
ndash Group of anomalies occuring together with a specific
common etiologybull Dia nosis made amp risk of recurrence is known
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 361
INTRODUCTION The birth of a child with a facial deformity is a devastating
event for most parents who often have never seen orheard about similar malformations For some parents it isvery difficult to accept the deformity of the child becauseit involves the face making the child appear completelydifferent from all the others Feelings of rejection guiltand anxiety gradually develop
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 461
Three-quarters of the malformations diagnosed at birth fall in the category ldquocraniofacialrdquo The most commonfacial malformations are cleft lip and cleft palate
Less frequent are the syndromes of the I and II branchialarches such as hemifacial microsomia (Oto-mandibularSyndrome) or Franceschetti syndrome (Treacher Collins)
Even more rare are the forms that primarily involve themidface and the skull called cranio-facial-synostosissuch as Apert Syndrome (1 born in 100000) or Crouzon
syndrome (1 in 25000)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 561
Craniofacial anomalies (CFA) are a diverse group ofdeformities in the growth of the head and facial bones
Anomaly is a medical term meaning irregularity or
different from normal These abnormalities arecongenital (present at birth) and there are numerousvariations - some are mild and some are severe andrequire surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 661
Types of Anomaliesbull Malformations
ndash Occur during formation of structures
bull Complete or partial absencebull Alterations of its normal configuration
bull Disruptions
ndash Morphological alterations of structures after formation
bull Due to destructive processes
bull Deformations
ndash Due to mechanical forces that mold a part of fetus over aprolonged period of time
bull Clubfeet due to compression in the amniotic cavity
bull Syndromes
ndash Group of anomalies occuring together with a specific
common etiologybull Dia nosis made amp risk of recurrence is known
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 461
Three-quarters of the malformations diagnosed at birth fall in the category ldquocraniofacialrdquo The most commonfacial malformations are cleft lip and cleft palate
Less frequent are the syndromes of the I and II branchialarches such as hemifacial microsomia (Oto-mandibularSyndrome) or Franceschetti syndrome (Treacher Collins)
Even more rare are the forms that primarily involve themidface and the skull called cranio-facial-synostosissuch as Apert Syndrome (1 born in 100000) or Crouzon
syndrome (1 in 25000)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 561
Craniofacial anomalies (CFA) are a diverse group ofdeformities in the growth of the head and facial bones
Anomaly is a medical term meaning irregularity or
different from normal These abnormalities arecongenital (present at birth) and there are numerousvariations - some are mild and some are severe andrequire surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 661
Types of Anomaliesbull Malformations
ndash Occur during formation of structures
bull Complete or partial absencebull Alterations of its normal configuration
bull Disruptions
ndash Morphological alterations of structures after formation
bull Due to destructive processes
bull Deformations
ndash Due to mechanical forces that mold a part of fetus over aprolonged period of time
bull Clubfeet due to compression in the amniotic cavity
bull Syndromes
ndash Group of anomalies occuring together with a specific
common etiologybull Dia nosis made amp risk of recurrence is known
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 561
Craniofacial anomalies (CFA) are a diverse group ofdeformities in the growth of the head and facial bones
Anomaly is a medical term meaning irregularity or
different from normal These abnormalities arecongenital (present at birth) and there are numerousvariations - some are mild and some are severe andrequire surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 661
Types of Anomaliesbull Malformations
ndash Occur during formation of structures
bull Complete or partial absencebull Alterations of its normal configuration
bull Disruptions
ndash Morphological alterations of structures after formation
bull Due to destructive processes
bull Deformations
ndash Due to mechanical forces that mold a part of fetus over aprolonged period of time
bull Clubfeet due to compression in the amniotic cavity
bull Syndromes
ndash Group of anomalies occuring together with a specific
common etiologybull Dia nosis made amp risk of recurrence is known
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 661
