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Case 13: Cleft Lip and Palate

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John Tankersley

on 22 November 2013

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Transcript of Case 13: Cleft Lip and Palate

Case 13: Cleft Lip and Palate
Group 12
Patient Profile:
A family presents to your General Dentistry office as new patients. Bob and Mary Jones have just moved to Houston with their son Michael from rural East Texas. The family has not had regular dental or medical care since Bob lost his job 4 years ago. Bob has a new job with excellent medical and dental benefits.
Medical and Dental History:
Multidisciplinary Team for Child with Cleft Lip and Palate
Mary is 3 months pregnant with their second child. Their son Michael is 8 years of age and was born with an uni-lateral cleft lip and palate. The family wishes to become regular dental patients and is concerned about Michael's "crooked" teeth and "funny-looking nose". His parents are also concerned that Michael is missing a tooth in the cleft site.
Oral Examination:
After your examination and radiographs you note that Michael's cleft is on the left side and runs through the left maxillary alveolus into the anterior hard palate. The soft palate has been repaired. The maxillary left lateral incisor is missing. A hole in the vestibule goes from the alveolus on the left side into the floor of the nose. Michael states that when he drinks liquids, fluid goes into his nose. Michael's oral hygiene in this area is poor. Bob and Mary were concerned that brushing in that area will "hurt something".
Plastic/craniofacial Surgeon
Congenital and acquired deformities in the skull
Specialized training in the diagnosis and treatment of skeletal abnormalities
Not tissue specific (bone, muscle, skin) [6]
Medical professional that specializes in infants, children and adolescents
Helps coordinate the many specialists involved [6,7]
Evaluates the position and alignment of the child's teeth. [6]
Pediatric Dentist
Dentist who will analyze and care for the child's dentition [6]
Outline all of the operations that a cleft lip child requires from birth to 18 years of age
What is the incidence of Cleft Lip and Palate in Caucasians, African-Americans and Native Americans?
What can you do in the general dental office to help for Michael's cleft care?
What is meant by the term "oronasal fistula"?
Oronasal fistula (ONF) is an abnormal communication between the oral cavity and the nose. ONF most common complication associated with cleft palate surgery. The rate of occurance can vary from 4-35%. ONF primary arises due to the repair of the palate and in occasions, specifically in adults, as a result of postoperative infection. (10)

ONF sites may vary. Some are located in the soft palate, but most often they are found in the hard palate.

Based on their size, fistulas may be classified as
small (< 2mm)
medium (3-5mm)
large (>5mm).

According to the location, fistulas are described as anterior fistula, midpalatal fistula, fistula at the junction of the soft palate and hard palate and soft palate fistula. (9)
The incidence of cleft lip varies widely
among different races. There is a
general trend for wider faces being
more susceptible to cleft lip and palate.
African-Americans have to lowest
incidence of CL/P at a range of 0.18
to 1.67 per 1,000 live births.
Caucasians are nearly twice as likely to to manifest this disorder at a range of 0.91 to 2.69 per 1,000 live births. Native-Americans had the highest rate of incidence at 0.79 to 3.74 per 1,000 live births.(3) Males tend to be at a higher risk for CL/P than females. Native Americans > Asians > Caucasians > Africans. CL/P: 1-2/1000, > frequency in males
CP: 1/2500, > frequency in females

1 Month:

The risk of fistula formation is directly correlated to the severity (width) of the original cleft.

Incidence is higher for incidence of fistulas is
after palatoplasty for
complete clefts of the
primary and secondary palates
than after closure of an
isolated secondary palatal cleft

The incidence of fistula formation in the palate is 12.5% for
bilateral clefts, 7.7% for unilateral clefts, and 4.6%
for isolated clefts of the secondary palate. (9)
-First visit with Plastic Surgeon to discuss treatment plan

-Meet with Nutritionist to ensure baby is gaining sufficient weight
2.5-3.5 Months
-First surgery is performed to repair the cleft lip
Mary is concerned about her new baby, what can you tell her is the likelihood that the next child will have a cleft?
6 Months:
-Introducing the baby to a cup so that when the cleft palate is repaired no objects will be irritating the soft tissue of the healing palate
9 Months:
-The cleft palate is repaired
-if the cleft is bilateral sometimes the repair is in 2 stages
3-4 Years:
-When the child begins to speak in sentences, a speech evaluation is recommended

-Speech therapy and/or surgery may be recommended
-pharyngeal flap surgery
5-9 Years:
-Revision or "touch-up" of the lip

-If the child has a gap in the bone of the gum line, a bone graft may be needed
-bone from the hip can be used to fill the gap in the gum line

-Orthodontic expansion may be needed
11-14 Years:
Other Members of the Multidisciplinary Team
-A revision of the lip and/or nose may be required as the child grows

-If speech is a problem at this point a pharyngeal flap may be needed (if one wasn't performed earlier)
12-16 Years:
-Orthodontics are started around this time
15-20 Years:
-Time for finishing surgeries as growth is completed
-girls (15-17 years, boys 18-21 years)

