Download Management of cleft lip and palate

Orthodontic Management
of
Cleft Lip and Palate Patient
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
AGENDA
• What is Cleft Lip and Cleft Palate ?
• Embryology
• Orthodontic Treatment
–
–
–
–
Infant
Deciduous dentition
Mixed dentition, prior to ABG
Permanent dentition, with or without jaw surgery.
• Q&A
12th July 2008
Dr. Christine Underhill
Basic Facts
• Orofacial clefts are the most common orofacial anomaly in newborn infants and the
second commonest congenital abnormality.
• Affecting approx one in every 800 births
worldwide
• Non “life-threatening” abnormality, which can
have significant effect on maternal bonding.
• A small proportion of oro-facial clefts may be
associated with a genetic syndrome
12th July 2008
Dr. Christine Underhill
Types of Clefts
Oro-facial clefts include the
cleft of the lip with or without
cleft palate (CL[P]) and the
isolated cleft palate (CP)
CL[P]
12th July 2008
Dr. Christine Underhill
CL[P]
CP
12th July 2008
Dr. Christine Underhill
Gender
• For Clefts affecting the Lip only or Lip
and Palate (CL[P]), males are more
commonly affected than females
(approx 2-1).
• Clefts palate alone (CP) is found in
approx 1 in 2000; females are more
often affected than males.
12th July 2008
Dr. Christine Underhill
Incidence
• CL[P] varies between different ethnic
populations
– Highest rates reported for Native Americans
3.6 per 1000
– Lowest rates for African-Americans
0.4 per 1000
• CP only is reported as being generally more
stable across different ethnic populations.
(0.6-0.8 per 1000 live births)
12th July 2008
Dr. Christine Underhill
CL[P] and CP are developmentally
and genetically different
• hereditary factors appear to play a more
important role in the occurrence of CL[P] and
• environmental factors in that of CP
12th July 2008
Dr. Christine Underhill
Incidence in Fiji
Not seen data for Fiji, but….Epidemiologic survey
on oral diseases in Fiji. V. Incidence of the cleft lip
and palate.
J Osaka Univ Dent Sch. 1986 Dec;26:249-53.
Usui M, Tsunemitsu A, Sobue S, Nakagawa H,
Shizukuishi S, Morisaki K, Ohmae H, Pal V.
12th July 2008
Dr. Christine Underhill
Orofacial clefts
Approx 40% presented with
CP only
Approx 60% presented
with CL[P]
12th July 2008
Dr. Christine Underhill
Of those with CL[P]…..
approx 30% involved the lip+/-alveolus, and
70% involved lip and palate
12th July 2008
Dr. Christine Underhill
Of those with CP.....
approx 30% involved the soft palate only
and 70% involved hard and soft palate
12th July 2008
Dr. Christine Underhill
Risk Factors for Orofacial clefts
• There is a known risk in taking certain types
of drugs during pregnancy e.g. Phenytoin,
sodium valproate, benzodiazepines and
corticosteroids.
• There may be a link to maternal smoking
whereby the risks for clefts are increased
among foetuses lacking enzymes involved
in the detoxification of tobacco-derived
chemicals.
• Alcohol use, and specifically type, may also
be a factor.
• There is debate on the role of folic acid;
there may be dose dependency.
12th July 2008
Dr. Christine Underhill
Embryology
• The lip has usually formed by 5-6 weeks
of intrauterine life.
• The palate has formed by 10 weeks
• The cleft may be picked up by high
resolution ultrasound at 20 weeks
gestation.
• Diagnosis is otherwise made after
delivery.
12th July 2008
Dr. Christine Underhill
Ultra Sound at 18th Week of
Pregnancy
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
facial morphogenesis
• In facial morphogenesis, neural crest cells
migrate into the facial region, where they form
the skeletal and connective tissue and all dental
tissues except the enamel. Vascular
endothelium and muscle are of mesodermal
origin (Cohen, 2000).
• The upper lip is derived from medial nasal and
maxillary processes.
• Failure of merging between the medial nasal
and maxillary processes at the fifth week of
embryonic development, on one or both sides,
results in CL.
12th July 2008
Dr. Christine Underhill
•
•
•
12th July 2008
CL occurs when an epithelial bridge fails,
due to lack of mesodermal delivery and
proliferation. CL usually occurs at the
junction between the central and lateral parts
of the upper lip on either side. The cleft may
affect only the upper lip, or it may extend
more deeply into the maxilla and the primary
palate. (Cleft of the primary palate includes
CL and cleft of the alveolus.)
If the fusion of palatal shelves is impaired
also, the CL is accompanied by CP, forming
the CLP abnormality.
In general, patients with clefts have a
deficiency of tissue and not merely a
displacement of normal tissue.
Dr. Christine Underhill
• Clefts of the primary palate occur anterior
to the incisive foramen.