Types of Anomaliesbull Malformations
ndash Occur during formation of structures
bull Complete or partial absencebull Alterations of its normal configuration
bull Disruptions
ndash Morphological alterations of structures after formation
bull Due to destructive processes
bull Deformations
ndash Due to mechanical forces that mold a part of fetus over aprolonged period of time
bull Clubfeet due to compression in the amniotic cavity
bull Syndromes
ndash Group of anomalies occuring together with a specific
common etiologybull Dia nosis made amp risk of recurrence is known
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 761
Etiology of CFAbull
GeneticchromosomalEnviornmental
bull Incidence
2-3 of newborn (4-6 by age 5)
In 40-60 of all birth defects cause is unknownbull Geneticchromosomal
10-15
bull Environmental
10bull Multifactorial (genetic amp environmental)
20-25
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 861
CAUSES OF CRANIOFACIAL ABNORMALITIES
1Chromosomal abnormalities
Numerical abnormalities Structural abnormalities
Autosomes Sex chromosomes
1 Deletion2 Duplication3 Inversion
4 Translocation
Down syndrome Turner syndrome Congenitalabnormalities
(if unbalanced)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 961
Environmental factors
bull Infectious agents rubella cytomegalovirus HSV syphilistoxoplasmosis
bull Radiation teratogenic effects
bull Chemical Agentsdrugs thalidomidevaliumphenytoin valproic acid amphetamines
bull Hormones
bull Late pregnancies downrsquos syndrome
bull Nutritional Deficiencies folic acid deficiencies
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1061
Role of an orthodontist in craniofacial anomalies
The orthodontist is an essential member of any craniofacial team
The role of the orthodontist on the team is tobull Help determine which craniofacial structures are abnormal in theaffected patientbull Determine the facial growth pattern and predict the futuremorphology
bull Estimate the effect that various treatment modalities particularlysurgery would have on subsequent growth and advise on theappropriate nature and timing of treatmentbull To Plan with the surgeon for the desired skeletal and soft tissue
alterationsbull To Prepare for the orthognathic component of the surgery bymanipulating the teeth and alveolar process and completeorthodontic corrections after the surgery
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1161
Cleft lip
Defective fusion of medial
nasal process with the
maxillary process leads to
cleft lip (CL)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1261
Cleft palate
Similarly failure of fusion
of palatal shelves leads to
cleft palate (CP)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1361
Frequently CL amp CP occur together
Approximately 45 cases are CL + CP while 30 areisolated CL and 25 isolated CP
Isolated CP appears to represent a separate entity
Other rare facial clefts like lateral facial cleft occurs as a
result of failure of fusion of maxillary and mandibularprocesses leading to a cleft from corner of mouth towardear
Oblique facial cleft extends from upper lip towards theeye and is almost always associated with CP Caused byfailure of fusion between maxillary process with lateralnasal process
Midline cleft of upper lip is extremely rare and representsfailure of fusion of medial nasal processes in the midline
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1461
ETIOLOGY Cause is still being debated
Important to distinguish between isolated clefts andclefts associated with developmental syndromes
More than 250 syndromes are associated with orofacialclefts and account for 3 - 8 of orofacial clefts eg
Pierre Robin syndrome Treacher-Collins syndrome etc Environmental factors like alcohol consumption viruses
etc also may combine with developmental factors
SYNDROMES
velocardiofacial syndrome goldenhar syndromestickler amp treacher collins syndromes
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1561
CLINICAL FEATURES
RACIAL PREVALENCE -
Clefting is one of the most common congenital defects in
humans
Prevalence varies between races mongoloids with the
highest incidence of 1 in 600-1000 births and the negroid
race with the least incidence of 1 in 2000 births
Isolated CP is less common than CL + - CP
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1661
SEX PREDILECTION -
CL + - CP is more common in males
More severe the defect greater is the male predilection
Male to female ratio for isolated CL is 15 1
MF ratio for CL+CP is 2 1
In contrast isolated CP is commoner in females with the MF
ratio being 1 2
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1761
SIGNS amp SYMPTOMS -
About 80 cases of CL are unilateral with 70 of
unilateral cases occurring on left side
A complete CL extends till the nose
