CLEFT LIP AND PALATE

Presenter:
C.Kartika
II MDS
CONTENTS:

✔Introduction

✔Incidence

✔Embryogenesis

✔Etiology

✔Classification

✔Diagnosis

✔Collaborative care
CONTENTS:
✔Treatment

1. At Birth

2. Primary dentition ROLE OF ORTHODONTIST

3. Mixed dentition

4. Permanent dentition

✔Conclusion

✔References
INTRODUCTION
 INCIDENCE:

✔Cleft lip and palate is a global problem.(0.28-3.74/1000 live births)

✔Least in negroids.(0.4%)

✔ Maximum in afghans.(4.9%)

✔The oral clefts-males >females.

✔Cleft lip alone- males > females.

✔Cleft palate- females >males.

John B. Thornton, Sue Nimer, and Paul S. Howar The Incidence.
Classification, Etiology, and Embryology of Oral Clefts Semin Orthod
1996;2:162-168.
 EMBRYOGENESIS OF CLEFT LIP AND PALATE:

Cleft Lip:
• Results from failure of union of Medial nasal process and Maxillary
process.

Cleft Palate:
• Cleft of primary palate results from failure of union of Medial nasal
process and lateral nasal process
• Cleft of secondary palate results from failure to descent the tongue
down and failure/delay in mesodermal migration of palatal shelf.
 EMBRYOGENESIS OF CLEFT LIP AND PALATE

John B. Thornton, Sue Nimer, and Paul S. Howar The Incidence.

Classification, Etiology, and Embryology of Oral Clefts Semin Orthod
 ETIOLOGICAL FACTORS:

GENETIC FACTORS

ENVIRONMENTAL FACTOR

SYNDROMES

John B. Thornton, Sue Nimer, and Paul S. Howar The Incidence.

Classification, Etiology, and Embryology of Oral Clefts Semin Orthod
1996;2:162-168.
 GENETIC FACTORS:
GENES CLEFT LIP/ PALATE
Bmp-1 to Bmp-9 Cleft Lip/Palate

Fgfr-1 to Fgfr-3 Cleft Lip/Palate

Fgfr-1 to Fgfr-18 MX hypoplasia Cleft Lip/Palate

Msx1 to Msx2 Cleft Lip/Palate

Pitx1-2 Treacher-collins syndrome,Cleft lip/palate

Sox9 Cleft Lip/Palate, Pierre-Robin sequence

Tgf-ß1 to Tgf-ß3 Cleft Lip/Palate

Dlx-1 to Dlx-6 Orofacial clefting

ENVIRONMENTAL FACTORS:
1.Rubella virus (German measles) 9.Smoking
2.Influenza 10.Alcohol
3.Cortisone administration 11. NSAIDs
4.Mercaptopurine
5.Radiation
6.Methotrexate
7.Valium
8.Dilantin

John B. Thornton, Sue Nimer, and Paul S. Howar The

Incidence. Classification, Etiology, and Embryology of Oral
Clefts Semin Orthod 1996;2:162-168.
ENVIRONMENTAL FACTORS:

❑Maternal Dietary Imbalance:

o Folic acid deficiency
o Hypervitaminosis A
 SYNDROMES:
1.X‑linked cleft palate 3. Van der Woude Syndrome

2.Ectodermal dysplasia syndrome 4. Pierre Robin sequence

 SYNDROMES:
5.Velocardiofacial syndrome

6.. Median facial dysplasia 7. Popliteal Pterygium syndrome.

CLASSIFICATION-1.DAVIS AND RITCHIE
CLASSIFICATION(1922)
Group I-Pre alveolar clefts-Lip clefts
only with subdivisions for unilateral,
median, bilateral

Group II-Post alveolar clefts-Degrees

of involvement of soft and hard palate
to be specified till the alveolar ridge,
submucous clefts included.

