Cleft lip and cleft palate

Under the guidance of :

Dr. Ritu Jindal Submitted By :
Dr. Jasvi Shergill Ravi Sher Singh Toor
Dr. Sandeep Mahajan MDS 1
st
year (2007)
Dr. Rohini Dua Dept.of Pedodontics.

Definition

It can be defined as congenital abnormal gap in the palate that may
occur alone or in conjunction with lip and alveolus cleft.

Ancient times
It was considered to be due the effect of evil powers or solar eclipse on
a pregnant woman .

Some tribes considered it to be a blessing and were supposed to bring
fortune to the family.

Now a days cleft lip and cleft palate baby leads a happy life in the
society without much esthetic or functional deficiencies.

How it happens ?
In the early weeks of development, long before a child is
born, the right and left sides of the lip and the roof of the
mouth normally grow together.

Occasionally, however, in about one of every 800 babies,
those sections don't quite meet.

A child born with a separation in the upper lip is said to
have a cleft lip.

A similar birth defect in the roof of the mouth, or palate, is
called a cleft palate.

Since the lip and the palate develop separately, it is
possible for a child to have a cleft lip, a cleft palate, or
variations of both.
Development of palate
Embryological development of palate can be divided into two parts.

Development of primary palate
It includes lip and the area anterior to the incisive foramen.
It develops from the fusion of maxillary and medial nasal process.

Development of secondary palate
It includes the plate behind the incisive foramen.
The palatal shelves are formed by contribution of maxillary and frontonasal
process.
The maxillary process gives off two offshoots called as palatal shelves that
grow medially towards each other.
The union of these two shelves is prevented by the tongue, there by leading to
downward growth of the shelves.
The tongue descends down by 81/2 weeks which results in the close proximal
relation of the two shelves, complete fusion occurs by 12 weeks.


A- Palatine shelves are forming from the maxillary processes and directed downwards on
each side of the tongue.
B- Tongue has been depressed and the palatine shelves have been elevated but not
fused.
C- Fusion of the shelves and the nasal septum is completed.
Pathogenesis of clefting
Various theories and mechanisms have tried to explain the
development of cleft lip and cleft palate. Some of them are:

Dursy- (Hypothesis): Failure of fusion between median nasal and
maxillary process.
Veaus Hypothesis: Failure of in-growth of mesoderm between the
two palatal shelves.
Excessive head width or diminutive palatal shelves.
Alterations in intrinsic palatal forces.
Excessive tongue resistance.
Non fusion of shelves.
Fusion of shelves with subsequent breakdown.
Failure of tongue to drop down as in case of Pierre Robin syndrome.
Inclusion cyst pathology.
Incidence of cleft
Overall incidence varies from 0.3 to 6.5 per 1000 live births.

Negroid race has least incidence while mongoloid have the
maximum.

Cleft lip is more common in males.

Cleft palate is more in females.

Unilateral clefts are more common as compared to bilateral.

Left side is more predisposition for clefts.

Incidence is increased with increase in parental age.

More chances of cleft in patients with family history of the same.
Etiology of cleft lip and palate.
Some of the postulated reasons are :
Heredity - Defect seems to run in families.
Environment Teratogens like rubella virus, thalidomide.
Mutant genes Some syndromes follow Mendelian inheritance.
E.g. Lobster defect-cleft with ectodermal dysplasia.
Chromosomal aberrations- Cleft can occur with many cromosomal
defects like trisomy 21.
Increased maternal age.
Decreased blood supply in naso-maxillary region.
Defeciency of folic acid and vitamin A.
Multifactorial inheritance- recent studies have shown that cleft
cannot be attributed to one single factor and is conglamation of
multiple genetic and environmental factors.

Classification of cleft lip and Palate
Davis and Ritchies Classification : (1922)

Pre alveolar clefts-unilateral, bilateral and median.
Alveolar clefts-complete cleft involving palate, lip, and
alveolar ridge.
Post alveolar cleft- comprises of different degrees of
hard and soft palate clefts up to the
alveolus.
Veaus Classification (1931)

Group 1- Clefts of small palate only.
Group 2-Cleft of hard and soft palate upto incisive
foramen.
Group 3-Complete unilateral clefts involving lips, hard
palate, soft palate and the alvelous.
Group 4-Complete bilateral clefts involving lips, hard
palate, soft palate and the alvelous.