A CP shows considerable variation in severity with the
defect involving both hard and soft palate or soft palate
alone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1861
CLASSIFICATION
1 Veaursquos simple classification (1931)
2 Pfeiferrsquos symbolic classification (1966)
3 Kernahan amp Starkrsquos striped Y classification (1971)
4 Krienrsquos LAHSHAL classification (1987)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 1961
Classification - Veau
GROUP IClefts of soft palateonly
GROUP IIClefts of soft andhard palate reaching anteriorly
to incisive foramen GROUP IIIComplete unilateral
alveolar clefts - generallyinvolve the lip as well
GROUP IVBilateral alveolarclefts - associated with bilateralclefts of the lip
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2061
PFEIFERrsquos SYMBOLIC
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2161
KERNAHANrsquos STRIPED Y
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2261
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2361
Problems associated with clefts
Cleft patients suffer from many direct as well as well asindirect problems
The most obvious problem is clinical appearance leadingto psychosocial problems
Feeding difficulties
Poor growth
Recurrent Ear infections
speech difficulties are common especially with CP
CP also causes collapsing of maxillary arch missing ofteeth supernumerary teeth leading to malocclusion
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2461
24
Management of cleft lip and palate
Family Systems Counseling
Considers each family member as part of asystem
Each member affects the others
System is interdependent
Within the system are subsystems
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2561
Feeding problems often associated with cleft anomaliesmake it difficult for the infant to maintain adequate
nutrition
These problems include insufficient suction to pull milkfrom the nipple excessive air intake during feeding
choking nasal discharge and excessive time required totake nourishment
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2661
Feeding by nasogastric tube
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2761
Feeding of
cleft lip and
palate
patients
Pigeon feeder
Haberman feeder
Squeeze bottle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2861
Cleft Babies Should Be
Kept In Upright Position
For Feeding To Make
Gravity Aid In Milk
Feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 2961
Feeding plates to assist in early feeding
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3061
OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate
the cleft and restore the seperation between the oral and nasal
The obturator prevents the tongue from entering the defect and
interfering with spontaneous growth of the palatal shelves
Reduces nasal regurgitation
Also helps in the development of the jaws and speech
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3161
Cleft Lip Repair
Rule of 10rsquos by MILLARD Surgery gt 10 weeks old
Weight gt 10 pounds
Hemoglobin level gt 10 gdL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3261
Cleft Lip Repair(types)
Millard Repair - Rotation advancement technique
Randall - Graham - Triangular flap interposition
Rose - Thompson - Straight line repair Risk of verticalcontracture
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3361
Cleft Lip Repair
Goals Bridge the cleft
Create a complete muscular sling around the entirecircumference of the oral cavity
Approximate cleft edges Maintain Cupids bow and philtral dimple
Align vermillion border
Create an intact nasal floor and sill
Produce symmetry of the alar base and columella
Reconstituting the circumferential integrity of theorbicularis oris muscle
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3461
Speech and Hearing
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear
Speech problems are usually treated by a speech-language pathologist
Encourage the childs early attempts to make soundseven before the cleft is repaired
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3561
Role of Orthodontics
a Infant Orthopedics
b Treatment in deciduous dentition
c Treatment in mixed dentition
d Treatment in permanent dentition
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3661
Role of presurgical orthopedics
Introduced by McNeil in early 1950rsquos
Proposed Benefits
1 Control and modify the post-natal maxillary and Orofacialdevelopment2 Stimulation of palatal shelf growth3 Constriction of expanded anterior part of maxilla
4 Reposition of premaxilla to aid the surgeon prior to lip repairor primary bone grafting
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3761
Neonatal Orthopaedics
Performed on new born before surgicalrepair of lip