Group III-Alveolar clefts- Is complete

clefts of palate, alveolus ridge and lip
with subdivisions
Davis for HP.
JS, Ritchie unilateral, median, of congenital clefts of the lip
Classification
bilateral
and palate. JAMA 1922;79:1323-1327.
2.VEAU’S CLASSIFICATION(1931):

Veau V. Division: Palative, Anatomic, Chirurgie, Phonetique,

Paris: Masson, et cie, 1931.
 CLASSIFICATIONS:
3.Classification by FOGH ANDERSON(1942):

• Group 1: Clefts of Lip:

• Single: Unilateral or median cleft lip
• Double: Bilateral cleft lip

• Group 2: Clefts of Lip and Palate:

• Single: Unilateral clefts
• Double: Bilateral

• Group 3: Atypical Cleft extending into incisive foramen eg., Median

cleft lip.
Fogh-Andersen P. The Inheritance of Cleft Lip and Cleft Palate.
Copenhageno A Busch, 1942.
 CLASSIFICATIONS:

4.KERNAHAN AND STARK’S CLASSIFICATION(1958):

⮚Cleft of the primary palate: Cleft lip alone or lip with alveolus.
⮚Cleft of the secondary palate: soft palate only or soft and hard plate.
⮚Cleft of primary & secondary palate: unilateral or bilateral.

Kernahan DA, Stark RB. A new classification for cleft lips and
palates. Plast Reconstr Surg 1958;22:435-441.
CLASSIFICATIONS:

5.KERNAHAN STRIPPED Y CLASSIFICATION(1958):

Kernahan DA, Stark RB. A new classification for cleft lips and
palates. Plast Reconstr Surg 1958;22:435-441.
CLASSIFICATIONS
6. LAHSHAL CLASSIFICATION:
L ---- Lip
A --- Alveolus
H --- Hard plate
S ----- Soft Palate
H ------ Hard palate
A ------ Alveolus
L ------- Lip.

John B. Thornton, Sue Nimer, and Paul S. Howar The

Incidence. Classification, Etiology, and Embryology of
Oral Clefts Semin Orthod 1996;2:162-168.
MOST COMMONLY USED CLASSIFICATION:

KERNAHAN STRIPPED Y CLASSIFICATION (1958)-

Based on using the incisive foramen to divide anterior and

posterior cleft deformities
DIAGNOSIS:
Prenatal Diagnosis:

1. Cleft lip may be detected with ultrasound, beginning around

the 13th week of pregnancy as the fetus continues to develop.

2. 3D and 4D ultrasound imaging of fetus makes it easier to

accurately diagnose a cleft lip, Cleft palate, better than 2D
ultrasound technique.
 DIAGNOSIS:

3. The Prenatal diagnosis of facial clefts allows for adequate

counseling and planning for postnatal care after delivery.

4.But most cases of cleft lip and cleft palate are noticed right
away at birth and don't require special tests for diagnosis.
TREATMENT
COLLABORATIVE CARE

I. Cleft lip and palate is a complex craniofacial anomaly typically

requiring treatment from a range of specialists to produce
excellent outcomes.
COLLABORATIVE CARE

Travis L. Gibson, and Pradip R. Shetye; Collaborative care and the

modern craniofacial treatment team; Semin Orthod 2017; 23:255–260
 ROLE OF THE ORTHODONTIST

PRE SURGICAL INFANT ORTHOPAEDICS

TREATMENT IN DECIDUOUS DENTITION

TREATMENT IN MIXED DENTITION

TREATMENT IN PERMANENT DENTITION

Alazmi KF. Orthodontists role in the management of cleft lip

and palate patients.Dent Pract: 2018;1(1): 16-28
Neonate and Infant

• In 1990’s - Pre-surgical maxillary orthopedics is initiated

during the first week or early second week after birth, known
as Nasoalveolar Molding. (NAM) To restore
normal anatomy)
Neonate and Infant

Nasoalveolar Moulding-Performed immediately after birth

Raised level of hyaluronic acid

Raised levels of maternal estrogen

Facilitates easier moulding

Grayson BH, Maull D (2004) Nasoalveolar molding for infants born

with clefts of the lip, alveolus, and palate. Clin Plast Surg. 31: 149-
PNAM TECHNIQUE:

• The alveolar ridges are molded to reduce the size of the cleft

( 1 to 2 mm)

• The use of buttons, nasal stents, taping, lengthens the columella

which realigns the lateral alar cartilages
PROCEDURE:PNAM TECHNIQUE:
IMPRESSION MAKING

APPLIANCE FABRICATION

APPLIANCE INSERTION AND TAPING

Grayson B, Santiago P, Brecht L, Cutting C. Presurgical

nasoalveolar molding in infants with cleft lip and palate. Cleft
IMPRESSION MAKING:PNAM TECHNIQUE:
APPLIANCE FABRICATION:

•The NAM plate described by Grayson and Maull is fabricated

on the dental stone model.

