DEPARTMENT OF PAEDIATRIC

DENTISTRY

SEMINAR OF CLEFT
MANAGEMENT
 CONTENTS
 Prenatal Diagnosis.
 Protocol For Dental Care.
 A Multi- Disciplinary Team.
 Management
 Dentofacial Orthopedics
 Management of cleft Lip & Nasal Deformity.
 Cleft Palate Repair.
 Orthodontic Treatment.
 Role of E.N.T. Specialist, Speech Pathologist.
 Correction of Maxillary Hypoplasia
 Correction of Enamel Hypoplasia.
 Role of Prosthodontics
 Role of Psychologist
 PRENATAL DIAGNOSIS
AND COUNSELING
• Intrauterine diagnosis of orofacial clefts is
possible by ultrasonography.
• Complete clefts are seen easily at 16
weeks gestation.
• Incomplete clefts are seen more readily at
27 weeks.
• Palatal clefts are difficult to visualize by
prenatal ultra sonography.
• The family or obstetrician may request
prenatal consultation with a surgeon.
 Protocol For Dental Care of Cleft
Lip and Palate in Children
 At Birth
• Predental treatment is provided which comprises feeding
plate, pre surgical orthopedics and helps surgeon in repair
by stimulating palatal bone growth and preventing collapse
of dental arches.
 3-5 Month.
• Alignment of the primary teeth and palatal expansion to be
started using a simple fixed appliance like warch & Arnold
expander plastic surgeon to repair the lip.
• Suction myringotomy for “Glue ear”
 12 Months.
• Pedodontic review palatal pro sthetic speech.
Appliance may by required to correct velo
pharygeal incompetence.
• Plastic surgeon to repair the cleft palate.
 2-6 Years.
• Pedodontic showed review facial growth and development with
regular monitoring one year interval.
• Preventive measures for caries like fissure, sealing, fluoride.
• Restorative
 6-7 years.
• Removal of super numerary teeth, correction of cross bite.
• Orthodontic consultation.
 8-9 years.
• Suitability about bone grafting.
• Dental bone assessment (OPG, wrist, lateral cephalogram,.
• Review by the plastic surgeon, speech pathologist & ENT
surgeon.
• If needed to relieve crowding and retroclination of the anterior
teeth.
 9 years.
• Combined orthodontist and pedodontist
coalescence.
• Bone graft alveolar cleft at half to 1/3 root
development of permanent cuspid.
 10-12 years.
• Orthodontic consultation
• Monitoring changing dentition and growth.
 12-15 years.
• Orthodontic treatment.
• Speech pathologist to review changing of
the pitch of voice in boys.
 A Multi-Disciplinary Team for Cleft
Lip and Palate Patients.
 Obstetrician = Refers the child to plastic surgeon
and pediatrician for expert opinion counseling the
parents.
 Pediatrician or Neonatology's=Provide medical
care refers the case to the plastic surgeon.
 Plastic Surgeon:-Carries out initial lip repair
and palate surgery – performs pharyngoplasty or
reversionary lip & nose surgery.
 Oromaxillofacial Surgeon= Usually comes in the
picture of bone grafting – if any final orthopedic
surgery is performed at later stage.
 Neurosurgeon= 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 pre surgical orthopedic treatment for the
baby.
 Pedodontist monitor the growth and development.
 To maintain perfect oral health.
 To guide the occlusion and facial growth.
 Motivates the parent & the child to cooperate with
the treatment.
 Orthodontist: Carries out definitive orthodontic
treatment once the full permanent dentition is
erupted.
 Speech pathologist: =
• Monitors the speech development to normal.
• Test for an adequate palato pharyngeal closure and guiding
the surgeon as to whether a pharyngeal flap may be
necessary.
 Audiologist:- To test hearing in the baby
infants & the young child providing essential
information in hearing loss for both speech
patholigist and otolarynologist.
 Otolarynologist: Concerns with the health of
nasopharyngeal tissues including tonsils, adenoids
and middle ear structures.
 Blockage of the auditory canal and gluteneous
secretion (glue ear) is very common in these disease.
 Psychologist: Plays on important role when the
child’s family is under stress.
 MANAGEMENT:
 Infancy:
General Consideration:- Patients with C.L.P. requires,
interdisciplinary care from a team of provides including a
geneticist, plastic surgeon, oral and maxillofacial
surgeon, otolaryngologist, dentist, orthodontist, speech
therapic audiologist, psychologist, social worker & nurse.
The role of each specialist depends on the age of the
patient.
 During the first days of the infant’s life:-
The infants with a cleft palate cannot generate the negative
intraoral pressure needed to suck from a bottle.
 The Nurse on the team or another feeding specialist must
instruct the parents in the use of special feeding device for the
infant eg:- Haberman nipple, catheter & syringe, spoon feeding.
 Infants with cleft palate have difficulty ventilating the
eustachian tube. This result in the accumulation of fluid in the
must be treated promptly with antibiotics.
DENTOFACIAL ORTHOPEDICS
 In unilateral complete cleft lip and palate (UCCLP) or
bilateral complete cleft lip and palate (BCCLP) with a
protruding premaxilla, labial repair is often
completed with tension on the closure.
 Orthopedic appliances bring the dentoalveloar
segments together facilitating a tension free labial
repair that requires undermining of tissues.
 In addition, alveolar approximate forms the skeletal
plateform for correction of the nasal deformity and
permits gingivoperiosteoplasty. Alveolar closure
eliminates an around fistula.
 The appliance is removed at the time of labial repair
and replaced with a passive appliance to maintain
the alveolar position.
 Management of Cleft Lip And Nasal
Deformity
 Single stage: repair the unilateral complete cleft lip
and nasal deformity in a single stage.
 Two stage repair: First repair unilateral cleft lip &