Rationalerealignment of the collapsedsegments before surgery Either simple passive active orthopaedic
extra orally activated pin retained Definitely makes lip and anterior palate
surgery easier at the time
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3861
Naso Alveolar Molding(NAM)
NAM is non surgical method of reshaping alveolus lip andnostrils before cleft lip and palate surgery lessening theseverity of cleft
It is the passive method of bringing the gum and lip together
by redirecting the forces of natural growth It is a modern presurgical orthopedic device that allows for a
positive growth of alveolar ridges into a improved arch form
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 3961
Advantages of performing NAM
provides a more coalescent cleft and an ideally shapedalveolar arch form
It diminishes tension during primary surgerymaking scarformation more diificult
Alignment of alveolar segment creates the foundation forgood lip symmetry
More favourable bone formation by reducing the cleft gap
Allows the surgeon to definitely correct the nose without
extensive dissection Diminished need for bone grafting during the mixed dentition
stage
Premaxillary Retraction
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4061
Premaxillary Retraction
In cases of bilateral cleft lip and palate premaxillarysegment may be positioned severely anterior to the maxillary arch if lipsurgery is undertaken with the premaxilla in such an abnormal positionthe chances of lip dehiscence by increased pressure at the suture linesare increased
Segments may be deviatedlaterally to one side of the cleftdefect In such cases a straightextra oral force would not placethe pre maxilla in the facialmidline this can be retracted by
the application of sequentialdifferential force to thepremaxilla with elastic strapsattached to the bulb prosthesis
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4161
An impression is made of the infants premaxilla forconstruction of an external acrylic bulb prosthesis
This appliance isfitted over theprotruding and
laterally displacedpremaxilla andanchored to theinfants head with abonnet appliance
LATHAMrsquo S APPLIANCE FOR PRESURGICAL
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4261
LATHAM S APPLIANCE FOR PRESURGICAL
REPOSITIONING OF THE PROTRUDED PREMAXILLA INBILATERAL CLEFT LIP AND PALATE
The appliance is designed so that it could be secured to the palatal segments
with stainless steel pins(pinning principle as described by Georgiade in 1970)
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4361
Turning the screw expandsthe gap between the
anterior borders of thelateral segments
The appliance is availablecommercially and
individually adapted to aplaster cast with the helpof an acrylic plate
Journal of Cranio-Maxillo-Facial Surgery 19922099-110
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4461
Angle brackets to keep roots
away from cleft
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4561
Mixed Dentition -
Maxillary protraction
Maxillary protraction is done using face mask
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4661
A study was done to investigate biomechanical effects of
maxillary protraction with and without maxillary expansion
on unilateral cleft lip and palate(UCLP)model before and after
alveolar bone graft (ABG)
The results showed that maxillary protraction with expansion
could presumably promote the orthopedic effects of the
facemask on UCLP patients and more uniform force would
obtain after ABG
Shanghai Kou Qiang Yi Xue 2012 Jun21(3)287-93
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4761
Face mask therapy
Indications
1 Sagittal deficiency of maxilla2 Anterior cross bite
3 Low mandibular plane angle
Contraindication - - True mandibular prognathism
- high mandibular plane angle
Advantage- No Need of RME
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4861
Palatal expansion
Objectives of treatmentAchievement of proper anterior andlateral overjet correction Correction of the antero-posteriordiscrepancy
Various expansion appliances used areFan shaped maxillary expanderButter fly expanderRapid maxillary expanderNickel titanium expander
Quad helix expansion applianceThe banded hyrax appliance andBonded rapid palatal expander
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 4961
Cleft Palate Repair(surgical management)
V-Y Pushback
Two Flap Palatoplasty
Four Flap Palatoplasty
Schweckendickrsquos Primary Veloplasty
Furlow Palatoplasty
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5061
Alveolar bone grafting
Types -
- Primary bone grafting ndash 2yrs of age
- Secondary bone grafting ndash 6-15years
- Delayed secondary grafting
Donor Site- Cancellous bone from Iliaccrest
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5161