•All the undercuts and the cleft space are blocked with utility wax
and prepared with hard, clear self-cure acrylic. It is lined with a
thin layer of a denture soft material.

•The plate must be 2–3 mm in thickness.

 APPLIANCE FABRICATION:

•A retention button is fabricated and positioned anteriorly at an angle of

approximately 40 degrees to the plate.

•Orthodontic elastics and tapes attached to the retention button secures

the molding plate in the mouth, resting on the alveolar ridges and palatal
shelves.
APPLIANCE FABRICATION:

•The nasal stent is not fabricated at this time. Instead its construction is
delayed until the cleft gap between the alveolar segments is reduced to
about 5–6 mm in width.

•A “swan neck” like wire extension with added soft acrylic at the tip that
serves as a nasal stent to mold the nasal alar cartilage.

•A small opening measuring 6–8 mm in diameter is made on the palatal

surface of the molding plate to provide air way.
APPLIANCE INSERTION AND TAPPING:PNAM
TECHNIQUE:
•The molding plate is checked for vestibular over extension, sharp edges or
rough surfaces that may irritate the soft tissue.

•The use of skin barrier tapes on the cheeks like Duoderm or Tegaderm is
advocated to reduce irritation on the cheeks.

•The appliance is then secured extraorally to the cheeks by surgical tapes that
have orthodontic elastic bands at one end.
PNAM TECHNIQUE:

• These barrier tapes remain on the cheeks for several days

while the surgical tapes and elastics are changed daily.

•The elastics (3/16- Heavy) should be stretched

approximately two times their resting diameter.
PNAM TECHNIQUE:

• Parents are instructed to keep the plate in the mouth full time

and to remove it for daily cleaning.

• The alignment of alveolar segments and premaxilla, correction

of nasal asymmetry, elongation of the columella are
accomplished before the primary surgical repair.
PRE SURGICAL INFANT ORTHOPAEDICS

VARIOUS TECHNIQUES:

1. Figuero’s technique
2. Da Silveira technique
3. Lious technique
4. Active Alveolar molding appliance
PRIMARY SURGICAL REPAIR OF ALVEOLUS, LIP
AND NOSE

• Surgical closure of the cleft lip and nose is performed from 2 to 3

months after birth.

• The “Rule of 10s” coined by surgeons Wilhelmsen and

Musgrave in 1969.
PRIMARY SURGICAL REPAIR OF ALVEOLUS, LIP
AND NOSE

•If the cleft is bilateral and extensive, two surgeries may be

required to close the cleft, one side first, and the second side a
few weeks later.

•The most common procedure to repair a cleft lip is the Millard

procedure pioneered by Ralph Millard.
 PRIMARY SURGICAL REPAIR OF ALVEOLUS, LIP
AND NOSE

• Definitive lip repair-2 to 3 months

• Repair of the palate-12 months to 2 years of age.

● Early repair of the palate and the resulting scar tissue may have
restricted effect on the growth and development of the maxilla, which
is reflected in the occlusion. (cross-bite)
Primary Dentition Stage (6 months to 6 Years)

• The facial soft tissues may mask the underlying skeletal

deficiency of the midface in young children.

• At 2 to 3 years of age, the establishment of the primary

dentition permits classification of the type of developing
malocclusion.
Primary Dentition Stage (6 months to 6 Years)

•Dental compensation for maxillary skeletal deficiency may result

in retroclination of mandibular incisors with proclination of the
maxillary incisors to mask the anteroposterior discrepancy.

•The scar tissue following lip repair may force the maxillary
incisor axially incline.
 Mixed Dentition Stage (6 to 12 Years )

Children a period of psychosocial transition, the dissatisfaction

with appearance experienced with craniofacial anomalies(social
withdrawal, social anxiety, and self-consciousness).
Mixed Dentition Stage (6 to 12 Years)

• There is need for orthodontic treatment during the early mixed

or early permanent dentitions in correcting midface deficiency

• Modification or redirection of growth (functional or orthopedic

appliance) by use of face mask has increased the success
rate of circum-maxillary suture expansion.
Mixed Dentition Stage (6 to 12 Years)

• Constriction of the maxilla (V-shaped arch form) contributes to

the posterior cross bite.

