Cleft lip 1/Dental implant courses by Indian dental academy

INTRODUCTION The cleft lip and palate deformity is a congenital defect of the middle third of the face, consisting of fissures of the upper lip and / or palate. The reason this condition is given so much importance is because human relationships are built on face value.

Historically, clefts of the lip and palate have had varied significance; in some tribes they were regarded as marks of beauty, in others as signs of supernatural ability. In most cultures, however, they were regarded as major, life-threatening abnormalities, and infants with these defects were often not allowed to live.. The correction of such conditions is often a very challenging task to the most efficient clinician. It requires not only a few but the group functioning of a large number of individual these figureheads must come together to examine analyse and make a definite treatment plan that will enable a fool proof prognosis. Hence to achieve this goal we need to have good communication co operation and co ordination.

CLASSIFICATION Davis and Ritchie’s classification of clefts (1922) position /relation Group 1 Prealveolar cleft Lip clefts only, with subdivisions for unilateral, median and bilateral Group 2 Postalveolar cleft Degrees of involvement of the soft and hard palates could be specified, upto the alveolar ridge; submucous clefts could also be included.

Group 3 Alveolar clefts Complete clefts of the palate, alveolar ridge and lip, with sub divisions for unilateral, median and bilateral.

Lashan classification Presented by Okreins in 1987 L – Lip A – Alveolus H – Hard palate S – Soft palate H – Hard Palate A – Alveolus L – Lip Venu’s classification of clefts (1931) Group I - Cleft of the soft palate only Group II – Cleft of the hard and soft palate to the incisive foramen Group III - Complete unilateral cleft of the soft and hard palate, and the lip and alveolar ridge on one side.

Group IV – Complete bilateral cleft of the soft and hard palate, and the lip and alveolar ridge no both sides.

Kernahan and Stark’s classification of clefts (1958) Clefts of primary palate only Unilateral (right or left)

Complete Incomplete Median Complete (Premaxilla absent) Incomplete (Premaxilla rudimentary) Bilateral Complete Incomplete Clefts of secondary palate only Complete Incomplete Submucous Clefts of primary and secondary palates Unilateral (right or left) Complete Incomplete Median Complete Incomplete Bilateral Complete Incomplete

Diagnostic and Examination Procedures : Every patient with an oral cleft should be examined by surgical, medical, dental, and speech specialists. The following procedures will facilitate the diagnosis: 1) case history and recording of defect; 2) study casts and photographs; 3) various radiographic procedures; 4) medical, surgical, speech, and psychosocial recording.

Study casts and photographs, along with various radiographic procedures, help the dentist to study the growth and development patterns of oral-facial-cranial structures and to observe the effects of surgical and orthopedic intervention upon the physiology and anatomy of the structures involved.

General case history : A well-designed case history will provide all members of the team with the information they need. This form should be limited to general information about the cleft, history of cleft type, history of treatment, and the family social and economic back-ground. It is essential that the information be arranged in concise form for rapid recording and extrapolation.

Dental history : All dental anomalies such as those involving number, shape, form, and formation of the teeth should be included in this form. The shape of the arch (anteriorly, posteriorly, and laterally), the arch relationship, tooth relationship, and type of malocclusion should also be included.

Any dental caries, missing teeth, the condition of gingival and periodontal tissue, any periapical lesions, and other information of dental significance should also be recorded.

1) Impressions for study casts : The dentist’s responsibility starts shortly after the birth of a child with a cleft. At this time, and semiannually until the child is 2 years old, the dentist makes impressions of the infant’s maxillary and mandibular regions, and he also makes cephalometric and photographic records. On the child’s second birthday and on each succeeding one, he repeats the impressions and the radiographic and photographic records.

Infant – Maxillary and mandibular impression trays for infants are not manufactured and must be constructed. The first step is to adapt a piece of baseplate wax against the maxillary or mandibular ridge. The wax is held with one finger and molded against the tissue with the other fingers. The wax pattern obtained is invested and processed in acrylic resin. The procedure is repeated on different types of clefts until a sufficient number of trays is obtained. Additional trays also can be constructed on the casts collected in the series.

Holes are drilled in the tray to provide mechanical retention and escape ways for excess impression material. Additional retention is achieved by painting the internal surface of the tray with an impression adhesive.

An irreversible hydrocolloid material is used for maxillary and mandibular impressions. The amount of water used for these impressions is five-sixths of that recommended by the manufacturer, and water is issued at a temperature of 1100F in order to speed the setting of the material.

The maxillary impression is made with the infant’s head tilted at a downward angle of 15 degrees. The head is tilted slightly upward for the

mandibular impression. This position makes it possible to maintain a direct view of the oral cavity at all times, and it directs the flow of the material toward the oropharyngeal space .

While the impression is being made, at least four assistants should be available to 1) hold the infant’s head, 2) depress the tongue and hold the suction, 3) hold the infant’s body and feet, and 4) mix the impression material. The infant is restrained in a receiving blanket.

Proper instruments should be available on the bracket table to gain access to material should it be displaced or lodged in the nasal and oral pharynx. The tray should not be over packed with the impression material, nor should too much force be applied in placing the tray in position. The part of the tray that will be directly over an undercut should contain less of the impression material. The procedure for removing the impression from the mouth must be modified according to the location of the undercut.

Older children and adults -

A stock tray of adequate dimensions is

selected. If a registration of the entire cleft is desirable, the stock tray is modified with modeling compound extending posteriorly to the postpharyngeal wall. This added section to the tray is under extended about 4 to 5 mm in all directions, leaving an adequate space for impression material. The fast-setting, irreversible hydrocolloid is used for registering the preliminary impression. The following suggestions should be kept in mind when the impression is made.

1. If the patient is a child, he should be given the opportunity to see and examine the tray; in some cases, he may be permitted to try the tray in his mouth. He should be told that his cooperation is needed; otherwise, it will be necessary to make several impressions. It is advisable to keep his mind occupied by talking to him.

2. The patient should have an early morning appointment.

3. The patient should have an empty stomach.

4. A topical anesthetic should be used on a child who has a severe gagging reflex.

5. The tray should not be overloaded with impression material. Excess material in the nasopharynx will increase the difficulty of removing the impression without a fracture.

6. all oral perforations should be packed with gauze that has been saturated with petroleum jelly.

2) Radiographs : As with the dental impression, cephalometric data are recorded periodically. A cineradiographic study with synchronized sound of oralpharyngeal structures in function can help the dentist to evaluate velopharyngeal function and tongue position in postoperative and velopharyngeal-incompetent

individuals.

A

series

of

cephalometric

radiograhs can also be of great assistance. Sound spectrograms of speech are used for comparative studies of speech changes. A pressure and flow measuring device permits the study of the relationship between the nasal emission and speech quality. The forms or charts for collecting data from the various examinations are designed for use with modern computers.

The technique employed in obtaining child and adult roetgenographic cephalometric data was described by Broadbent in 1931. Since that time, many other investigators have elaborated and added to this technique.

Numerous head – holding devices have been introduced to the profession.

The technique employed in obtaining child and adult roetgenographic cephalometric data was described by Broadbent in 1931. Since that time, many other investigators have elaborated and added to this technique.

Numerous head-holding devices have been introduced to the profession.

The technique of infant cephalometry has been described by Pruzanski and Lis and by Mazaheri and Sahni.

The roentgenographic cephalometer is an accurate and scientific instrument for evaluating cranial-facial proportion and growth. Recently many investigators have used it for

the evaluation of velopharyngeal

relationship during various functional activates of nasal-pharnygeal dimension, lip and tongue positions, etc. a)Intraoral Radiographs : The intraoral radiograph is used to determine the condition of the teeth and surrounding structures. This type of radiograph includes full mouth x-ray, bite wings, and occlusal x-rays. b)Cineradiography : A cineradiographic unit is used to record on film the function of the mandible, tongue, velum, and surrounding tissue during phonation, blowing, and swallowing. The major components of the cineradiographic structure are : a rotating anode roenjtgenographic tube with a 0.3 – mm focal spot ; a 9 – inch image intensifief tube with a light intensification factor of approximately 3600 an Aurican 16 mm motion picture camera with its optical system for recording sound – on-film data at 24 frames per second, and a timing device capable of accurately recording exposure time to 0.001 second. A specially designed cephalostat consisting of ear rods and platic forhead positioner calibrated to orient the patient to his initial position for subsequent studies can be used.

The distance between the roentgenographic tube and the intensifier tube is fixed. The tubes are adjusted so that the central rays of the roentgen tube will pass through the patient and strike the center of the receiving screen of the image intensifier. A full-wave generator with an outputsmoothing device supplies the power for the rotating roentgen tube. The generator has a stepless control of both kilovolts and millimaperes. The sound-on-film recording apparatus is visually monitored for recording all data presented by the operator and / or patient. Settings of 65 to 75 kv and 1.75 ma; with a 0.27 mm copper filter and a 0.5 mm aluminum filter, are

used. Radiation dosage received by each subject, for 30 seconds’ duration, averages 0.25 r.

Recording Analysis of Cephalometric and Cineradiographic data.