• Clefts of the secondary palate are due to
lack of fusion of the palatal shelves, and
always occur posterior to the incisive
foramen
12th July 2008
Dr. Christine Underhill
Development of the Face (I)
•
•
•
•
•
•
•
•
•
•
•
12th July 2008
5 facial primordia
Frontonasal prominence
Paired maxillary prominences
Paired mandibular prominences
Surround primordial mouth (stomodeum)
Neural crest: source for almost all
connective tissues in the face
Frontonasal prominence forms forehead
and nose and a short margin of mouth
Lower jaw and lip form first
Nasal placodes (and pit): surrounded by
medial & lateral nasal prominences
Nasal pit remains connected to mouth
Maxillary prominences grow toward
each other, pushing nasal prominences
Medially
Dr. Christine Underhill
Development of the Face (II)
• Medial nasal prominences
merge with each other and with
lateral nasal & maxillary
prominences
• Nasolacrimal groove: between
lateral nasal and maxillary
prominences
• Becomes nasolacrimal duct
• Intermaxillary segment
• Merger of medial nasal
prominences
• Gives rise to philtrum,
premaxillary bones, primary
palate
From Moore, 1982
12th July 2008
Dr. Christine Underhill
Development of the Palate:
1. Primary Palate
Palatal development begins
in week 5, but weeks 6-9
are most critical
•
• Formation of intermaxillary
segment from merged
medial nasal prominences
• Primary palate forms from
median palatine process
• Ossifies as the premaxillary
portion of the maxilla
12th July 2008
Dr. Christine Underhill
CP is a partial or total lack of fusion of
palatal shelves.
It is thought to occur in a number of ways:
•
•
•
•
•
Defective growth of palatal shelves
Failure of the shelves to attain a horizontal position
Lack of contact between shelves
Rupture after fusion of shelves
The secondary palate develops from the right and
left palatal processes. Fusion of palatal shelves
begins at the 8th week of the foetal period and
continues usually until the 12th week. One
hypothesis is that a threshold exists beyond which
delayed movement of palatal shelves does not allow
closure to take place, and this results in a CP.
12th July 2008
Dr. Christine Underhill
Development of the Palate:
2. Secondary Palate
• Lateral palatine processes
• Ingrowths from maxillary
prominences
• Eventually project horizontally above
the tongue
• Fuse with each other, primary palate
and nasal septum
• Nasal septum
• Downgrowth of med. nas. promin.
• Fusion with lateral palatin processes
starts anteriorly, then moves back
• Hard palate
• Primary palate: premaxilla
• Lateral palatine processes: maxilla
• Soft palate: unossified portion of
lateral palatine processes
12th July 2008
Dr. Christine Underhill
Treatment
Cleft Lip and Palate patients present a
multitude of problems:
Functional Impairment
• Suckling
• Swallowing
• Speech
• Hearing
• Malocclusion
12th July 2008
Dr. Christine Underhill
Aesthetic Compromise
• Physiological
implications
• Sociological
implications
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
Long list of list of procedures these
children undergo
• Neonatal orthopaedics-orthodontist
• 3-12 months repair of lip and anterior maxillaplastic surgeon
• 9-18 months repair palate-plastic surgeon
• 5 yrs revision of lip repair-plastic surgeon
• Grommets placed due to ‘glue ear’- ENT
• 7-10 yrs orthodontics/ ABG / repair OAF- oral
surgeon
• 12-18 yrs orthodontics/orthognathic surgery
12th July 2008
Dr. Christine Underhill
11 month old girl cleft lip repair
12th July 2008
Dr. Christine Underhill
Successful treatment requires a
multidisciplinary approach
•No doubt this is required.…however,
no consensus in sequence and
timing due to:
–
–
12th July 2008
Lack of randomised clinical trials
comparing outcomes, effects of timing etc
Treatment sequence and timing not
always problem specific.
Dr. Christine Underhill
Orthodontic treatment:- performed
at different stages of development.
• Neonatal maxillary orthopaedics as an infant
• Orthodontic-orthopaedics in deciduous
dentition.
• Orthodontics in the mixed dentition.
• Orthodontics alone or in conjunction with
maxillofacial surgery (+/_distraction
osteogenesis) in the permanent dentition.
(Patients with cleft of lip only or soft palate only,
defect will not effect dentition.)
12th July 2008
Dr. Christine Underhill
Neonatal Orthopaedics
• Performed on new born before surgical repair of
lip.
• Rationale...realignment of the collapsed
segments before surgery
• Either simple passive, active orthopaedic, extra
orally activated, pin retained
• Considerable debate re true long-term benefits
but……
• Definitely makes lip and anterior palate surgery
easier at the time.
12th July 2008
Dr. Christine Underhill
Pre surgical plates, moulding
plates, feeding plates…….