• Tooth-borne maxillary expansion appliances such as a rapid

palatal expander, a W-arch, or a Quad-helix can be anchored
on the permanent first molars and extended anteriorly to
improve arch form while correcting the crossbite.
Mixed Dentition Stage (6 to 12
Years of Age)
Mixed Dentition
Stage (6 to 12
Years of Age)
Mixed Dentition Stage (6 to 12 Years of Age)

Apart from these conventional methods, A Fan shaped expander

with a protocol of Alternate Rapid Maxillary expansion and
constriction(AltRAMEC) for the growth of a hypoplastic maxilla for
growing patients with cleft lip and palate
Alveolar Bone Grafting:
Primary Alveolar Bone Grafting:( 1st 2 years of age)

• Jolleys and Robertson (1972), patients with complete clefts of

the lip and palate who had received primary bone grafting had
limitation of maxillary growth compared to a control group of
patients with clefts but no primary bone grafting.

• The primary alveolar bone grafting was discontinued because it

resulted in crossbite, malocclusion and malunion of maxilla
Secondary Alveolar Bone Grafting
• Secondary is delayed alveolar bone grafting, performed after
primary lip repair.

• The age at which the bone graft is placed defines:

1.Early secondary bone grafting (2 to 5 years),
2. Intermediate secondary bone grafting (6 to 15 years),
3.late secondary bone grafting (>6 years to adult).
Secondary Alveolar Bone Grafting

Intermediate secondary alveolar bone grafting (6 to 15 years of

age).

• The success of this intervention requires collaborative treatment

planning between the orthodontist, surgeon, and other team
members.

Peter D.Waite and Daniel E. Waite. Bone Grafting for the

Alveolar Cleft defect. Semin Orthod 1996;2:192-196.
Secondary Alveolar Bone Grafting

Intermediate secondary alveolar bone grafting has five main

benefits:

1. Bone graft is placed before eruption of teeth adjacent to the cleft,

improving the periodontal support of those teeth, If a bone graft is
placed after eruption of the canine, the bone will resorb quickly.

2. Closure of oronasal fistulae, with three-layered closure technique

(graft sandwiched between the two soft tissue planes)has an increased
success rate.

3. Support and elevation of the alar base on the cleft side to achieve
nasal and lip symmetry
Intermediate secondary alveolar bone grafting has
five main benefits contind:

4. Construction of a continuous arch form and alveolar ridge

moving teeth bodily and for uprighting roots into the cleft site.

5. Achieve stabilization and repositioning of the premaxilla in

those patients with a bilateral cleft.
Ideal Timing for secondary alveolar bone grafting:

•The optimal age for bone grafting is between 9 and 11 years

(Bergland et al., 1986) when the canine is between half and
three-quarters formed.

•Pharyngeal flap or Pharyngoplasty is performed at this age to

improve speech.
Ideal Timing for secondary alveolar bone grafting:
• Performing the graft before the eruption of the permanent canine is
recommended.

• Cancellous bone graft is preferred over cortical bone because it re-

vascularizes more rapidly and is less likely to become infected.

• Traditionally, the iliac crest, ribs, and tibia have been used because
of their abundant supply of cancellous bone.
Alveolar bone grafting:
Orthodontic considerations associated with secondary bone
grafting:

1. Transverse arch expansion,

2. Incisor alignment,

3. Eruption of the maxillary canines.

PERMANENT DENTITION STAGE

• During this time, the adolescent growth spurt and onset of puberty
occur.

• The skeletal discrepancy becomes accentuated and facial

appearance and occlusal relationships deteriorate.
PERMANENT DENTITION STAGE

• These changes occur at a time when individuals are most self-

conscious about their body image and facial appearance.