Analysis of skull shape by an electronic method has enabled us to quantify and analyze our cephalometric data with-maximal accuracy and minimal professional supervision. The following is a brief description of the technique. c) Laminography : Laminography has been used for the study of cranialfacial growth and velopharynx orifice size during a sustained sound.

Recently Mazaheri and Biggerstaff introduced a sectional laminograph for the study of the temperomandibular joint. d) Pantomography : Panoramic x-rays have been used for both the clinical diagnosis of the oral-facial region and also for growth appraisal of this area.

3) Photographs : Photographs are used for diagnosis, teaching, and illustration of before and after treatment. By precise orientation of the head, distortion and magnification are minimized; therefore, the photographs can be used for, facial analysis. On an average, eight photographs are taken of each patient, to include extra-and intra-oral views, full face, left and right profile, teeth in occlusion (in infants, the maxillomandibular relationship). Left and right occlusion, anterior palate, and posterior palate. If the patient is wearing a prosthetic speech appliance, anterior and posterior views of speech appliance are added to this list.

4) Speech recording : Most patients have a disc, wire, and/or tape recording. An infant’s babbling, crying and, later, speech should be part of the initial diagnostic procedure. The periodic recording of speech progress, along with various speech tests, is quite helpful to all speech and nonspeech staff, as well as to the parents and the patient.

5) Sound spectrographic recording : This type of recording is helpful for initial diagnosis and follow-up of the patient. The sonograph, which has been used by many clinicians and researchers, is an instrument which analyzes a complex signal as a function of both frequency and time. The resultant portrayal, known as a sonagram, displays frequency along the vertical axis, time along the horizontal axis, and intensity by the darkness of the pattern. This type of automatic analysis is very useful in giving a clear and permanent picture of complex signals that vary with time. The signal spectrum is scanned by either a 45 or 300 cycle band-pass filter. The output of the analyzing filter is then recorded on dry facsimile paper that is fastened around a drum rotating in synchronization with the magnetic recording disc.

A second type of analysis, known as a section, is displayed at the upper half of the sonagram. This auxiliary presentation with the addition of the section micrometer provides, at any preselected point in time, portrayal of amplitude in the horizontal direction versus frequency in the vertical direction. The display is made on a uniform decibel scale with a range of 35 db.

A third type of portrayal, providing a permanent record of the variation of average amplitude versus time, was obtained by using the amplitude display unit. This display, using an amplitude scale that is logarithmic over a 24-db range, is produced on the top 1 ½ inches of the sonagram.

The fourth type of analysis, scale magnification, is one in which any 10% portion of the vertical frequency scale is expanded by a factor of 10.

With the built-in calibrator, it is possible to obtain fine measurements of frequency changes.

6) Measurement of Nasal and Oral Pressure and Flow : The measurement of oral and nasal pressure and flow should be part of the initial diagnostic record. Several instruments are available commercially to record the oral and nasal pressures and flows. They all have advantages and disadvantages. When used in combination with other diagnostic apparatus, however, this type of instrument has a great value in cleft diagnosis.

7) Otologic and Hearing Examination : A periodical otologic examination and evaluation of patient acuity should be part of the patient’s record. Pure tone air-bone tests, speech reception threshold, and discrimination evaluations by voice are given in an acoustically controlled chamber.

8) Phychologic and social considerations : Psychologic evaluations are useful in planning the individual patient’s treatment program. For example, they can assist the social worker in his contacts with the parents. Parents should be given the opportunity to discuss the findings with the social worker and the psychologist in a joint conference.

Since more than 10% of the general population seeks help at some time in their lives for mental or emotional problems, it can be expected that a similar percentage of people with the cleft palates will seek psychologic help in the form of counseling or psychotherapy. Assistance in obtaining these services should be made available to the patient, perhaps through an appropriate community agency.

Social service in a clinical setting should be available to enable the patient to make full use of medical, dental, and speech care, both preventive and therapeutic, so that he can achieve the fullest possible physical, emotional, and social adjustment. Social service is concerned with the following factors.

1. Evaluating financial ability in meeting clinic care costs: determining eligibility for full or partial assistance from public funds.

2. Relationships between the child, his family, and the community.

3. The effect of a patient’s disability on the family.

4. Family strength and ability to meet patient’s needs in order to maximize rehabilitation and prevent family disintegration.

5. Community resources designed to meet the social, psychologic, educational, recreational, and ancillary medical needs of the patient.

A social evaluation which is made by examining social history data and intra family relationships helps to determine social casework goals.

Social casework includes a plan of action to help the patient and his family resolve problems in order to adjust to the present situation. The focus, timing, and extent of social casework are determined by the medical-dental plan of treatment for which the medical staff carries ultimate responsibility.

Social casework is therefore part of comprehensive medical-dental care.

Through social service, the clinic team is aided in understanding the significance of social, economic, and emotional factors in relation to patient disability treatment and rehabilitation.

Requirements of speech appliance A. The prosthesis must be designed for the individual patient in relation to his oral and facial balance, masticatory function, and speech.

B. Knowledge related to removable partial and complete denture should be used in designing the maxillary part of the cleft palate prosthesis.

Preservation of the remaining dentition and surrounding soft and hard tissue in cleft palate patients is of utmost importance. Improper design and the cleft palate appliance can result in premature loss of both hard and soft tissue, further complicating prosthetic habilitation.

C. The prosthetic speech appliance should have more retention and support than most other restorations. The crowning and splinting of the abutment teeth in adult patients may increase retention and support of the prosthesis and may extend the life expectancy of abutment teeth.

D. Mouth preparations should be completed before making final impressions. When lateral and vertical growth of the maxilla is incomplete and partial eruption of the deciduous and permanent teeth is evident, careful mouth preparations should be made. To provide support for the prosthesis, these preparations may include gingivectomies to expose clinical crowns (two make them usable) and the placement of coping on remaining teeth to prevent decalcification and caries.

E. Weight and size of the prosthetic speech appliance should be kept to a minimum.

F. Materials used should lend themselves easily to repair, extension, and reduction.

G. Soft tissue displacement in velar and nasopharyngeal areas by the prosthesis should be avoided.

H. Velar and pharyngeal sections of the prosthesis should never be displaced by prosthesis should never be displaced bilateral and posterior pharyngeal wall muscle activities or tongue movement during swallowing and speech.

I. The superior portion of the pharyngeal section should be sloped laterally to eliminate the collection of nasal secretions. The inferior portion of the pharyngeal section should be slightly concave to allow for freedom of tongue movement.

J. The location and the changes of the speech bulb should include consideration of the following factors.

1. The speech bulb should be positioned in the location of greatest posterior pharyngeal and lateral pharyngeal wall activity, since voice quality is judged best when the speech bulb is at these positions.

2. The inferior-superior dimension and weight of the speech bulb may be reduced without apparent effect on nasal resonance. (The lateral dimension of the bulb does not change significantly as the position is varied).

3. The speech bulb should be placed on or above the palatal plane when posterior and lateral pharyngeal wall activities are not present or when visual observation of the bulb is not possible because of a long, soft palate.

4. The anterior tubercle of the atlas bone can be used as a reference point ; however, the relative position of the tubercle of the atlas bone varies in different individuals, and the positions of the velopharyngeal structures change in relation to the tubercle as the individual moves his head. therefore, the atlas bone is no longer used as the reference point for positioning of the pharyngeal section of the bulb.

Psychologic considerations : A few remarks to be made regarding psychologic problems in prosthetics are limited to patients requiring prosthetic speech appliances.

There may be occasional of fixed bridges or complete dentures in which negative results are attributable to emotional problems, but most such problems are associated with the placement of a prosthetic speech appliance.

In children, the single greatest cause for the failure to adjust to a speech appliance is the anxious parent. Although is may be theoretically possible to have an excessively anxious child patient with calm, composed and understanding parents, we have found this to be true only in cases in

which the child was brain injured or mentally retarded, or presented with primary psychopathology such as schizophrenia. Fortunately such cases are rare.

The prosthodontist must attempt to assess by himself or with consultative help, of the emotional stability of the prospective patient and particularly his parents. This is an easy task for a prosthodontist associated with a cleft palate team. “Self concept or body image�. Occasionally patients have rejected the recommendation for a prosthetic speech appliance or, after a time, have even rejected the appliance itself, since they have come to regard it as symbolic of a defect. Some have stated quite frankly that the appliance is, or would be, a constant reminder that they were somehow inadequate or incomplete.

Treatment anticipate these attitudes and to institute as much guidance and counseling as possible and as soon as possible. Such course is suited for parents of a young patient. However it many not be applicable to teenagers and young adults.

In these cases, attempts to talk them out of their attitudes may only intensify the problem.

PEDODONTIC CARE FOR CHILDREN WITH CLEFT LIP AND CLEFT PALATE The pedodontist or general dentist is often confronted with the parents of a child with a cleft lip and palate who want to know what to do but are confused. The dentist cannot effectively involve the parent in the habilitation of the child unless he develops an understanding of the parent’s background. With such an understanding, he can help the parent anticipate and schedule the extended medical, dental, and speech therapy that are required while minimizing the secondary handicaps in the area of

personality

development.