than lip nasal adhesion.

Reasons For Two Stage Repair
 Minimize tension.
 Increase the bulk of the orbicularis oris muscle to

construct the filtral ridge.

 Increase the vertical dimension of labial elements.

Particularly on the medical side and

 Gives the surgeon two chances to correct the position

of the lower lateral cartilage.

 TIMING OF NASOLABIAL REPAIR
 Labial repair is traditionally carried out when the child is
approximately 10 weeks of age, weight 10 pounds, and has a
serum hemoglobin value of 10mg 1 ml & total leukocyte count
less than 10,000/C.C. it is important to wait until the period of
postnatal anemia is corrected. The child should be gaining
weight and growing before under going nasolabila repair.
 TECHNIQUES OF NAGOLABIAL REPAIR.
• Type of cleft lip surgery:-
• Millard’s rotation advancement flap and tennison randall triangular
flap methods.
• Rose Thompson straight line repair, the skoog’s procedure are less
frequently used.
• Rectangular flap method of triangular hagedorn le mesurier are
rarely used.
• For bilateral cleft lip can be repaired in two stage by in a single
stage by veau -III procedure, millards single stage procedure or
black procedure.
• Basic steps in cleft lip repair.
• The lip is closed in three layers – mucosa, muscle, skin.
 AIM OF REPAIR
 To achieve equal length of filtral ridges an either
side.
 Horizontal cupid’s bow.

 Accurate repair of muscle, skin, mucosa without

vermilion deformity.
 Proper alignment of white line.