12th July 2008
Dr. Christine Underhill
Feeding plates to assist in early
feeding
• Obturator plate
12th July 2008
Dr. Christine Underhill
NAM Nasoalveolar moulding
12th July 2008
Dr. Christine Underhill
Orthodontic orthopaedic treatment
in the deciduous dentition
• In vicinity of cleft alveolus ….delayed eruption,
malformation or absence of deciduous lateral
incisor
• Unilateral or bilateral cross bites often
present…often associated with functional shift.
• soft tissue drape often disguises skeletal defect at
this stage.
• Treat with expansion now.. Together with
protraction headgear to ‘develop the maxilla’
• Definitely effective at the time…can exhaust
patient cooperation
• No solid data that in the long term benefits
12th July 2008
Dr. Christine Underhill
Mixed dentition…common since
event of alveolar bone grafts (ABG)
• Requires careful assessment of problem, risks
and benefits
• Timing of treatment closely related to timing of
planed bone graft.. either before lateral incisor
erupts (argued can effect maxillary growth), or
before canine erupts
• When root of canine 1/3 to ½ developed.
• Orthodontic treatment involves expansion to
develop favourable arch form, alignment ..care
not to move roots into cleft defect.. correct root
angulation post grafting
12th July 2008
Dr. Christine Underhill
Repaired cleft palate in 8 year old
12th July 2008
Dr. Christine Underhill
Quadhelix to expand prior to ABG
12th July 2008
Dr. Christine Underhill
angle brackets to keep roots away
from cleft
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
Alveolar bone grafting (ABG)
•
•
•
•
Provides continuity of alveolar ridge…
Provides bone for canine to erupt
Osseous support for adjacent teeth
Majority of canines erupt spontaneously…others
require surgical exposure often in combination
with orthodontics.
• The erupting teeth often appear to then
stimulate the formation of new alveolar bone
12th July 2008
Dr. Christine Underhill
Elimination of the residual alveolar
cleft by secondary bone grafting and
subsequent orthodontic treatment.
Cleft Palate J. 1986 Jul;23(3):175-205
Bergland O, Semb G, Abyholm FE.
•
•
Assessed 450 grafted cleft sites.
In 292 of the cases, the canine had reached its final position in the arch,
which allowed a four-group semi quantitative assessment of the newly
obtained interdental septum on dental radiographs.
•
The best results have been achieved in cases where the bone graft was
carried out prior to the eruption of the canine. In this group, a normal
(category I) interdental septal height was achieved in 64%
Slightly lower (category II) interdental septal height in 32%
Interdental septal height classified as type I and II were considered to be
acceptable (96%)
The cleft space was closed in 90 percent of the cases.
No significant difference between unilateral and bilateral cases was found.
When the same procedure was carried out after eruption of the canine, the
results were less favorable
•
•
•
•
12th July 2008
Dr. Christine Underhill
Long-term results after
secondary bone grafting of
alveolar clefts
J Oral Maxillofac Surg. 1987 Nov;45(11):913-9
Enemark H, Sindet-Pedersen S, Bundgaard M.
• The aim of this study was longitudinally to evaluate the treatment
results after secondary bone grafting in 224 cleft patients with an
observation period of more than four years.
•
Group A included 94 patients with a mean age of 10 years, operated before
eruption of the canine; group B included 72 patients with a mean age of
13.1 years operated after eruption of the canine; and group C included 58
patients operated after the age of 16 years (mean age, 20.4 years).
•
The evaluation of the treatment results included longitudinal comparison of
marginal bone level, periodontal status on cleft-related teeth, dental status
in the bone grafted region, aesthetical and functional properties of the
reconstructed alveolar process, as well as the influence on growth of the
maxilla.
12th July 2008
Dr. Christine Underhill
erupted canine
12th July 2008
Dr. Christine Underhill
Orthodontics in the permanent
dentition
• Orthodontics alone... adolescent.
• Orthodontics in conjunction with
orthognathic/distraction surgery... adults.
• Long term retention especially important.
• Long term stability of results???…
12th July 2008
Dr. Christine Underhill
Adolescent treatment
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
Adult treatmentOrthognathic surgery
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
12th July 2008
Dr. Christine Underhill
In Summary
• Oro facial clefts require a
multidisciplinary approach
• Treatment extends over many years and
risks exhausting patient cooperation
• Need to keep the patients best interests
in mind.
12th July 2008
Dr. Christine Underhill
Thanks
I would like to thank:
• Dr Kit Chan, Consultant Orthodontist at the
Westmead Children's Hospital in Sydney.
• Dr Peter Fowler, Consultant Orthodontist,
Christchurch Hospital New Zealand.
for all their help, advise, and photo’s !
My husband and sons for teaching me how to
use power point!
12th July 2008
Dr. Christine Underhill