By

providing

frequent,

consistent,

and

knowledgeable interpretations for the parents and child of the treatment offered by all members of the professional team and by realistically appraising the difficulties and imperfections inherent in the participation of both specialist and parent, the dentist can carry out a valuable and unique professional service. However, in his concern for parent conunseling, the pedodontist or general dentist must not overlook his important role in providing general dental care for children with cleft lip and palate. It is trite to state that good treatment requires proper diagnosis, but these children have unique dental conditions which the dentist must keep uppermost in his mind during diagnosis and treatment planning.

Radiographic findings : Bailet and his associates have shown that the dental development of children with cleft lip and palate may be delayed. The dentist will need to evaluate dental development radiographically so that he can properly plan treatment such as space management which must be coordinated with eruption. The parents should also be advised concerning any delay in tooth eruption.

Carr and Mink have indicated that ectopic eruption of the maxillary 6-year molar is common in children with cleft palate. Any good pedodontic text will show several techniques to treat this condition; however, radiographic diagnosis and early treatment are important to help reduce the amount of resorption of the second primary molar and to improve the prospects of guiding the 6-year molar into normal relationship.

Primary and permanent lateral incisors may be congenitally absent.

More commonly, however, there will be supernumerary teeth on the alveolar ridge or in the palate in the area of the clef. This area of the cleft of the alveolar ridge must be evaluated radiographically so that these conditions can be considered in treatment planning.

The radiographic examination should include a Panorex or full intraoral series, bite-wing radiographs, and an occlusal radiograph of the alveolar cleft. The occlusal radiograph provides a better view of all of the teeth in the area of the cleft.

Study models are of special importance in the orthodontic evaluation of the child with cleft lip and palate. Yet even dentists with considerable clinical experience in treating these children may forget that there are usually nasal-oral fistulae just labial and just lingual to the alveolar ridge in the area of the cleft.

To prevent impression material from being forced into the nose through these fistulae, the dentist must obdurate them with a small piece of gauze. The saliva will hold the gauze in place while the impression is being seated, or the gauze can be teased a short distance into the fistula. The gauze will be removed with the impression.

If some material is inadvertently forced into the nose and remains when the impression is removed, the dentist may require the assistance of the otolaryngologist to remove the material.

Behavior Management : During the collection of records and the examination and treatment of the child with a cleft lip and palate, the dentist must control the child’s emotional adaptation to the dental environment. Most children with clefts of the lip or palate are reasonably mature in their approach to dental treatment.

However, certain of these children seem to have had most of their emotional control drained by their previous medical experiences, and they may whine and sob during much of the dental appointment. The fact is, however, that this sobbing may help the child reduce his anxiety and prevent him from building up any resentment toward the dentist. These children are usually

observed to be friendly toward the dentist both before and after dental treatment.

Because of the surgical repair of the cleft lip, the tissue in the anterior maxillary mucobuccal fold is tight and especially sensitive and resistant to the penetration of the needle and the deposition of the anesthetic solution.

Placing local anesthesia in this area may prove to be the most severe test of the dentist’s ability to manage the child’s behavior effectively.

After the topical anesthetic has been allowed superficially to anesthetize the area, the dentist should deposit a small amount of anesthetic just below the epithelium. After 2 or 3 minutes, this small amount will have anesthetized the tissue and it will be less painful to deposit the remainder of the anesthetic.

It must be remembered that the cleft has interfered with the innervation of the teeth. The anesthetic solution must be deposited on the same side of the cleft as the teeth that are to be treated.

If anesthesia of the lingual tissue is needed, the needle can be passed through the interdental papilla. If the anesthetic is deposited properly, the dentist will seethe lingual tissue blanch. This will provide adequate anesthesia for the extraction of a tooth and avoid a painful injection into the scar tissue of the repaired cleft palate.

Most extractions in children with cleft lip and palate are handled in exactly the same way as with other children. The exceptions are supernumerary teeth that have erupted lingually in the area of the cleft or teeth in the mobile premaxilla of a Veau Type IV cleft palate.

When a supernumerary tooth positioned lingually in the area of the cleft is to be removed, it is usually necessary to supplement the labial anesthetic by depositing the solution directly into the periodontal membrane of the tooth to be extracted. This will allow for the routine extraction of the tooth without pain to the child. However, because of this problem with

anesthesia, it is frequently convenient to have these teeth extracted under general anesthesia during a plastic surgery procedure.

The extraction of any tooth in the mobile premaxilla in a Veau Type IV cleft palate must be accomplished by using an elevation technique in which the tooth is “wedged” out rather than pulled out with the application of forceps. The premaxilla must be carefully stabilized with the fingers and thumb of the opposite hand. The consultation of an oral surgeon should be freely sought if any difficulty is anticipated.

Before a supernumerary tooth is removed, the clinician must evaluate its usefulness in maintaining the alveolar process and preventing the collapse of the posterior segments. Pruzansky and Aduss state that “the bulbous and fully-toothed alveolar process are an impediment to arch collapse”. Removal of a tooth in the cleft site may allow for the collapse of the posterior segments or may allow the nasal-oral fistula in the area to become larger.

Stabilization of Posterior Segments : If the dentist wishes to prevent collapse of the posterior segment subsequent to the extraction of a tooth, surgical closure of the cleft palate, or orthodontic repositioning of the posterior segment, a simple transpalatal arch should be placed. If maxillary anterior teeth need to be replaced, a Hawley type removable appliance can be used to stabilize the maxillary arch.

Preventive Care : Even more importantly than for the child with a normal self-cleansing dentition, the cleft palate child must be placed on an extremely aggressive program of home care. Mink, Dixon, and Kraus et al. have documented the fact, long recognized by clinicians, that children with cleft lip and palate have numerous malformed and hypoplastic teeth. These defects provide many areas for plaque accumulation and cause a configuration of the oral

cavity that is not self-cleansing but in fact is often difficult to keep free of debris. Tote and Sawinski and Tote et al. have demonstrated that instruction in tooth brushing using a disclosing tablet as a teaching aid will produce a marked improvement in oral hygiene. Fodor and Ziegler studied the motivational effect of disclosing tablets and showed that they were the key factor in improving oral hygiene in children.

Any preventive program for children with cleft lip and palate must include instruction in the use of a disclosing tablet so that the child and parent will have a clear concept of the areas of the teeth not being cleaned adequately.

Strakey has advocated a technique for the parent to use in brushing the preschool child’s teeth. the child stands in front of the parent and leans back against her body. The parent cradles the child’s head in her left arm so that her left hand is free to retract the lips while the right hand wields the brush. McClure and Kimmelman and Tassman have shown that brushing performances for children under 7 years of age are briefer, more haphazard, and more erratic than in the case of older children. In addition, some children in the 3 to 5yer age group are unable to wield the brush. McClure has also shown that parents without instruction brush more efficiently than do preschool-age children even when the children have received instruction.

Parents of a preschool-age cleft palate child should be taught by the dentist or his staff how to brush their child’s teeth. the parents should brush for the child until he is motivated and has demonstrated his ability to brush thoroughly for himself.

In addition, the patient should be taught the proper use of dental floss.

The floss must pass through the contact points of all teeth and then be drawn occlusally against the proximal surfaces of both teeth involved in the contact. The use of dental floss becomes an important adjunct to cleaning the teeth, if all possible debris is to be removed.

As with any patient, the dentist will need to carry out a careful diagnosis of the child’s present oral hygiene and dietary habits. He will evaluate a dietary record and make recommendations regarding the diet. The topical application of fluoride is also a part of the preventive program. Of great importance is a regular evaluation of the patient’s compliance with instructions on home care and the frequent reinforcement of its importance.

Jacobson and Rosenstein have noted the difficulty that some children have in brushing their maxillary anterior teeth because of the interference of the tight upper lip. The plastic surgeon will often surgically deepen the labial sulcus in these children, and the dentist may be called upon to construct an appliance to hold the surgically created sulcus. Porterfield et al advocate the use of a fixed appliance attached to bands on the 6 year molars with a labial arch wire.

The plastic surgeon may perform this surgery for prosthetic reasons or for speech and esthetic reasons but, since an aggressive program in home oral hygiene will overcome any interference form a tight lip, the sulcus need not be deepened to improve hygiene alone. However, the child must be directed and motivated to clean this area specifically.

Restorative Care : Because of the hypoplastic defects, especially of the anterior teeth, few children with cleft lip and palate escape the need for restorative dental care, no matter how aggressive the caries prevention program. The dentist must carefully explore every hypoplastic defect for caries. Also, every tooth with an abnormal shape must be carefully examined because caries may be present in areas where it is not usually found.

Even if the hypoplastic defects are not carious, the shape of the tooth and the presence of hypoplasia must be considered in planning for their successful restoration. Because these hypoplastic defects often prevent the normal preparation of the tooth for an amalgam restoration, stainless steel

crowns are often used. The use of cast gold crowns, even on the primary teeth, should also be considered.

