DISCUSS CLASSIFICATION,CLINICAL

FEATURES AND MANAGEMENT PROTOCOL FOR CLEFT PALATE PATIENTS

Shivani /44 BDS 4th yr

CLEFT PALATE

Definition A congenital split of the palate that may extend through the uvula,soft palate and into the hard palate;lthe lip may or may not be involved.

CLASSIFICATION

Davis and Ritches classification(1922) Group 1: Prealveolar clefts Group 2: Postalveolar clefts Group 3: Alveolar clefts Veaus classification (1931) Group 1: cleft of the soft palate only Group 2: cleft of the hard and soft palate to the incisive foramina Group 3: complete unilateral cleft Group 4: complete bilateral cleft

VEAUS CLASSIFICATION

Only cleft of soft palate

cleft of soft and hard palate

Complete unilateral cleft

Complete bilateral cleft

Fogh and Anderson classification (1942) Hare lip Hare lip and cleft palate Isolated cleft palate

Kernahn and Starks classification a) Cleft of primary palate-

Unilateral
Median
Bilateral

complete incomplete
Complete(premaxilla absent) Incomplete(premaxilla rudimentary) complete incomplete

b) Cleft of secondary palate only-

complete incomplete submucous

c) Cleft of primary and secondary palate-

Unilateral
Median
Bilateral

complete incomplete complete incomplete complete incomplete

SYMBOLIC CLASSIFICATION

Schuchardt and Pfeiffers classificationR L Lip

.. .. . ..... ..

Alveolus
Hard palate Soft palate

Kernahns stripped Y classificationR L

1 2 3 7 8 9 Soft palate 6 4 5 Lip Alveolus Hard palate anterior to incisive foramen Hard palate

Millards modification of stripped Y:

Nose 1 2 3 4 9 8 7 5 6 Nasal floor Lip Alveolus Hard palate

Hard palate 10
11 Soft palate

CLINICAL FEATURES

Cleft palate babies are usually brought to OPD with a chief complaint of: a) facial deformity b) inability to suck mothers milk c) nasal regurgitation later stages: d) speech defect and e) rare cases, middle ear infection

ON EXAMINATION OF UNILATERAL CLEFT CASES REVEALED:

Nose deformity Lip deformity Cleft alveolus Hypoplastic or collapsed maxilla on the side of cleft

ON EXAMINATION OF BILATERAL CLEFT CASES REVEALED:

Protruded premaxilla Small prolambium Absent or short columella Shallow gingivolabial sulcus

OLDER CASES SHOW:

Malposition rotated incisors Hypoplastic teeth(especially lateral incisors and canine on cleft side.) Posterior crossbite Supernumerary teeth Crowding of dental arch

OTHER CASES SHOW:

presence of natal or neonatal teeth Increased incidence of absent lateral incisors and premolars Ectopic eruptions

IT MAY ALSO BE ASSOCIATED WITH:

Hearing loss a) otitis media b) middle ear disease Speech difficulties a) p,b,t,d,k,g Nasal deformities Syndromes like: a) Pierre Robin Syndrome b) Van der Woudes Syndrome

MANAGEMENT PROTOCOL
A MULTIDISCIPLINARY TEAM FOR CLEFT LIP AND PALATE PATIENTS

Obstetrician
Refers the child to plastic surgeon and pediatrician Counselling the parents

Pediatrician or Neonatologists
Provides medical care Refers the case to plastic surgeon

Plastic Surgeon
Heads the team Discuss the case with members of team in confrence held monthly or weekly Carries out initial lip repair and palate surgery Performs pharyngeoplasty, lip surgery, nose surgery

Oral Maxillofacial Surgeon

Bone grafting Any orthognathic surgery

Neurosurgeon
If any craniofacial syndrome is associated with it.

Pedodontist
Provides presurgical orthopedic treatment Monitors the growth and development To maintain perfect oral health To guide the occlusion and facial growth Motivates the parent and child to cooperate the treatment

Orthodontist
Provides presurgical dental orthopedic treatment Definite orthodontic treatment in permanent dentition

Speech Pathologist
Monitors the speech development to normal Tests for an adequate palatopharyngeal closure and guiding the surgeons as to whether a pharyngeal flap may be necessary

Audiologist
Test hearing

Otolaryngeologist
Health of nasopharyngeal tissues,tonsils,adenoidsand middle ear structure Blockage of auditory canal

Psychologist

AGE SPECIFIC INTERVENTION

Refers to cleft lip and palate team Medical diagnosis and genetic counseling Address psychosocial issues Provide feeding instructions Make feeding plan Refer to cleft palate team Provide feeding instructions and monitor growth Begin presurgical orthopedics(if required) Monitor feeding and growth Repair cleft lip Monitor ears and hearing Begin,continuous presurgical orthopedics (if indicated)

Prenatal

Birth1 month
1-5 months

16-24 months 2-5 years 6-11 years

Assess ears and hearing Assess speech language Monitor development Assess speech language Manage velopharyngeal incompetence Monitor ears and hearing Assess speech language Manage velopharyngeal incompetence Orthodontic interventions Alveolar bone grafting Assess school psychosocial adjustment Jaw surgery,rhinoplasty Orthodontics,bridge and implants Genetic counseling