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridgehellip Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneouslyhellipothers
require surgical exposure often in combination
with orthodontics
The erupting teeth often appear to thenstimulate the formation of new alveolar bone
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5261
Indications for Alveolar bone Graft
1 To stabilize the premaxilla2 To close the oronasal fistula3 To ensure better periodontal support to erupting teeth andteeth adjacent to cleft site
4 To lend support to the depressed lip over the cleft5 To provide bony continuity in the alveolus for tooth eruptionand for orthodontic movement of teeth adjacent to cleft into
their optimal position
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5361
A study was done by timo peltoma to examine possibleassociations between severity of clefting in infants and maxillary
growth in children with complete unilateral cleft lip and palateThe results demonstrated the large variation in the severity ofunilateral cleft lip and palate deformity at birth Patients withlarge clefts and small arch circumference arch length or both
demonstrated less favorable maxillary growth than those withsmall clefts and large arch circumference
TIMO PELTOMAuml KI BRUNO L VENDITTELLI
Cleft PalatendashCraniofacial Journal November 2001 Vol 38 No 6
T i D i i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5461
Treatment in permanent Dentition
This is the phase of comprehensive Orthodontic treatment
Main features including -
1 Face mask therapy with prior RME2 Tooth movement to finalise the occlusion
3 Management of arches4 Correction of individual tooth irregularity5 Closure of spaces wherever possible6 Planned space maintenance in areas of missing teeth for
prosthetic replacement7 Pre and postsurgical orthodontics
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5561
Retention-
One of the nightmares for an orthodontst is Greater chance ofrelapse in CLP patients brsquocoz of the Surgical scarUsually require a long term retention
Appliances-
- Soldered lingual retainer- Upper Hawleyrsquos retainer
- Bonded spiral wire retainer in UL anterior region
Di t ti O t i
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5661
Distraction Osteogenesis
Indicated in cases of severe maxillo- mandibular discrepancy
Advantages-Less relapse tendency
It results in reliably lengthening the bones ofthe midface and mandibleMaxillary advancement between 4 and 12 mm isachieved during 3-4 weeks and a satisfactory class1 or class 2 molar
Relationship can be obtained
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5761
A study was done to evaluate the treatment outcome andlong-term stability of skeletal changes following maxillary
advancement with distraction osteogenesis in adult subjectsof cleft lip and palateCONCLUSIONS Successful advancement of maxilla wasachieved by distraction osteogenesis in adult subjects
with cleft lip and palate Most of the relapse occurred duringthe first 6 months of post-distraction period and after thatthe outcomes were stable
Singh SP Jena AK Rattan V Utreja AK Unit of Orthodontics Oral Health Sciences Centre PostGraduate Institute of Medical Education and Research
Chandigarh India
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5861
summary
Oro facial clefts require a multidisciplinaryapproach
Treatment extends over many years and risksexhausting patient cooperation
Need to keep the patients best interests inmind
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 5961
ldquoThere is no area of dentistry more fascinating and
satisfying than rendering dental care to the
unfortunate patients with cleft lip and palaterdquo
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6061
Cleft lip amp palate Diagnosis amp Management by samuel berkowitz
Dental orthopedia amp treatment of cleft palate by calvin case Management of cleft lip and palate in the developing world by
michael mars et al
The orthodontist and complex craniofacial anomalies by Bruce Ross
Longmanrsquos text book of medical embryology
Peltomaki T Associations Between Severity of Clefting andMaxillary Growth in Patients With Unilateral Cleft Lip and PalateTreated With InfantOrthopedicsCleft PalatendashCraniofacial JournalNovember 2001 Vol 38 No 6 582-86
Chen ZX pan XG Maxillary protraction with and without maxillaryexpansion on unilateral cleft lip and palate model a finite elementanalysis Shanghai Koi Qiang Yi Xue2012 Jun21(3)287-93
Treatment outcome and long-term stability of skeletal changesfollowing maxillary distraction in adult subjects ofcleft
lip and palate by Singh SP Rattan V
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161
8132019 Craniofacial Anomalies Seminar
httpslidepdfcomreaderfullcraniofacial-anomalies-seminar 6161