The steel crowns are sometimes the only full coverage possible on primary teeth in which almost all coronal tooth structure has been lost. The crowns can be contoured so that they “snap� over the typically bulbous cervical third of the primary molar just occlusal to the very constricted neck of the tooth. However, the adaptation of the metal at the cervical can be evaluated only by radiographic interpretation and clinical palpation, whereas the cast gold crown adaptation can be evaluated on the die. Unless there are some very serious economic considerations, the cleft palate child should receive a nearly ideal type of dental service. Cast gold crowns can be successfully constructed for most of these teeth needing full coverage and will provide the maximum in self-cleansing qualities.

Since some children must wear removable appliances such as speech bulbs or palatal obturators which require efficient retention, the dentist should modify his steel crowns in these cases to include a labial or lingual lug. This lug is made by soldering a square wire in the midline one-third of the labial or lingual surface of the crown. The solder is flowed over the oclusal surface of the wire so that a guide plane is created to lift the wrought clasp wire into the undercut when the appliance is seated.

Of more immediate concern to the child in the mixed dentition is the esthetic restoration of the hypoplastic maxillary anterior teeth. The acid etching technique advocated by Doyle and by Laswell et al. can help to retain an acrylic tooth-colored restorative material in the hypoplastic defects. The preparation should include only the areas of hypoplasia, and the mechanical retention should be minimal. This will serve adequately as an intermediate restoration until a full coverage restoration can be more advantageously placed.

SURGICAL MANAGEMENT OF THE CLEFT LIP AND CLEFT PALATE Clefts of Primary Palate Timing of surgery : As in any purely elective operation, there is always a difference of opinion as to the optimal time for surgical repair. Since there are several schools of thought on the subject, we have established a group of arbitrary criteria to determine, for practical purposes, the optimal time for surgery, in our experience.

1) The child must be free of any systemic or local disease which would contraindicate surgery.

2) The child must have a minimal weight of 7pounds.

3) The child must be in a weight-gaining phase.

Consequently, this has placed most cleft lip patients between 2 and 6weeks of age at the time of the primary surgery. We have recommended this time for surgery because of factors other than that of correcting the purely cosmetic deformity. The alveolus develops with the lip embryologically so that the more extreme the lip deformity, the greater the bony defect and loss of normal dental arch. Early closure of the lip has been imperative to permit early alignment of the bony arch. We feel that the early closure can accomplish this relationship and that it can better the potential for growth and development of the bony components of the middle third of the face.

In recent years, the introduction of maxillary orthopedics has presented a substantial argument for a change in procedure, permitting orthodontic manipulation of the maxillary segments to improve bony position prior to surgical repair of the cleft lip. Maxillary position is of importance, particularly in the wide cleft of the lip and alveolus, where mechanical and technical problems are encountered in the attempt to repair

the cleft surgically. In the more minor clefts of the lip, the bony defect is a less significant factor technically in the closure of the lip. Consequently, in the past we have deferred maxillary alignment by mechanical means, if necessary, until a later date, usually 3 to 5 years of age.

Surgical procedures : The history of cleft lip surgery is replete with numerous procedures which have been initiated, forgotten, and revived. The major historical factors involved in these numerous procedures, described by many people in many lands, have resolved themselves into several major categories. The simple linear closures of the lip were originally described by Rose of London and Thompson, then later modified by Hagedorn. The advocates of the triangular flap looked upon Mirault as their champion, upon whose operation were based a great many of the lip repairs performed in this country prior to 1948. mirault’s operation, as modified by Brown an McDowell was probably the most common operation performed for the repair of the unilateral cleft lip prior to the advent of the Le-Mesurier repair.

The Tennison repair is another triangular flap type of repair of a cleft lip, which was developed during the popularity of the LeMesurier repair in an attempt to preserve more tissue and create better lip balance. A number of the LeMesurier repairs developed increased length on the repaired side in the postoperative period. Modifications of these operations were developed by numerous plastic surgeons, among them Marcks and Bauer, whose procedures were further varied by Randall, Haggarty, and Skoog. The development of the Millard rotating advancement procedure in 1955 attracted a considerable wave of popularity which seems to have persisted to the present time.

Consequently, the most popular operations at the present time for the repair of the unilateral cleft lip are the LeMesurier, Tennison, Millard, and

Mirault procedures. In order to point out the use and advantages of the various types of procedure, these procedures are described and illustrated.

The operative procedures on the primary cleft lip may be performed under either local or general anesthesia. When local anesthesia is utilized, it appears to be best suited for repair in infants under 1 month of age. General anesthesia, generally administered through intraoral insufflation or endotracheal tube, has become more popular with the advent of modern improved types of general anesthesia. In all types of cleft lip repair, we supplement the general anesthesia with local infiltration of Xylocaine with 1:100,000 Adrenalin. In order to minimize any possible distortion resulting from the mechanical presence of the tube, we arrange to have the anesthetist at the left side of the table and the endotracheal tube taped to the midline of the lower lip. We prefer to sit at the right side of the table so that the view of the patient from above and below is unobstructed, permitting easier access to the intraoral aspect of the lip, as well as a better view of the symmetry of the nose and lip from below.

It is needless to mention the necessity for atraumatic technique during the course of the operation. Atraumatic sutures, with little or no use of tissue forceps, is used routinely. We prefer skin hooks to tissue forceps which, even though delicate, do produce some tissue trauma. Small lip clamps are applied bilaterally prior to the making of the incisions in order to minimize blood loss. We routinely use methalvene blue as the marking agent in order to determine the lines of our incisions.

Regardless of the technique or procedure involved, there are a number of criteria which are essential during the course of the repair which must be considered. Among these are approximation of all tissues with a minimum of tension, accurate closure of the lip in layers, and definite cooptation of the muscularis of both sides of the lip. Symmetry of the nostrils, as far as possible, and careful alignment of the vermilion border

with adequate development of a buccal sulcus and advancement of the mucous membrane to produce normal eversion of the lower third of the lip are also important.

Prior to 1952. a major portion of the primary cleft lip repairs were done by the Brown-McDowell modification of the Mirault lip repair. This results in a satisfactory lip in a large series of cases. In our experience, however, the absence of the Cupid’s bow and the mucocutaneous ridge is almost universally apparent. The tendency for the lip to appear thin and hypoplastic becomes more obvious as the child grows older. Consequently, this and hypoplastic becomes more obvious as the child grows older.

Consequently, this operation gave way in about 1952 to the Le-Mesuriertype technique.

The LeMesurier operation altered the geometry of the primary cleft lip repair by the development of a quadrilateral flap in contradistinction to the triangular flap of the Mirault. The advantages of the LeMesurier lip repair were the alteration of the linear scar, addition of considerable tissue in the lower third of the lip to produce a marked fullness, and preservation of the normal vermilion mucocutaneous line. This also permitted the development of a minimum of tension in closure of the severe cleft lip.

The Tennison operation with the insertion of the triangular flap rather that the quadrilateral flap into the medial portion of the lip, appears to have gained considerable popularity, particularly among the younger surgeons. It discards a minimum of tissue and provides a satisfactory prominence of the lower third of the lip, preserving the Cupid’s bow and a satisfactory mucocutaneous line.

The Millard operation has obtained considerable prominence in the course of the last several years in that it has developed the idea of rotation advancement of the involved portion of the nose and lip, which appears to be more in keeping with their natural development embryologically. In most

cases, the Millard procedure works extremely well in partial clefts of the lip.

Some surgeons are utilizing the Millard procedure for all types of cleft lip, whether partial or complete. Many surgeons have difficulty in utilizing the Millard operation in the wide complete cleft in the lip because of the inability to rotate the flaps adequately to gain normal length of the involved portion of the lip. It has been our experience that the Millard procedure can be utilized for all types of lip defects and is used to its best advantage by one who has experience with various other types of procedures, since much of the benefit of the operation depends upon previous experience in the handling of tissue in this area.

Bilateral Cleft Lip One of the major problems in the treatment of a bilateral cleft lip deformity is the treatment of the prolabium and associated premaxilla. The premaxilla varies greatly in size, shape, and position. The premaxilla usually contains the two central incisors but may contain other teeth as well. various types of bilateral cleft deformities make it impossible to standardize a procedure for management.

Resection or osteotomy of the vomer to permit retropositioning of the premaxilla has often been done at the time of the lip repair as a preliminary procedure. This has, in the past, led to maldevelopment of the middle third of the maxilla, in our experience.

In order to minimize the multiple problems, such as tight lip and unsatisfactory central one-third in the repair of the bilateral cleft lip, the one-stage repair of the deformity has been abandoned in favor of the twostage procedure. This two-stage technique involves closure of one side of the bilateral cleft in the fashion similar to that of a unilateral cleft, followed by closure of the residual cleft in 2 to 3 months. Such staging permits maximal salvage of available tissue. The technique utilizes a maximal amount of soft tissue available in reconstruction of the lip; at the same time,

it creates a buccal sulcus across the anterior premaxilla, reducing the protruding premaxilla as slowly and gently as possible, by utilizing the function of the closed lip. This operation is usually performed under the same criteria as the unilateral cleft procedure. We recommend the bilateral Tennison approach to the closure, not only for giving additional length to both the prolabium and lateral lip flap, but also in order to improve the appearance of the lip by symmetrical philtral scars.