Veaus Cleft Palate Veaus Cleft Lip
Fogh Andreasons classification: (1942)
Group 1- Clefts of lip.
Group 2 Clefts of lip and palate.
Group 3 Clefts of palate upto incisive foramen.

Schuchard & Pfeiffers Classification :
Symbolic Classification in which different regions are
depicted and then are shaded according to the type of
cleft depending on weather its total or partial
Kernahans Stripped Y Classification (1972)
This is a symbolic classification in which numbering is
given to each site representing the oral cavity. The
shaded area denotes presence of cleft in the particular
area.
Embryological Classification
Kernahan, Stark (1958) and Spina (1974)
They have classified cleft lip and palate depending on
the embryological principals.
Kernahan and Stark classification:
Group I : Cleft of primary palate only.
Unilateral, Bilateral, Total, Subtotal.
Group II : Cleft of the secondary palate only.
Total, Subtotal, Submucous.
Group III : Cleft of both primary and secondary palate
Unilateral, median, Bilateral
Spinas Classification:
Group I: Pre-incisive foramen clefts.
Unilateral, Bilateral, Median.
Group II: Trans incisive foramen clefts.
Unilateral, bilateral.
Group III: Post Incisive Foramen clefts.
Total, Partial.
Group IV: Rare facial clefts.


Types of cleft lips and Palates.
A- Normal anatomy E-Group II complete.
B-Group I Unilateral F-Group III unilateral.
C-Group Ia unilateral G-group III bilateral.
D-Group Ia bilateral
Millards Modification of stripped Y (1976)
He added another parameter to the Kernahans
classification and that was addition of nasal floor.
LAHSHALs Classification
This was given by Okriens in 1987, He developed a
paraphrase for each area and the cleft could be denoted as such.

L - Lip H Hard palate
A Alveolus A - Alvelous
H Hard palate L - Lip
S Soft palate







Clinical Features:
Chief Complaint Deformity of Face.
Unable to feed.
Nasal regurgitation of fluids.

Congenitally missing teeth.
Neonatal teeth.
Ectopic Eruption.
Supernumerary teeth.
Dental Problems Micro & Macrodontia.
Fused teeth.
Anomalies in tooth size and shape
Enamel hypoplasia.
Deep bite / Cross bite.
Crowding / Spacing of teeth.
Esthetic Concerns Loss of Facial Morphology
Missing Structure

Disorders of middle Ear.
Hearing and Speech Pathology Nasal Twang in Voice.
Difficulty in articulation.


Psychological effects. Due to the defect the patient
are object of curiosity, pity and
often are separated from their
normal counterparts which can
lead to a social and mental
trauma.

Until the foundation of Lancaster cleft palate clinic in Pennsylvania,
Independent clinicians carried out the treatment of children with clefts. The
patient had to go from one clinic to the other for correction.
Later it was Copper who came up with an idea that all clinicians providing
treatment to the child can act as a team.

Multi-disciplinary team for cleft lip and palate patients.
Obstetrician Refers the child to plastic surgeon/pediatrician
Counseling the parents.

Pediatrician Provides medical care.
Refers the case to plastic surgeon.

Plastic Surgeon Heads the team, discusses the case monthly.
Carries out initial lip repair and palate surgery.
Performs phyrangoplasty and nose surgery.

Oral maxillofacial Bone grafting
Surgeon If any orthopedic surgery is, performed at later stage


Neurosurgeon if any craniofacial syndrome is associated.


Pedodontist A key member who sees the baby and the
parent at the time of repair of the lip.
Provides presurgical orthopedic treatment.
Monitors the growth and development.
To maintain perfect oral health.
To guide the occlusion and facial growth.
Motivates the parent and the child.




Orthodontist Provides pre surgical consultation.
Carries out definitative orthodontic treatment in
the permanent dentition.