• Impairment of speech from the resulting hypernasality was

greater in adolescents 15 to 18 years of age.
PERMANENT DENTITION STAGE

Growth pattern:

• Patients with unilateral complete clefts of the lip and palate

typically become more maxillary deficient and mandibular
prognathic in their appearance, because of sagittal maxillary
deficiency.
 PERMANENT DENTITION STAGE

THE GOSLON YARDSTICK(Mars et al 1987)

• GOSLON Yardstick is a clinical tool that allows categorization of the
dental relationships in the late mixed and or early permanent dentition,
into 3 stages and 5 groups based on severity of malocclusion and
skeletal discrepancy.

Mars M, Plint DA, Houston WJ, Bergland O, Semb G; The Goslon

Yardstick: a new system of assessing dental arch relationships in
children with unilateral clefts of the lip and palate; Cleft palate.
 1987;24(4):314-22.
PERMANENT DENTITION STAGE
THE GOSLON YARDSTICK

Divided into 3 stages:

Stage 1: Anteroposterior Assessment

Stage 2: Vertical Assessment

Stage 3: Transverse Assessment

THE GOSLON YARDSTICK:PERMANENT DENTITION STAGE:
These were distributed into 5 groups:

Group 1-excellent

Group 2-good

Group 3-fair

Group 4-poor

Group 5-very poor

Mars M, Plint DA, Houston WJ, Bergland O, Semb G; The
Goslon Yardstick: a new system of assessing dental arch
relationships in children with unilateral clefts of the lip and
palate; Cleft palate. 1987;24(4):314-22.
Skeletal-Facial Considerations:PERMANENT DENTITION
STAGE

• All three dimensional information of patient’s face is

documented with analysis and prediction tracings for planning
treatment.

• If the skeletal discrepancy is mild and aesthetic concerns are

minimal, dental compensation by orthodontic treatment alone
may be recommended.
PERMANENT DENTITION STAGE

• If facial balance and skeletal discrepancy is severe then

treatment plan combines surgery and orthodontics for its
correction.

• The presurgical orthodontic treatment requires decompensation

of the maxillary and mandibular teeth and placed in their correct
relationship to the underlying skeletal bases.
• With conventional orthognathic surgery techniques for patients with
severe maxillary hypoplasia, surgeons would advance the maxilla as
much as possible in the presence of the scar tissue from the lip and
palate repairs.

• The remaining skeletal discrepancy would be corrected with a

mandibular setback.

• This is a surgical camouflage, the inability to correct the underlying

DISTRACTION OSTEOGENESIS

• With the advent of distraction osteogenesis, correction of

severe maxillary hypoplasia solely by advancing the maxilla is
possible.

• Such correction would be accomplished by expansion of the

scar tissue at the same time distraction osteogenesis is
performed.
Hitesh Kapadia; Management of severe maxillary hypoplasia
• The Rigid External Distraction (RED) of maxilla involves
cementation of an intraoral tooth-borne splint in the maxilla with
hooks extending extraorally for traction.
 DISTRACTION OSTEOGENESIS
• A complete LeFort I osteotomy is performed, and a RED device is placed
intra-operatively.

• The activation of screw done at a rate of 1 mm per day till +ve overjet is
achieved.

• Following advancement, the RED device is maintained for 2 to 3 weeks for

bone consolidation.

• This is followed by a retention period during which the patient wears a

protraction face mask.
Jeffrey C. Posnick.Orthognathic surgery for cleft and palate patient.Semin
DISTRACTION OSTEOGENESIS

• Internal distractors, which typically are bone-borne, thus

activation of the system is possible via an intraoral approach.

• This method has the added benefit of allowing for long

consolidation periods (3 months).

• After the desired advancement is achieved, the turning arms are

removed and the submucosal components stay in place.
ANTERIOR MAXILLARY DISTRACTION OSTEOTOMY
• Anterior maxillary segmental distraction first reported by
Karakasis and Hadjipetrou(2004)-marked the premier
application for the correction of maxillary hypoplasia
secondary to CLP.