The premaxilla is not joined to the lateral maxillary process at the initial surgery. It is joined at the time of the cleft palate repair which, in bilateral complete clefts, is a two-stage procedure. The first stage closes the anterior portion of the defect by the vomer flap technique. The completion of the muscle sling over the premaxilla permits continued retropositioning of the premaxilla. Definitive positioning may require maxillary orthopedics, as well as stabilization by subsequent bone grafts.

Secondary operations : Residual Unilateral cleft lip deformities : The better the primary cleft repair, the fewer secondary deformities anticipated. Some residual deformity may be present, however, as a result of intrinsic developmental errors as well as technical inadequacies. These deformities may be minor enough to escape secondary repair or obvious enough to require revision.

Minor defects associated with initial repair are inevitable. We feel, however, that the so-called typical cleft lip deformity, a notched lip with a poor scar, has become less significant with improved primary repairs. One of the major residual deformities is in the abnormal development of the nose. This problem is one of considerable severity, since it is progressive with growth and development.

A common secondary lip deformity includes an inadequate buccal mucosa, associated with secondary contracture. This results in a tightness of

the upper lip. Asymmetry of the nostrils, usually with deviation of the septum and frequently with a conspicuous scar, is often noted. a standard secondary lip repair tends to correct all of these in order, by means of scar revision, secondary rhinoplasty with submucous resection, and mucous membrane advancement. In recent years, we have found that a routine Millard type of approach solves many of the above problems in secondary lip deformities. This seems to be especially true when the nostril asymmetry is the major problem associated with the short, notched lip.

A major residual problem which should be resolved is the large nasal oral fistula resulting from a wide cleft involving the maxilla, a condition associated with loss of support of the lip, nasal floor depression, and muscle inadequacy of the upper portion of the lip. Currently, we are treating this problem with mucous membrane advancement and a rotation of a muscle flap to the floor of the nostril. Ideally, this type of case should merit a bone graft to correct the alveolar ridge defect and stabilize the maxillary segments. This would of course, require previous orthodontic alignment of the maxillary arch.

Occasionally it becomes necessary to use a dental appliance to maintain a restored sulcus following the release of the lip from its maxillary attachment, in order to improve the appearance as well as the function of the lip.

A residual irregularity of the exposed mucosal portion of the lip can frequently be improved by a standard lip shave procedure for recontour of the vermilion.

Residual bilateral cleft lip deformities In most cases of bilateral cleft lip, there is a congenital deficiency of the columella. This defect requires a later operation, usually at about 5 years of age, to reconstruct the columella and to minimize the porcine type of nose deformity. A modification of the Marcks columellar lift is performed

when the lip is of adequate vertical length but has poor vertical or initial repair scars. This permits utilization of the transverse fullness of the lip and revision of the scars in a single procedure. The Cronin type of columellar lift is utilized when the lip and tissue of the floor of the nostrils are generally satisfactory. The Barsky type of columellar lift is very similar to the Cronin except that it utilizes tissue from the upper third of the lip. Thus, it is indicated when there is excessive vertical length of the lip. This permits reconstruction of the columella and shortening of the vertical length of the lip in the same procedure.

The one-stage bilateral cleft lip repair frequently resulted in the loss of transverse length of the lip because of a discarding of excess amounts of mucous membrane. This tightness of the soft tissue frequently fostered maldevelopment of the middle third of the maxilla, which became more apparent with increase in age and growth. We find this problem fading with the increased use of the two-stage lip repair. However, such defects still are found. The abbe lip switch operation is used to furnish increased transverse length, at the expense of the lower lip.

Maxillary bone grafts, using split ribs are the treatment of choice for reconstruction of the anterior maxilla when flattening or retrusing is present.

Bone grafting The timing indications, and management of maxillary bone grafting have been a controversial subject for several years. now that sufficient time has elapsed for long-term evaluation, those proponents of early bone grafting (defined as that performed prior to closure of the palate) are losing interest.

Basically there are two indications for delayed or secondary bone grafting : functional and esthetic. The first is for stabilization of the

maxillary arch after arch alignment has been achieved. The second is for correction of a depressed alar base. The most practical source of bone is the rib because of easy accessibility and abundant supply. During the period of graft healing, it is frequently beneficial to maintain the position of the dental arch with an intraoral appliance for a minimum of 3 months.

There is a variety of methods for bone grafting the maxillary arch.

The method used depends upon the nature of the defect and the desired accomplishment. Types include : inlay grafts, in which either bone chips or a block of bone is placed between the ends of the maxillary segments in order to establish bone continuity ; onlay grafts, in which segments of bone span the defect ; and a combination of these two. The latter is our preferences.

Clefts of secondary palate Anatomically, the palate creates a mechanical barrier between the oral pharynx and the nasal pharynx. The anterior portion of the palate is bony and fixed, whereas the posterior half is muscular and labile. The muscular portion of the palate changes size, shape, and configuration with almost every conscious, as well as unconscious, motion of the patient’s musculature. This controls the amount of air and sound which passes through the mouth as well as the nose. Consequently, the palate is of prime importance in the development of normal speech. The primary purpose of reconstructing the palate is to furnish the mechanical as well as functional means to develop normal speech.

A cleft plate has defects and deficiencies in three dimensions. The failure of fusion in the midline is the most obvious defect. The degree of hypoplasia varies, becoming most marked clinically in the partial clefts. The third dimension of deficiency is in length. Failure of the palate to reach the posterior pharynx at the level of the atlas creates an inadequately functioning palate and velopharyngeal insufficiency. Any surgical

procedure which fails to correct or restore both the mechanical and functional aspects of the palate must be considered inadequate, since both of these aspects must be complete in order to furnish the mechanism for normal speech.

There are various schools of thought on the subject of the time for repair of a primary palatal defect. We recommend primary repair of the palate at approximately 18 months of age, early in the development of definitive speech, except in the case of bilateral complete cleft of the palate.

For the latter, we recommend a two-stage procedure consisting of a vomer flap forreconstruction of the anterior or what would normally be the bony palate, along with stabilization of the premaxilla at 12 to 15 months, followed by closure of the soft palate as a second stage approximately 3 months later. This permits utilization of the maximal amount of tissue with the optimal opportunity for primary healing of the various areas.

There are numerous procedures designed for repairing cleft palate deformities. This variety is necessary because of the wide variation in types of cleft palate deformities. In our experience, the optimal surgical success in closures of primary defects are as follows.

Submucous clefts : Generally, a V-Y palatoplasty is indicated.

Incomplete cleft : Wardill V-Y palatoplasty.

Complete Clefts without Prepalatal Tissue Involvement : generally our approach has been the Wardill V-Y procedure, but the von Langenbeack procedure is acceptable.

Complete clefts with primary palatal involvement : V-Y Palatoplasty, two or four-flap.

Wide cleft and bilateral Clefts : Frequently it is advantageous to treat these closures in two stages, using a vomer flap for anterior closure at approximately 12 to 14 months of age, followed in 3 to 4 months by the VY procedure as mentioned above.

Secondary procedures on secondary palate: Approximately 15 to 20%(depending on the series) of patients with clefts of the secondary palate will require secondary palatal procedures because of inadequate alveolar-pharyngeal closure. This may be due to scar contracture, poorly designed initial operative procedure with subsequent inadequate palatal tissue in the anterior-posterior direction, or slower growth of the middle third of the face.

The principle followed in correcting these defects is to accomplish closure either by moving the soft palatal tissue posteriorly for proper abutment against the posterior pharyngeal wall or by building out the posterior pharyngeal wall for contact with the soft palate. Among the several procedures described for achieving the former (lengthening the tissues in an anterior-posterior direction) pushback in a V-Y fashion and pushback with resurfacing the resulting defect on the anterior nasal surface of the soft palate either with an island flap, skin graft, or superiorly based pharyngeal flap. The latter, in addition to securing coverage and thus preventing scar retraction, acts as an obturator. Procedures for bringing the posterior pharyngeal wall forward include autogenous implants of cartilage or bone or synthetic implants in the form of molded silastic blocks or injection of synthetic material to balloon out the tissue. The posterior wall can be built out by the Hynes procedure which creates an anatomic Passavant’s ridge and is formed by detaching the salpingopharyngeus muscle at its distal attachement bilaterally and rotating it 90 degrees to meet its fellow in a transverse direction at the level of the atlas.

Another method for creating adequate velopharyngeal closure is the Rosenthal pharyngeal flap which utilizes the posterior pharyngeal muscle based either superiorly or inferiorly, which is sutured to the soft palate. This

creates an anatomic obturator which minimizes the velopharyngeal space and depends on lateral pharyngeal muscle motion for maximal success.

The decision as to which of these multiple procedures is to be used depends on the individual patient situation,

with many things to be

considered, such as motion of the palate, condition of the palate in relation to scarring, the velopharyngeal gap, and the age and mentality of the individual.

Complications associated with cleft lip and palate repair. (Bonnie L. Padwa, John B. Mulliken, Boston USA) “Incising a cleft lip is like cutting a diamond. The diamond lasts forever but the repaired lip affects a lifetime.