Speech Pathologist Monitors the speech development to normal.

Audiologist To test hearing in the baby, infant and child.

Otolaryngologist Concerns with the health of nasopharyngeal
tissues, including tonsils, adenoids and middle
ear structures.

Psychologist Plays an important role when the childs family
is under stress.


Protocol for Dental Care of Cleft Lip and Palate in Children.
Protocol is developed to provide a comprehensive treatment in alliance
with other experts to attain optimal treatment in the cleft lip & palate
patient.

At birth
Attend referral
Predental treatment Feeding plate.
Pre-surgical orthopedics.
Help surgeon in repair by stimulating palatal
bone growth and preventing collapse of
dental arches.
Make study records by photographs, models.


3-5 Months.
Introduce the parents to dental care for the primary teeth.
Alignment of primary teeth and palatal expansion to be started using a
simple fixed appliance like W-arch and Arnold expander.
Plastic surgeon to repair the lip.
Audiology, ENT surgeon to repair the lip.
Suction myringotomy for glue ear









Arnold expander


12 Months
Pedodontic review, palatal prosthetic speech appliance may be required
to correct velopharyngeal incompetence.
Explain possible eruption abnormalities.
Plastic surgeon to repair the palate.
Speech pathology first assessment.
Review by audiologist and ENT surgeon.
2-6 years
Pedodontist should review facial growth and development with regular
monitoring at one year interval.
Preventive measures for caries like fissure sealants, fluoride
application.
Restorative if needed.
Plastic surgeon to review every 12 months.

6-7 years
Pedodontist to review the case.
Preventive or early orthodontic intervention (like removal of
supernumerary teeth, correction of cross bite)
Radiographic evaluation (special occlusal view)
Orthodontic consultation.

8 years.
Suitability about bone grafting.
Dental bone assessment (OPG, Cephalogram)
Review by plastic surgeon, speech pathologist and ENT
surgeon.
Pedodontist to review if orthodontic intervention is needed.


9 years
Combined orthodontist and pedodontist coalescence.
Bone graft alveolar cleft at half to one-third root development of
permanent cuspid.
Review by other experts.

10-12 years
Pedodontist to plan future treatment.
Orthodontic consultation.
Monitoring changing dentition and growth.
Preventive measures with a review of dental health


12-15 years
Orthodontic treatment
Pedodontic review at yearly intervals regarding other dental
treatments.
Oral surgeon to assist if orthodontist requires.
Review by plastic surgeon
Speech pathologist to review.
Management of cleft lip and palate Patients
For successful treatment of the patient with cleft lip and palate some pre-
requisites are necessary before the comprehensive treatment can be
initiated. These are:

Parent Counseling:
The most important people associated at this stage are parents.
They need support and information regarding the treatment aspects.
It is important to negate fears and guilt regarding the child that a parent may
have.
Mother plays important part in the form of a nurse as well as a mother.
Nursing management:
After the obturator has been fitted the mother will take care of this appliance.
After each feed the plate is removed and cleaned with running water and
soaked once a day for 20 min. in Hibitane solution.
Feeding management:

Children having cleft palate face inability to feed, as the child is
not able to create negative pressure required for suckling of milk
from the mothers breast. which is solved by using breast pumps,
obturators, and spoon feeding.
Another problem is regurgitation of milk through the nose, which
can be solved by rising the childs head around 45 degrees.
Cleft lip Repair
Timing : Rule of 10
(Hb. 10gm%, age 10 weeks, weight 10 lbs., TLC < 10,000 per cc mm.)

Types of cleft lip surgery
For unilateral: (common)
Millards rotation advancement flap,
Tennison-Randall Triangular flap.
Less frequently used are:
Rose thompson Stright line repair
Skoogs procedure.
For bilateral:
Single stage by Veaus III Procedure
Millard single stage Procedure

Basic steps in cleft lip repair.