 Symmetrical nostril floor, and finally an esthetically

acceptable scar.
1. Straight Line Lip Repair.
Indication:- of incomplete and narrow clefts.
Advantage :- Easy repair
Disadvantage:- Limited Indications.
 Tennison Randall Repair
 A triangular flap is created on the lateral side
of the cleft to fit into the triangular.
 This procedure can be planned exactly after
initial measurements the results can not be
modified once the lip is cut.
 The scar is more prominent than in other
procedures.
• Advantage:- Measured techniques
More easily taught.
Can be used for wide dept.
• Disadvantage: Scar interrupts the philtrum
line difficult to modify during
procedure.
 VEAU REPAIR
 There is only a displacement, deformation and under
development of the muscles and the skeletal tissue.
 The surgical procedure should thus aim at returning
there structures to their correct positions.
 The naso labial muscles are reconstructed accurately
and within a few weeks, without any form of flap
closure.
 This method gives satisfactory results in bilateral
cleft lip.
 MILLARD’S Techniques (Rotation advancement
technique) principles of closing bilateral cleft lip.
• Maintain symmetry
• design the prolabium of proper size & shape.
• Ensure primary muscular continuity.
 • Construct the median tubercle from lateral labial
elements.
• Peeform primary construction of the columella &
nasal tip.
Procedure :-rotation flap and columella flap are
planned on the medial side of the cleft. after full
thickness of the lip is cut along the marking rotation
gap is produced on the medial side which is filled by
an advancement flap planned on the lateral side of
cleft.
Advantage:- Minimal tissue is discarded
Allows modification during repair
Disadvantage: Difficult for use in wide cleft.
May narrow the nostrial.
 CLEFT PALATE REPAIR
Basic goals of palate repair
 Separation of oral and nasal cavities.
 Construction of watertight and airtight velopharyngeal valve.
 Preservation of facial growth.
 Development of esthetic dentition.

 Development of functional occlusion.

TIMING OF SURGERY
 Early repair leads to a better speech development but severe

mid facial growth retardation and dental malocclussion.

 Palate repair after full growth of maxilla midfacial growth

retardation & dental malocclusion problem is less but speech

problem become more severe.
 Palate repair should be done 1-1½ years age give the best

balanced result.
 Only soft palate are closed by 6-18 months.
 TECHNIQUES OF PALATE REPAIR
 Single stare technique.
eg:- von langenbeck repair
Ven wardill kilner v-y push back palatoplasty at are
1½ years.
 Two stare technique:-
• First stage : soft palate repair before 18 month.
• Second stage hard palate repair at 4-5 years.
eg. Schweckendiek technique.
 1) Primary Veloplasty By Schweekendiek.
• First soft palate is closed at an early age 16-12 months)
• Hard palate closed after few years.
• Principle of this techniques is that the soft palate aids in the
speech and is essential to be closed early for velopharyngeal
mechanism.
Disadvantage:- Speech problem (Severe)
Additional surgical procedure.
2) VON LANGENBECK’S PALATO PLASTY.
• Use bipedicled mucoperiosteal flaps of the hard and soft
palate for repair of the defect.
• There interiorly and posteriorly based flaps are advanced
medially closed the palatal defect.
Advantage:- Easy to perform, requires less
dissection. results in decreased denuded palate.
Disadvantage:- Failure to provide additional
palatal length.
- Poor results in large clefts.
- Currently not commonly used.
 Veau-Wardill-Kilnar-v-y- Pushback
palatoplasty.
 Two mucoperiosteal flaps are raised from a 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 the palatal muscle.
 Suturing done anterior of the nasal layer and
progressed toward Uvula.
ORTHODONTICS AND MAXILLARY
ORTHOPAEDICS.
Different stages of dentition methods.
A) predental treatment.
B) Deciduous dentition ( 3 to 6 years)
C) Early mixed dentition ( 7 to 9 years)
D) Late mixed and early permanent dentition.
E) Permanent dentition.
A) PRE DENTAL TREATMENT

I Feeding palate proper feeding advise pre-surgical

feeding plate.
II.To help the surgeon in the repair of the cleft by
pushing.
III. To stimulate palatal bone growth and to restore
orofacial functional matrix.
IV. To expand or prevent the collapse of maxillary
segment.