Most common facial birth defects occurring is 1 in 1750 newborns. A three dimensional anomaly that involves soft and skeletal tissue that changes in the fourth dimension with growth and movement. Complication and long term problems occur in the management of patients with clefts because of lack of understanding of principles and ill advised techniques.

Cleft lip : Repair of a cleft lip includes anatomic correction of labial skin, muscle, and mucosa, with emphasis on symmetric labial height, and cupid’s bow along with a full vermilion. Nasal cleft is corrected simultaneously.

In unilateral complete cleft lip and palate or a bilateral complete cleft lip and palate with a protruding premaxilla, labial repair is under tension and although dehiscence is unlikely, tension leads to a wide scar and distortion of the prolabuim nose.

Because infant wound healing produces the best scar, it is imperative to provide a favorable environment for primary nasolabial repair. This is the basis for preoperative dentofacial alignment. Preoperative orthopedic appliances being the dentoalveolar segments together, which facilitates a tension free labial repair with less undermining of tissues. Alveolar

approximation also forms the plat form for correction of the nasal deformity and permits gingivoperiosteoplasty.

The advantages of alveolar closure include avoidance of an oronasal fistula and the possibility of alveolar bone formation that may obviate the used for bone grafting in the mixed denture.

Effect of labial repair and premaxillary orthopedics on maxillary growth : The benefit of preoperative orthopedics in the final outcome of cleft patients is controversial. Although it seems that premaxillary orthopedics improve the surgeon’s ability to close the lip and correct the nose, there are concerns regarding its impact on facial growth. Some reports suggests that it interferes with maxillary growth, whereas other reports refute these claims.

Evidence also exists that labial repair perse may interferes with facial growth based on studies in animals and humans. “Bardach’s” studies proved (1998) that increases pressure from the repaired cleft lip was the cause of maxillary growth restraint.

(1996) Felho et al documented facial growth with lateral uphalograms in 93 adult unilateral complete cleft lip and palate patients.

Patients without repair

- n = 35

Only labial repair

- n = 23

Palatal + labial repair

- n = 35

Acc to cephalometric measurements, concluded that differences in dentofacial morphology in patients with unilateral complete cleft lip and palate seem to be influenced principally by the labial repair rather than the palatal closure.

Nasolabial stiumata : Unilateral cleft lip : Assymetry of the repaired unilateral cleft lip that calls attention to the viewer. Usual signs are a shortness of the lip on the repaired side (seen as a peaked cupid’s bow). Misplaced rotation advancement scar and a slight depression below the nasal sill.

Major problem is the failure to appreciate and correct the thin vermilion component on the medial side of the cleft. The result is exposure of the mucosa. On the cleft side of the median tubercle with chronic dry lip.

Assymmetrics in the fullness of the vermilion can be unproved by autogenous dermal grafts to “plump� the tubercle and resection of mucosa in areas of excess.

The nasal deformity is more eye catching than the repaired lip. The caudal septum is demarcated to the noncleft leds, and the alar cartilage is dislocated off its normal position over riding the upper lateral cartilage.

Typically the alar base is laterally displaced and underrotated.

In childhood this involves symmetrical positioning of the alar cartilage, medical advancement and rotation of the alar base, which are often done in conjunction with release of the lateral vestibular web. Formal rhinoplasty with nasomaxilary osteotomis and septal resection is performed after complete facial growth.

Bilateral cleft lip : Less satisfactory than the unilateral cleft lip. The typical labial stigmata are a broad, bowed, and undimpled philtrum, lateral muscular bulges and a thin median tubercle, accentualed by hanging lateral labial elements. The nasal stigmata are a flat, broad nasal tip, excessive interalar width and a short columella.

The revision rate for bilateral cleft lip is lower than that of unilateral cleft lip because of the advantage of preoperative symmetry. If the primary repair is performed properly revision of the cutaneous lip is rarely necessary.

Primary columellar construction is advocated that molecules positioning of the alar cartilages and excision of redundant skin from the nasal tip and upper columella. The broad mosi is corrected in adolescences by nasomaxillary osteotomies.

Cleft palate : The objective of palatal closure is to construct a functional mechanism for velopharyngeal competence during speech. Separation of the oral and nasal cavities also is believed to improve drainage from the middle car cavities of by proper orientation of the velar muscles. Tuning of palatal repair continues to be controversial because of concerns about a deleterious effect on facial growth.

Effect of palatal closure on maxillary growth many studies have shown that cleft palate repair interferes with max growth.

Liao et al used cephalometric comparisons of patients with bilateral complete cleft of the primary palate and bilateral complete cleft of the secondary palate (without cleft lip). They found that subjects with bilateral clefts of the primary palate had longer max length, more protruded max, more few jaw relations and a larger overjet than patients with bilateral cleft of the secondary palate.

Sim Han et al cephal studies to compare craniofacial morphology in patient with unitat cleft lip and alveolus, unilate complete cleft lip and palate and isolate cleft palate same cone.

Velopharyngeal incompetence : It the time of palatoplasty the muscles of the soft palate are reoriented and detached from their abnormal attachyment to the past edge of the hard

palate and approximated transversely to conducted the velopharyngeal sphincter. •

This insufficiency can be treated by various surgical techniques and prosthetic devices. Palatal lifts and speech bulbus are generally reserved for the minority of patients with inadequate velar tissue, hypotomia with minimal movement of the soft palate and pharyngeal walls, and severe obstructer sleep apnea

PROSTHODONTIC REHABILITATION FOR CLEFT PALATE PATIENTS In cleft palate habilitation, the prosthodontist has the same goals as any other professional person working in this habilitation area: 1) to improve appearance and 2) to provide adequate function, including an adequate speech mechanism. Prosthetic treatment of the cleft lip and palate condition is so wide in scope that one might generalize by saying that it starts at birth and ends with death. As an example of this, a marked asymmetry of the dental arch is often seen in the cleft palate new born and, unless this is corrected before surgery commences, severe future problems can be expected.

Maxillary orthopedics : Since McNeil wrote of the pre-surgical orthopedic treatment of the maxillary arch of cleft lip and palate infants, approximately 20 years have elapsed. During those years, treatment centers and private practitioners around the world have experimented with and modified the so-called McNeil technique. For some persons, the idea of bone grafting the cleft alveolus gradually became associated with the early use of orthopedic appliances as part of a dual treatment approach. Others, however, have been convinced neither of the need for early bone grafting nor of its effectiveness

and have employed only early orthopedic techniques. Still others have employed neither technique.

At birth, certain variables can exert a profound influence on the results obtained with these patients. Some of these variables are as follows.

1) length of the minor segment; 2) position of the minor segment; 3) position of the anterior portion of the greater segment or of the apparent tissue deficiency; 5) area of coverage or extension of the appliance; 6) growth potential of the patient; 7) appliance design; active or passive; 8) parent management of the child and appliance and degree of cooperation.

In fact, however, these eight variables can be reduced to four primary considerations; configuration and extent of the cleft, growth potential of the patient, parental cooperation, and appliance design. As yet we have no accurate means of assessing the growth potential of the patients. Nor are there exact means of determining in advance the degree of parent cooperation that can be expected. However, we can assess the configuration and degree of the cleft arch with reasonable accuracy and design our appliances according to prior clinical experience. Early orthopedic treatment on any given patient should be undertaken on the basis of a joint decision of the surgeon, the orthodontist, and the prosthodontist.

Our appliances are of two types : the passive or holding type and the active or expansion type. The type of appliance to be appliance to be placed will be determined by the configuration of the cleft. Generally, if any degree of collapse is manifested, an expansion appliance is placed. If the collapse is manifested, an expansion appliance is placed. If the collapse appears to be primarily in the anterior region, a fan type of split holding appliance is used.

The premaxillary molding can be controlled by the amount of lingual support that the appliance gives the premaxillary area. in cases of arch collapse, surgical closure of the lip is delayed until the expansion appliance has achieved an ideal arch configuration. Cases presenting initially with an

ideal arch alignment or with a wide cleft configuration are operated on as son as the holding appliance is placed. In either situation, the age at which the cleft lip is surgically closed ranges between 1 and 10months. It should be stressed that the primary purpose of the appliance prior to lip closure is not to proliferate tissue or initiate growth but to guide the maxillary segments into proper spatial position with each other and with the mandibular arch. After the maxillary appliance has the segments in good alignment, the plastic surgeon restores lip continuity. The molding pressure of the surgically closed cleft lip, along with the appliance, helps to create an ideal arch form.

Success in achieving and maintaining a good arch alignment is considerably greater in patients whose initial arch configuration is wide : that is, if the smaller segment (in the case of the unilateral complete cleft) or the buccal segments (in the case of a bilateral complete cleft) are positioned lateral to a position that would constitute an ideal arch configuration. The more lateral these segments are to that ideal position, the greater the chance of success in arriving at and maintaining a good arch configuration. On the other hand, when the initial arch configuration demonstrates some degree of collapse, even though the segments may be expanded into an ideal relationship, the end results often are less than satisfactory. Perhaps the variables that permit arch collapse, prenatally and before lip closure, continue to operate so as to compromise the results of treatment.