Aim
Achieve equal
length of philtral ridges
horizontal
cupids bow
accurate repair of
muscle, skin, mucosa
maintain vermilion
border as much as
Possible
Symmetrical nostril floor
& aesthetics
Millards Repair: The rotational flap (a) ; Columella flap (c) are planed on the
median side of the cleft.
After full thickness of the lip is cut along the marking, a
rotation gap is produced on the medial side which is filled
by an advancement flap (b) planned on the lateral side of the
cleft.

In this minimal tissue is discarded and the result can be modified during the surgery.
Tennision Randall repair. A triangular flap is created on the lateral
side of the cleft to fit into the triangular defect produced on the
median side of the cleft. It can be performed only after initial
measurements.
The result cannot be modified once the lip is cut.
The scar is more prominent.
Veaus III. repair
It is the simplest one straight line closure and having
satisfactory results in bi lateral cleft lip.
The vermilion flap from either lateral side of the cleft is
brought down over the pro labium to augment the
vermilion in the center of the upper lip
Cleft palate repair
Timing: Experience of most of the surgeons show that repair of palate
between 12-18 months of age gives best results.

Types of cleft palate repair:
Cleft palate is repaired by mucoperiosteal flaps.
There are two ways:
Single stage repair (Von langenbeck repair & Ven wardill Kilner):
-At the age of 18 months.
-V-Y push back palatoplasty, produces normal speech in
50-70% cases, But midfacial growth retardation problem is
not solved.
-Repair by double opposing Z-plasty of Furlow is a new
procedure aimed at reducing the midfacial growth
retardation problem.
Two stage repair:
First Stage-
Soft palate repair before 18 months followed by obturation of
hard palate till the second stage repair.
Second stage repair-
At 4-5 yrs. Hard palate repair.

This Schweckendiek two stage procedure allows better midfacial growth,
but speech results have been not so good.
Veau-Wardill-Kilnar V-Y Pushback platoplasty :
-Two mucoperiosteal flaps are raised from the hard palate and nasal
layers are mobilized.

-Abnormal attachment of palatal muscles are divided from the
posterior border of the hard palate to be sutured in midline to the
opposite side of the palatal muscles. (intravelarveloplasty)

- Suturing is started from anterior end of the nasal layer and
progressed towards the uvula.


Two flap palatoplasty (diagrammatic representation)
Pre-Dental Treatment
Feeding plate if required?
Decision regarding assisting the surgeon should be left to the
surgeon.
To stimulate palatal bone growth and to restore orofacial
functional matrix
To Expand or prevent the collapse of maxillary segment.

Primary dentition treatment:
Proper alignment and/or expansion of the primary dentition can
be done more easly.
Simple form of fixed maxillary lingual appliance (i.e either a W-
arch or an arnold expander) are preferred over the removable
split palatal type of appliance because of high relapse rate with
removable appliance.
Mixed dentition treatment
Various problems which require attention at this stage,
these are:
Minor cross bites.
Corrected by expansion by usual methods, once
complete then retention is required.( because there is no mid
palatal suture system to fill the bone and consolidate the
expanded maxillary segments).

Retro inclination of permanent incisors and anterior cross bite.
This can lead to esthetic, speech and
psychological problems. To correct this partial banded approach
is needed, after correction full time retention is needed.

Crowded dentition.
Serial extraction may be required, primary
cuspids are removed to treat incisor crowding and primary
molars may be removed to hasten the eruption of the first
bicuspids.

Alveolar bone grafting.
Alveolar bone grafting is done just before
canine erupts.

Correction of anterior & posterior
cross bite in the deciduous &
mixed dentition.
a. Complete unilateral cleft lip &
palate (un operated)
b. Palatal segments in contact.
c. Palatal cleft closed at 6
months of age.
d. Bilateral buccal and anterior
cross bite.
e. Arnold expander is in place
f. Cross is still present due to
excessive scar.
g. Expander is fully extended in
early mixed dentition.
h. Anterior cross bite was
corrected, but buccal cross
bite is still present.
Alveolar Bone Grafting.