B) PRIMARY DENTITION TREATMENT

- Simple form of fixed maxillary lingual appliance (i.e
warch or an Arnold expander) are preferred over the
removable palatal expansion for improving speech.
C) MIXED DENTITION TREATMENT
I. Minor crossbites may be neglected but severe
crossbites one corrected by expansion by usual
method.
II. Retroclination of permanent incision and anterior
cross bite to correct this usually partial banded
approach is needed .
III. Crowded dentition: This may require serial
extraction primary cupids are removed to treat
incisior crowding & the primary molars.
IV. After alveolor bone grafting.
To movement carriage enough space is created
in the arch to allow the cuspids to erupt.
 PERMANENT DENTITION TREATMENT
 The problem at this stage are posterior cross bite
and malposed permanent incisors.
 If orthognathic surgery is done to correct the
underlying skeletal imbalance pre operative and post
operative orthodontic treatment is needed to
achieve proper alignment, position and indication of
the teeth on their respective arches.
ROLE OF ENT SPECIALIST, SPEECH
PATHOLOGISTS AND SPEECH THERAPY
 ENT specialist, Audiologist and speech specialist
work together to note the middle ear problems and
progress in speech.
 Detect abnormalities in articulation and resonance
which is develops due to velopharyngeal in
competence after palatoplasty.
 The abnormalities detected by video fluoroscopy or
nasopharyngoscopy.
PROCEDURE FOR CORRECTION OF VELOPHARYNGEAL
INSUFFICIENCY
 Pharyngeal flap 2) Sphincter pharyngoplasty.
- Pharyngeal flap designed on the basis of location and extent of
lateral pharyngeal wall motion. The raw under surface of the flap
is lined with tissue from the nasal side of the soft tissue palate to
prevent contracture and narrowing of the flap the donor site on
the posterior pharyngeal is closed.
• ALVEOLAR BONE GRAFTING TIME 8-11 years.
- Cancellous bone is used for alveolar grafting.
- It promotes more rapid vascularization due to presence of living
osteoblasts.
- DONAR SITE OF BONE
- Ilium, calvaria, tibia mandible or ribs.
- The bone should be placed within the cleft from the piriform
aperture to the level of the alveolar crest.
- Gingival mucoperiosteal flaps are used for oral closure over an
alveolar bone graft because they are well vascularized.
 ADVANTAGE
 Bony support to teeth.
 Helps stabilize the maxillary segments.
 Aesthetic appearance of the alveolus.
 Closure of oro nasal fistula.
 Gives supports to the alar bone of the nose.
 Provides bone for a titanium implants.
OPERATIVE CORRECTION OF MAXILLARY
HYPOPLASIA
Maxillary hypoplasia is three dimensional
deficiency
 Class III malocclusion ( Sagittal plane)
 Narrowed arch (horizontal plane)
 Over closure the mandible (vertical plane)
 TREATMENT
 Destruction osteogenesis.
 Pre surgical orthodontics & Lefort – I osteotomy.

 Fabrication of an over lay denture may be necessary

for improved occlusion and appearance.

DENTAL ENAMEL HYPOPLASIA:
Defect occurs in central & lateral incisors.
Treatment
 Restoration
 Placement of stainless steel crown.
 Fluoride application.
 Dietary advice.
 Preventive oral health care
 ROLE OF PROSTHODONTIST
 Replacement of absent maxillary lateral incisor.
 Replacement by fixed partial denture and
implantation method.

ROLE OF PSYCHOLOGIST
 The psychiatrist and psychologist evaluate the
patient for strength and weakness in cognitive
interpersonal, emotional, behavioural and social
development: emphasis is placed on the patient’s
ability to cope with the emotional and psycheal
stress created by the cleft defect. Consultation with
the parents and schools regarding educational or
behavioural management if carried out when
indicated.
 CONCLUSION
 The management of cleft lip & palate is
necessary at correct time. If delayed in
the treatment there may be possibility to
developed abnormalities.
 So to prevent some problems like speech
problem facial asymmetry, feeding
problem & infection to nasal cavity &
unasthetic appearance. The treatment is
necessary.
 REFERENCES
 Pediatric Oral & Maxillofacial Surgery by
Leonard B. Kaban , Maria T. Troulis.
 Facial cleft and cranio synostosis By
Timothy A. Turvey, Kathorine W L VIG ,
Raymond J. Fansecu.
 Clinical Pedodontics By Sidney B. Finn.
 Oral & Maxillofacial Surgery by Chitra
Chakravarthy
 Clinical Pedodontics By Shobha Tandon.