A decrease in the size of the cleft is apparent in over 90% of these patients. Although the palatal appliance may stimulate growth in some manner, the changes observed are probably due primarily to the intrinsic growth potential of the patient. Extraoral forces are not needed to mold the grater segment into an ideal configuration ; instead, this is accomplished by the forces of the surgically united lip segments.

It has been observed clinically that the forward growth of the lesser segment can displace the appliance anteriorly. A second observation has been that posterior growth of both greater and lesser segments occurs independently of the appliances. Thus, a patient who is wearing an appliance to maintain lateral dimension of the arches can still manifest unimpeded growth in the anteroposterior dimension. These observations indicate that the growth potential is innate in the cleft individual and not initiated by the presence of a maxillary positioning appliance. It must also be stated that, in cases of tissue apposition at the cleft site, there was no coverage by the maxillary appliance because the appliance had been relived in that area.

One area of concern is the parental management of the child and the maxillary appliance. Passive appliances need no parental control, but active appliances need no parental control, but active appliances can present problems because they must be activated by the parents to start the segments moving. When the child has come home from the hospital after lip closure, the parents must see to it that he wears the appliance at all times. If the appliance is left out of the mouth after lip closure, lateral collapse of the segments can occur within 24 hours, creating enough change so that inserting the appliance after that time will not be effective because it no longer fits. Consequently, new models are needed to make an appliance that will fit the collapsed arches.

Another time of concern is the eruption of the maxillary first deciduous molars. Eruption of the teeth must not be impeded by the appliance. Therefore, if the first deciduous molars erupt and displace the appliance, the chance for segment collapse is good, unless proper adjustments are made in the appliance.

Sometimes an appliance needs to be expanded on a child who has had poor segment position. If the parents activate the appliance without regard

for fit, the expansion creates a dislodging force for which the parents compensate by adding more adhesive to the appliance. The parents may think the appliance is fitting and continue to expand it ; however, at the next appointment the prosthodontist sees an appliance which is too big for the segment relationships. The appliance is then reduced to its original position for a fresh start.

Many children learn that removing the appliance attracts attention and they do so frequently, thereby reducing its effectiveness.

Loss and breakage can also allow collapsing changes to occur if the parents do not call immediately for an appointment to rectify the problem.

Some parents call 1 or 2 weeks later to inform us of such a situation. The parents dental cleft palate I.Q. is a big factor in the degree of urgency that they feel. They must be told repeatedly of the need for the child to wear the appliance at all times.

Sometimes there is parental concern about pressure created by appliances. This pressure is transient ; once the appliance is removed, the tissue returns to its normal contour in just a few days.

Several salient

points warrant

re-emphasis

regarding infant

appliances.

1) Active or holding appliances can achieve and / or maintain ideal arch configurations in patients with complete clefts of the lip and palate.

2) Once the lip has been surgically closed, the greatest tendency for additional collapse is seen in those patients who presented initially with some degree of arch collapse.

3) Regardless of treatment techniques, a considerably higher percentage of success is achieved in patients whose initial arch configurations are wide.

4) Studies attempting to relate arch form and occlusion in the permanent dentition to early treatment techniques must take into account the following factors. a) The exact nature of the of the cleft condition, including measures of cleft width. b) A quantification of the spatial relationships of the arch segments prior to treatment. c) An assessment of the growth potential inherent in the particular categories of cases being studied. d) A profound awareness of growth and development in the normal individual and in the cleft lip and palate types being studied, and a recognition that homogeneity among cleft lip and palate types may be the exception rather than the rule.

5) Parental cooperation is essential for successful treatment.

6) Lip closure can increase deformation or arch collapse unless controlled by appliances. This is an application of Wolff’s law that functional stresses shape bone.

PROSTHODONTIC MANAGEMENT Treatment options for the management of a congenital cleft lip and cleft palate have been enumerated and described briefly. As noted the prosthodontist may be enlisted to provide indicated services at various intervals during the maturation of the cleft palate patient. The type of procedure of prosthesis required is determined by the stage of development, the nature, and the extent of the abnormality being treated. Representative chronologic modes of treatment and their rationale are discussed herein. The basic approaches to care can be applied to more extensive problems as they occur.

Infant phase :

The early alignment of malposed maxillary arch segments requires the construction of a baseplate type of prosthesis retained primarily by positive tissue adaptation to deliver a slight predetermined force for movement. Without teeth for retention and support, the infant must be kept under observation to ensure that the prosthesis remains in the intended position and is performing the desired function. Until the infant is acclimated to its presence, the prosthesis may require extraoral headbow retention. As growth begins to accelerate after the first 4 to 6 weeks of life, a more aggressive force can be imposed to direct movement of the segments.

A cast is obtained from an impression made with the clinician’s choice of material. An irreversible hydrocolloid is commonly used in a tray fashioned from hard base-plate wax warmed and adapted in the mouth or in easily modified stock trays. The cast is duplicated, since one is retained as a record and the other sectioned for construction of the activating prosthesis.

The surgeon and dentist (orthodontist or prosthodontist) determine the correction to be made, section the cast through the cleft as required, reassemble the segments with wax, block out as necessary, and duplicate the revised cast for construction of a prosthesis. Some clinicians advocate the use of template to aid in the survey and resection of the cast, however, experience may obviate the need for this additional procedure and equipment.

Hard-or-soft-base materials, or a combination of both, can be used for the prosthesis. It is sometimes describable to use a resilient material such as silicone for the initial prosthesis, since a one piece design is easiet to construct and can be readily replaced to increase the desired orthodontic force. Subsequently, a spring activator or jack-screw device may be used to permit periodic adjustment in the office or at home without remaking the prosthesis. The parent can be instructed in making a judgment as to the need for increasing the pressure and may turn the adjustment screw to keep the

force of the prosthesis active. When no longer adjustable, the prosthesis will need to be revised or remade. Should retention become an ongoing problem external bow assistance may be required.

Use of the prosthesis is continued until surgical closure of the lip is accomplished, usually 6 to 12 weeks after birth. After the lip operation continued use of the prosthesis may be indicated for segmental retention or feeding assistance. When teeth begin to erupt, problems in adaptation and stabilization become more frequent and use of the prosthesis may be discontinued.

Further

prosthodontic intervention probably will be

unnecessary until deciduous dentition is more complete and the child is cooperative enough to understand and undergo further intraoral procedures.

A management decision becomes necessary when the speech process has developed enough to assess the level of palatopharyngeal competence.

Even though it is possible to construct and place an obturator as early as 18 months of age, little benefit is likely, and other management problems maybe created if the child cannot understand treatment rationale. The speech pathologist will play an important role in making collective judgments a to the type and timing of prosthetic or surgical intervention during this early period.

To permit undisturbed growth, surgical closure of the cleft palate usually is delayed until the child is about 18 months of age. The procedure may be staged, depending on the problems anticipated in closure, quality and quantity of soft tissue available, and expected results. An alternative approach is to perform a primary closure to include operation on the soft palate and a pharyngeal flap in one procedure. When the hard-plate cleft is wide, closure of the soft palate alone may be indicated, and if insufficient palate length is anticipated, prosthesis is used to obturate the hard-palate defect and provide speech assistance in the palatopharyngeal region. Should it be determined that a palatal operation has resulted in palatopharyngeal

incompetence, an obturator may be the adjunctive or transitional treatment of choice during the phase from 18 to 36 months.

Childhood phase : At approximately 3 years of age, the average child should be capable of understanding and cooperating to the extent that indicated active treatment can begin. Children with cleft palates tend to score slightly lower on tests of intelligence and creativity when compared to noncleft peers. The significance of this conclusion is somewhat questionable since certain studies show that cleft children are not dull and that they have a normal range of intelligence quotients.

The primary dentition usually erupts by 3 years of age and a definitive occlusal relationship, good or bad, has been established. Most patients with complete cleft palates will require orthodontic treatment, which may have already been started if the maxillary orthopedics concept has not been espoused. At this time, attention is focused on arch alignment, not tooth alignment, to provide better occlusal function and to encourage a more favorable maxillomandibular dental relationship when the permanent teeth erupt. Although it is somewhat inconvenient and complicated, the coordination of orthodontic and prosthodontic treatment during this period is possible.

Primary indications for a prosthesis at this stage are the replacement of missing teeth, retention of arch alignment, and speech assistance through the closure of nasoalveolopalatal fistulas and use of a pharyngeal obturator.

To satisfy these objectives, the typical prosthesis will consist of anterior, palatal, and pharyngeal sections. deciduous teeth seldom have natural

contours that are conductive to the retention and stability of an obturator prosthesis. Thus it is usually necessary to place orthodontic bands with attached tubes or lugs, cast or preformed crowns, direct bonded plastic brackets, or overcontoured restorations on teeth essential for support and retention of the prosthesis. In most instances, the teeth involved will be maxillary cuspids, first or second primary molars, or first permanent molars if erupted. Single bilateral molar abutments are insufficient to prevent the rotary movement of the prosthesis around a mid-arch fulcrum, which often occurs with a pharyngeal obturator. An anterior indirect retainer or, preferably, abutment is needed to control such movement during mastication, deglutition and speech.