Aim
Restore the bony contour
of the alveolus
Stabilize the
maxillary expansion
Provide a matrix
through which the
Teeth may erupt
Allow the teeth to have
a healthy supporting
peridontium

Alveolar bone grafting Involves:

Pre surgical Palatal expansion (if required) with fixed appliances such
as quard helix
Preparation of recipient area by extraction of retained primary teeth
several weeks before surgery.
Bone harvest for the graft is usually autologous illiac crest
corticocancellous bone, but must be obtained from the mandibular
symphsis, tibia, rib or calvarium.
The procedure may include revision of lip and /or palate repair if
necessary and will definitively close any remaining fistulae.

Samman et al. (1994) showed that timing of the operation, preoperative
gingival health and careful tissue and graft handling during surgery are
more important in determining the success of the operation than the
anatomical source of the bone graft.
Before After surgery
Periapical radiograph of a cleft bone grafting.
Lateral incisor is present on the palatal aspect of the canine tooth.
Also present is a small supernummary tooth (arrowed), was removed at
the time of surgery.
The cleft is been filled with cancellous bone, harvested from illiac crest.
After 3 months there is movement of lateral and canine and both these
teeth are erupted through the graft into the mouth, and were aligned
orthodonticaly.
Bone grafting
Bone grafting case
before.




After 3 months.
Permanent Dentition Treatment:
In mixed dentition, only the minimum of active
orthodontic treatment (if any) is done, leaving the bulk of the
treatment to be carried out in the shortest possible time when full
permanent dentition is present.
At 12-16 yrs. Dental suitability and motivation to cooperate with the
orthodontic treatment is assessed.
Rapid palatal expansion and/or fixed orthodontic therapy is undertaken
at the optimum time- occasionally elective extraction of teeth is
indicated.
Further orthodontics, in conjunction with orthognathic surgery may be
required in the event of significant skeletal dysplasia.
Definitative orthodontic treatment once active, the skeletal growth
ceases
Pre and post surgical orthodontics in conjuction with orthognathic
surgery.
Orthognathic Surgery

If maxillary / mandibullar skeletal discrepancy exists at the time of physical
maturity an osteotomy may be required along with any soft tissue revision.
A Le Fotre I osteotomy with modification my be performd to correct occlusion
and facial appearance.( Tideman et. El.1980).
More severe skeletal deformities require a staged procedure involving a Le
Forte II, Subsequently a Le Forte I osteotomy followed by a mandibular
procedure.

If necessary, an esthetic rhinoplasty and cheiloplasty should be performed as a
final surgical stage.
Occasionally, however functional lip and nose revision is combined with
alveolar bone grafting at an earlier stage to reduce the impact of the aesthetic
deformity on the growing child.

The above procedures are only some of the many that are needed by a patient
with cleft lip and palate.

A . Patient shown is 15 yrs. The nasal tip is broad and deviated.
B. Lateral view shows mid facial retrusion from infraorbital rims to
dentition, with poor support from upper lip.
C. Intra oral view of ant. Cross bite.
D. Lateral cephalogram demonstrates class III malocclusion, and
anterior cross bite.
E. Lateral cephalogram 2 yrs. After le fort I osteotomy/maxillary
advancement and malar implants.
F. 2 yrs. after maxillary advancements, insertation of malar implants,
elevation of left alar cartilage, sepetal resection and
nasomaxillary osteotomies.
G. Harmonious sagittal relationship.
H. Intra oral view after completion of ortho. treatment.
Conclusion

The successful habilitation of the child born with cleft lip and palate
requires close cooperation among the many specialist on a high
volume team.

A coordinated approach is preferred to help the child achieve ideal
speech, occlusion, facial appearance, and self esteem.

Providing the patient with the ability to pursue and achieve personal
success in life without particular regard to the original cleft deformity
is the ultimate goal.

Pictures: Cleft Lip

Pictures: Cleft Palate
References
Handbook of pediatric dentistry by Cameron, Widmer.
Text book of pediatric dentistry by S.G. Damle.
Text book of pedodontics by Shobha Tandon.
Pediatric oral and maxillofacial Surgery by Leonard B. Kaban, Maria
J. Troulis.
www.Pubmed.com
www.cleftlip.com
www.webmd.com
www.widesmiles.com






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