TECHNIQUES:

1. Cohn stock(1921)
2. Wassmund(1935)
3. Wunderer(1963)
4. Cupar(1955)
ANTERIOR MAXILLARY DISTRACTION OSTEOTOMY

• Cohn stock(1921)-A mucosal incision is applied in the

buccal side of the maxilla above the roots of incisors..This
incision is extended to the distal section of first premolars
bilaterally.
• It is common to use a microsaw or piezoelectric device,
followed by chisel since a high risk of injury to tooth roots
exists.
• Consequently, osteotomies are performed after extractions of
first biscuspids.
 ANTERIOR MAXILLARY DISTRACTION OSTEOTOMY
• After that, a wedge of palatal bone was removed through
transverse palatal incision to provide a greenstick fracture and
the anterior maxillary segment was retracted through elastic
force.
• After a 5 day latency period, the maxillary distraction was
initiated at a rate of 0.4mm twice a day to correct horizontal
and vertical maxillary hypoplasia.
ANTERIOR MAXILLARY DISTRACTION OSTEOTOMY

• Its unique advantage of preserving velopharyngeal function

makes this procedure widely applied.
INDICATIONS:

1. Correction of bimaxillary protrusion

2. Anterior open bite
3. To retract anterior teeth when that cannot be accomplished by
conventional orthodontic treatment
4. Marked protrusion of the maxillary teeth.
5. Improvement in apperance.
COMPLICATIONS OF AMO

1. Loss of teeth vitality

2. Persistant periodontal defects
3. Communication with nasal cavity or antrum
4. Occlusal step formation.
CONCLUSION:

Orofacial clefts have been identified to have a multifactorial

etiology and therefore require an interdisciplinary treatment
approach, comprising a team effort in which an orthodontist plays
a vital role and works hand in hand with various specialists to
provide the best possible line of treatment with a single minded
approach , that is to minimize if not eliminate the physical, social
and the emotional hardship that a person with orofacial cleft
presents.
 REFERENCES:

• Graber, L.W., Vanarsdall, R.L. & Vig, K.W.L., Orthodontics:

Current Principles and Techniques, 5th edition Elsevier Health
Sciences.

• Samuel Berkowitz; Cleft Lip and Palate; 2nd Edition.

• Travis L. Gibson, and Pradip R. Shetye; Collaborative care and

the modern craniofacial treatment team; Semin Orthod 2017;
23:255–260.
 REFERENCES:
• Pradip R. Shetye, and Barry H. Grayson; NasoAlveolar molding
treatment protocol in patients with cleft lip and palate; Semin Orthod
2017; 23:261–267

• Mars M, Plint DA, Houston WJ, Bergland O, Semb G; The Goslon

Yardstick: a new system of assessing dental arch relationships in
children with unilateral clefts of the lip and palate; Cleft palate. 1987
Oct;24(4):314-22.

• Aly LA, Hammouda N; Secondary closure of alveolar cleft with

resorbable collagen membrane and a combination of intraoral
autogenous bone graft and deproteinized anorganic bovine bone. Ann
Maxillofac Surg 2016;6:165-71.
 REFERENCES:

• Hitesh Kapadia; Management of severe maxillary hypoplasia

with distraction osteogenesis in patients with cleft lip and
palate; Semin Orthod 2017, 23(3):314-317.

• John B. Thornton, Sue Nimer, and Paul S. Howar The

Incidence. Classification, Etiology, and Embryology of Oral
Clefts Semin Orthod 1996;2:162-168.

• Kernahan DA, Stark RB. A new classification for cleft lips and
palates. Plast Reconst Surg 1958;22:435-441.
REFERENCES:

• Davis JS, Ritchie HP. Classification of congenital clefts of

the lip and palate. JAMA 1922;79:1323-1327.
• Fogh-Andersen P. The Inheritance of Cleft Lip and Cleft
Palate. Copenhagen: A Busch, 1942. 5. Kernahan DA, Stark
RB. A new classification for cleft

• Grayson BH, Maull D.Nasoalveolar molding for infants

born with clefts of the lip, alveolus, and palate. Clin
Plast Surg. 2004;31: 149-58.
REFERENCES:
• Alazmi KF. Orthodontists role in the management of cleft lip
and palate patients.Dent Pract: 2018;1(1): 16-28
• Grayson B, Santiago P, Brecht L, Cutting C. Presurgical
nasoalveolar molding in infants with cleft lip and palate. Cleft
Palate Craniofac J 1999;36:486-498.

• Jeffrey C. Posnick.Orthognathic surgery for cleft and palate

patient.Semin Orthod 1996;2:205-214.

• Peter D.Waite and Daniel E. Waite. Bone Grafting for the

Alveolar Cleft defect. Semin Orthod 1996;2:192-196.