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 Ritchies 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
Venus 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 Starks 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 dentists 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 infants maxillary and mandibular regions,
and he also makes cephalometric and photographic records. On the childs
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 infants 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 infants head, 2) depress the tongue and hold the
suction, 3) hold the infants 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 infants
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 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 patients 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 patients
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 patients disability on the family.
4. Family strength and ability to meet patients 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 parents
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 childs
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 dentists ability to manage the childs 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 childs teeth. the child stands in front of the parent and leans
back against her body. The parent cradles the childs 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 childs 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 childs 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 patients 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. miraults 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 Cupids 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 Cupids 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 patients
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 V-Y
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 Passavants 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 cupids
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 surgeons 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. Bardachs 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 cupids 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 Wolffs 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 clinicians
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 V-shaved 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
patients 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

Infant
Childhood
Adjunctive
Adult

10) References
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