With mouth preparation completed, preliminary impressions in wellformed and adapted stock trays are made with irreversible hydrocolloid. If sufficient attention has been given to tray selection and modification. A second or final impression may be unnecessary unless more accuracy is needed. In the latter situation, an autopolymerizing resin tray fabricated on the relieved stone cast obtained from the primary impression can be used with alginate, silicone, or Thiokol rubber impression material as desired.

Small palatal or nasolabial perforations should be packed with petrolatum gauze or lubricated cotton to prevent the flow of impression material under pressure into inaccessible regions associated with the defect. The inclusion of the entire oronasopharyngeal area in the impression is unnecessary, since a more effective pharyngeal obturator can be developed using a secondary impression technique with other materials. However, a reproduction of at least the velar portion of the cleft is desirable to aid in the placement of a retentive loop or grid for carrying the impression and retaining the final fabrication materials of the pharyngeal obturator.

Stainless steel or wrought 0.036-inch wire clasps, contoured and incorporated into a heat-cured acrylic resin base with required tooth

replacements, form a satisfactory transitional prosthesis for support of a pharyngeal obturator in the young patient. Once the palatal section of the prosthesis is processed and finished, it is adjusted in the mouth for comfort and fit. If this is the initial prosthesis experience, a short period of use without the obturator may be desirable to accustom the patient to its feel and manipulation. Should the distal retentive loop impinge on the palate, it may require temporary coverage with wax or acrylic resin.

Adjunctive or interim phase Under current management schemes, the adolescent child probably has been provide with an adequate prosthetic or surgical mechanism for acceptable speech. With societal demands for an esthetic appearance, elective orthodontic treatment is commonplace and teenagers with the typical oral hardware are seen everywhere. Thus, orthodontic and prosthodontic treatment device worn by the cleft palate patient are not too dissimilar from those worn for esthetic reasons by normal peers and, therefore, are readily accepted. As the teenaged child grows to young adulthood, however, complications often develop relative to the orientation and dimensions of occlusion. Facial proportions, masticating performance, and personal hygiene become more relevant.

Interceptive orthodontic treatment shortens and frequently simplifies this phase of care, but because of midface underdevelopment, the cleft patient usually requires solutions for difficult occlusal problems involving vertical and horizontal maxillomandibular relationships. A situation that is frequently seen is illustrated. A in this patient, despite a rather long and aggressive period of orthodontic treatment, it was impossible to bring the maxillary bicuspids and cuspids into a normal occlusal relationship. A large interarch distance persisted and definitive prosthodontic treatment included an anterior overly prosthesis to achieve a minimal end-to-end anterior relationship. Some provision must be made for the protection of overlaid

teeth if they are to be considered as long term support for a definitive prosthesis. Treatment in the teenaged years most often involves some secondary operation to improve the premaxilla-lip relationship.

Gross underdevelopment in the midface of a patient who presented with complete crossbite of permanent teeth initially resulted in a closed vertical dimension of occlusion. The orthodontist expanded the arch to somewhat normal maxillomandibular alignment. The realigned arch was stabilized with fixed restorations to include a cross-arch 10-gauge gold bar.

A removable overlay prosthesis preplanned with a temporary restoration.

Distorted maxillomandibular jaw relationships frequently present more complex restorative problems. A severe intraoral problem is reflected in the collapsed facial appearance of the teenaged patient seen. A coordinated sequence of orthodontic, surgical, and prosthodontic procedures is required. With permanent teeth in place, malocclusion developed, displaying malrelated horizontal and vertical dimensions, poor orientation of the plane of occlusion, and malposition of the dentual units. Preliminary orthodontic alignment prepared the patient for orthognathic surgery. after a period of postoperative retention, definitive fixed and removable prosthetic restorations were constructed before carrying out secondary plastic surgical procedures involving the lip and nose. The use of prostheses as support or scaffolding for secondary operations requires coordinated preplanning by the surgeon and the prosthodontist if optimal results are to be achieved. The placement of teeth and the control of base bulk should be approved by both surgeon and prosthodontist before the restoration is finalized.

The cleft palate population is not without those who are prone to neglect. Faced with an inevitable edentulous maxilla and collapsed arch resultant from a complete cleft palate a patient is best served by providing the best denture foundation possible under such adverse circumstances. For example. A young man presented with a history of minimal dental care,

poor dental habits, and little interest in embarking on a major restorative program with a questionable prognosis. A relative prognathism was ameliorated

with

a

vertical

ramus

osteotomy

to

improve

the

maxillomandibular jaw relationship for construction of a prosthesis.

Nonrestorable teeth were removed and complete maxillary and removable partial dentures were used to restore masticatory function and to provide facial support. The opportunity to achieve retention and stability of the complete maxillary denture in such situations is poor because of the Vshaved ridge, lack of hard palate, distorted arch form, and generally poor conditions for developing effective border seal. The improved jaw relationship partially offsets some of these deficiencies.

Dental restorations involving fixed prostheses may need to be delayed because of pulp size, tooth position poor oral hygiene, or periodontal disease. Since the success of definitive restorations is directly related to these factors, advancing the treatment timetable to accommodate the patient’s demand without assurance that the

conditions have been

appropriately addressed can lead to failure.

Adult phase : Education of the patient, good evidence of cooperation in care and maintenance, and timely coordinated treatment are essential ingredients in the provision of lasting definitive restorations. Adult patients requiring treatment probably will have had too little or too much previous attention.

The goals of treating these patients are the same as goals for any other age group, namely, intelligible speech, functional occlusion and acceptable cosmetic relationship. Because of compromising nature of the initial defect and possible intervening treatment the task of the prosthodontist involves not only the replacement of mixing structures but also and more importantly, the preservation of that which actually remains.

The maintenance of natural teeth is critical to the success of any fixed or removable partial prosthesis. Since the remaining teeth usually must resist more stress, wide distribution is important. Mechanical stress breakers have been used by some clinicians, but generally are ineffective in complex prostheses involving sizable obturators. Minimizing stress to any one structure or area, however, is desirable and can be achieved through attention to prosthesis design. Changes in support and adaptation of the prosthesis require regular ongoing service. Therefore, the simpler the prosthesis design, the easier it will be for the prosthodontist to maintain and for the patient to care for and manipulate.

Pertinent factors in the design and construction of a prosthesis related to ridge and palatal configuration. Soft-tissue health and response dentition, recording of jaw relationships, occlusal scheme, and use of materials have been discussed elsewhere in this text and will not be repeated here.

However, certain problems more common to the cleft palate patient need further elaboration.

Soft palate : The position and movement of the soft palate in relation to the pharynx changes with age. At birth and shortly thereafter, the soft palate at rest is roughly parallel to the roof of the pharynx so that the upper nasopharynx is only a narrow slot. Closure of the palato pharyngeal mechanism is accomplished by essentially a superior-inferior movement of the soft palate. As growth occurs in the pharyngeal area and as the adenoidal tissues regress, the movement of the soft palate takes on the characteristic anterior-posterior elevation displayed by most adults. When the adenoidal tissues are removed, the soft palate shifts to an anterior-posterior movement very abrupty. Palatopharyngeal closure is slightly below the level of the palatal plane upto 8 years of age and is consistently above the level of the palatal plane thereafter.

The extent of the closure of the soft with the posterior pharyngeal wall varies with head position. An extended head position results in a deeper nasopharynx than when the head is held in the Frankfort horizontal plane.

The pattern of soft palate movement varies between men and women. A study disclosed that the soft palate wax longer, the elevation grater, the amount of contact, with the posterior pharyngeal wall less, and the inferior point of contact with the posterior pharyngeal wall was consistently higher in men than in women.

CONCLUSION Congenital defects of the mid facial region is not rare .even though it requires the team work of a large number of faculty it still remains a tricky task to accomplish but not impossible. It is better to treat the individual right from birth rather than when he is older. Treating such individuals does not mean reconstructing their physical appearance alone but giving him a new life totally. For he is not affected phyisically, alone, but mentally too.

The prosthodontist plays his role to restore function esthetics and phonation. Various different prosthesis can be employed with regard to the type of defect and its extent. Thus it is essential to know what is normal to cure what is not.

PROSTHODONTIC MANAGEMENT OF CONGENITAL ORAL AND PARAORAL DEFECTS 1) Introduction 2) Classification 3) Diagnostic and examination procedure •

General

•

Dental

•

Impressions for study casts

•

Radiographs

•

Photographs

•

Speech recording

•

Sound spectrographic recording

•

Nasal and oral pressure flow

•

Otologic and hearing examination

4) Requirements of speech appliance 5) Psychological considerations 6) Pedodontic care for children 7) Management •

Surgical management - Primary - Secondary - Complications

• Prosthodontic management 8) Soft palate 9) Conclusion 10) References

Infant Childhood Adjunctive Adult

COLLEGE OF DENTAL SCIENCES DEPARTMENT OF PROSTHODONTICS INCLUDING CROWN & BRIDGE AND IMPLANTOLOGY

SEMINAR ON

PROSTHODONTIC MANAGEMENT OF CONGENITAL ORAL AND PARAORAL DEFECTS

PRESENTED BY DR. MELISSA FERNANDES