12-21 years

TREATMENT PLAN

STAGE 1
Maxillary orthopedic stage
Birth-18 months

STAGE 2
Primary dentition stage
18 months-5 years

STAGE 3
Mixed dentition stage
6-10 years

STAGE 4
Permanent dentition stage
12-18 years

Stage 1: Birth-18 months

Obturator
Feeding bottles Premaxillary Orthopedics Treatment of airway obstruction Primary Bone grafting

Palatoplasty
Secondary Palatal procedures

INTRAORAL MAXILLARY OBTURATOR

PROSTHESIS Provides a false palate against which an infant can suck. Provides maxillary cross arch stability Prevents arch collapse Prevents orthopedic molding of cleft segment into approximation.

IMPRESSION TECHNIQUE
An alginate impression in an upright position,is made with a modified stock tray. A stone model is then produced.

OBTURATOR CONSTRUCTION
Block out excessive undercuts with modeling dough or wax. Apply a tinfoil substitute over the entire surface of maxillary model. Pour mixture of soft self cure acrylic resin into the cleft to the level of the palate This provides retention of prosthesis by gently contouring into availaible undercuts.

CONTD..
Add autopolymerising acrylic resin to palate and extend well into the mucobuccal fold. Place the model in warm, moist environment to cure for 20 minutes. Remove the appliance from the model and rinse the wax aqnd modeling dough off with hot water. Then trim and polish the appliance

PARENTAL COUNSELLING
The mother is told about the obturator and she takes care of it. After each feed the plate is removed and cleaned with running water and soaked once a day for 20 minutes in Hibitane solution(5% chlorhexidine solution).

FEEDING BOTTLES
Cleft palate nurser- soft sided bottle; when the infant sucks, the bottle is sqeezed and the milk is delivered in mouth Haberman feederfeeding bottle with a valve which is placed at the nipple which holds the milk.

Haberman feeder

Pigeon cleft palate nurser- it is similar to Haberman feeder, but has a modification.. Along with the valve, the nipple is soft and thin so as to facilitate easy feeding.

Pegion cleft palate nurser

PREMAXILLARY ORTHOPEDICS
Premaxillary segment positioned severly anterior to the maxillary arch segments. In 1686, Hofman described the use of a head cap and premaxillary strap to reposition the premaxilla. This appliance is given after the one week of delivery of the obturator.

APPLIANCE

A baby bonnet is made to provide head gear anchorage. An elastic strap is placed over the protruding maxilla and anchored to the infants head using a bonnet. This is worn 24 hrs a day and is removed only for feeding. Desired movement is accomplished within 68 weeks.

With Appliance

Post Treatment

APPLIANCE CONTD
In case of laterally deviated premaxilla, EXTERNAL ACRYLIC BULB PROSTHESIS is provided. In 3-4 weeks the premaxilla is repositioned in midline,now the bulb appliance is replaced by single elastic strap for the next 1-2 months to bring it back into the position.

TREATMENT OF AIRWAY OBSTRUCTION

An obturator with a posterior palatal extension should be used which will bring the:
Backwardly placed tongue Downward and outward of cleft site

to

CONTD
If this is not successful then lip to tongue adhesion is done to move the tongue anteriorly. Or tracheostomy may be necessary. If cleft palate is associated with it, then cheiloplasty is done.

PRIMARY BONE GRAFTING

Alveolar grafting if done at 2 years of age,then it is known as primary bone grafting. It is now abandoned because the cases have reported that there is a) Retardtion of mid facial growth b) prognathism of mandible

Palatoplasty
Single stage repair Two stage repair
Von Langenbeck Repair

Veu Wardill V-Y Pushback palatoplasty

VEAU-WARDILL KILNAR; V-Y PUSHBACK

PALATOPLASTY

Markings are made.

Incision is made

CONTD.

Elevation of flaps and exposure of lining

Muscle is freed to make tension free muscle

CONTD.

Nasal lining and muscle is closed

Suture of levator veli palatinii muscle

CONTD

Complete closure of oral mucosa

TWO STAGE REPAIR

First stage
Soft palate repair before 18 months followed by obturation of hard palate till the second stage repair

Second stage
At the age of 4-5 yrs;hard palate repair is done.

SECONDARY PALATAL PROCEDURES

Palatal fistula closure,if any Velopharyngeal incompetence is treated if present.

Stage 2:18 months -5years

Adjustments of obturators

Restoration of decayed teeth

Maintainence of oral hygiene Evaluating the erupting dentition

Stage 3: 6-10 years

Correction of crossbite

Maxillary expansion Secondary alveolar grafting

SECONDARY ALVEOLAR GRAFTINGPROCEDURE Done just before the eruption of canines. Incision is made along the edge of the cleft. Mucoperiosteal flap is raised from the bony wall of the cleft to repair the nasal floor in alveolar area. Cancellous autogenous graft chips of iliac crest are filled in the cleft area and oral muco-periosteal flap is closed to complete the surgery.

Stage 4: 12-18 years

Fixed orthodontic treatments All types of skeletal and dental irregularities are corrected Cosmetic repair