-Jaw surgery: to bring the upper jaw forward and/or the lower jaw back
-Septorhinoplasty: straighten and refine the nose
-Malar implants: to build up the mid-face (cheekbone)
-Further revision of the lip and nose
The likelihood of having a second child
with CL/P increases when siblings or
parents also have the disorder. If the
parent or sibling has a CL/P,
the risk of the next child having the
disorder is 4%. Two siblings with cleft
lip and palate, increases the risk for the
next child to 9%. The parent and a child
with cleft lip and palate, raises the risk of the next child having the disorder to 17%. In the case of isolated cleft palate, the risk of subsequent pregnancies with one affected child is 2% and 6% if the parent had a cleft palate. (4) There are other factors including smoking, diet, and the intake of vitamins, such as folic acid, which can have an affect on the likelihood of CL/P disorders. (5)
Speech and Language Specialist
Comprehensive speech evaluation
Monitors child throughout all developmental stages [6]
Otolaryngologist (ENT)
evaluation and management of ear infections/hearing loss [6]
Evaluates and manages hearing difficulties [6]
Genetic Counselor
Examines child to assist in diagnosis
Counsels family on risk of recurrence during future pregnancies [6,7]
Nurse Team Coordinator
Liaison between family and medical team [6]
Social Worker
Gives guidance and counseling to the family in regards to the social and emotional parts of cleft abnormalities
Community resources [6]
Causes of ONF:

excessive tension on the primary repair site because
of inadequate medial mobilization of the flaps

excessive trauma to the margins of the palatal flaps
by instruments during surgery

faulty suturing

traumatic disruption of the healing wound


inadequate attachment of the palatal tissue to the
nasal mucosa

hematoma formation between the oral and nasal layers

flap necrosis. (9)
Cleft formation
Name 3 Ways to Replace the Missing Lateral
Canine Substitution
Craniofacial Devlopment
Tooth-Supported Restorations
The symptoms associated with ONF include nasal regurgitation of food and
speech problems
like hypernasality of voice (9)
Single-Tooth Implant
Multidisciplinary Team (MDT)- members from different healthcare professions with specialized skills and expertise [8]
1: http://www.cincinnatichildrens.org/assets/0/78/1067/1395/1883/fdf51e63-92ea-4877-b68c-641a933d9c2f.pdf
2: Dr. Letra Associate Professor Oral Biology Lecture Genetics of Oral/Facial Clefts 11/15/13
3. Vanderas, A. P. (1987). Incidence of Cleft Lip, Cleft Palate and Cleft Lip and Palate Among Races: A Review. Cleft Palate Journal , 24(3), 216 - 225.
4.Pediatric Cleft Lip and Palate . (2013, September 11). Pediatric Cleft Lip and Palate. Retrieved November 17, 2013, from http://emedicine.medscape.com/article/995535-overview#a03
5. Cleft Lip and Palate. (n.d.). Cleft Lip and Palate. Retrieved November 17, 2013, from http://texaschildrens.org/Cleft-Lip-and-Palate/
6. "Cleft Lip/ Cleft Palate." <i>Health Library </i>. N.p., n.d. Web. 20 Nov. 2013. &lt;http://www.hopkinsmedicine.org/healthlibrary/conditions/plastic_surgery/cleft_lipcleft_palate_90,P01847/Find a website by URL or keyword...&gt;.
7. "Pediatric Cleft Lip and Palate Treatment & Management." <i>Pediatric Cleft Lip and Palate Treatment & Management</i>. N.p., n.d. Web. 19 Nov. 2013. &lt;http://emedicine.medscape.com/article/995535-treatment&gt;.
8. "Multidisciplinary Teams (MDTs)." <i>Department of Health</i>. N.p., n.d. Web. 20 Nov. 2013. &lt;http://www.health.nt.gov.au/Cancer_Services/CanNET_NT/Multidisciplinary_Teams/index.aspx&gt;.
9.Oggle, O. (2002). The management of oronasal fistulas in the cleft palate patient. Oral and Maxillofacial Surgery Clinics, Retrieved from http://www.theidealface.com/Congenital_files/The%20management%20of%20oronasal%20fistulas%20in%20the%20cleft%20palate%20pati.pdf
10Sadhu, P. (2009). Oronasal fistula in cleft palate surgery. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 42. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825081/
11.American Cleft Palate Craniofacial Association (2009, November). Parameters for evaluation and treatment of patients with cleft/lip palate and other craniofacial anomalies. Retrieved November 20, 2013, from http://www.acpa-cpf.org/uploads/site/Parameters_Rev_2009.pdf
12. Congenital Malformations of The Lip And Palate, http://discovery.lifemapsc.com/library/review-of-medical-embryology/chapter-56-congenital-malformations-of-the-lip-and-palate
13. Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
14. Bradley K. Coots, Alveolar Bone Grafting: Past, Present, and New Horizons, Semin Plast Surg. 2012 November; 26(4): 178–183. doi: 10.1055/s-0033-1333887, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706037/#__ffn_sectitle
15. Woojin Lee, Nostril Base Augmentation Effect of Alveolar Bone Graft, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785587/#__ffn_sectitle
16. Rychlik, Dariusz, Bone Graft Healing in Alveolar Osteoplasty in Patients With Unilateral Lip, Alveolar Process, and Palate Clefts,. http://ovidsp.tx.ovid.com.libdb.db.uth.tmc.edu:2048/sp-3.10.0b/ovidweb.cgi?QS2=434f4e1a73d37e8ce3703c84bb996c0d51564061034d60c487c668ebf397e0c90fbaa4fa1a9cd2e46a058d926cb4b525b8cbe9b319dd27acccac864164f59b3df28f24a6bfedddc0ae76f98de4fcfc80bc74d0cb0b675148351baf0ff4ef92f2d9b0f6b792c9fc8148ebe1eadb1a67e1b77db617b814f6d56c421dea2f3703f38a2d0dd300f090aa0372e16638797dacc90d7da1525f92697e4cd89b10a7f7a0527b27f1086b7ff54a
17. KOKICH, V. O. and KINZER, G. A. (2005), Managing Congenitally Missing Lateral Incisors. Part I: Canine Substitution. Journal of Esthetic and Restorative Dentistry, 17: 5–10. doi: 10.1111/j.1708-8240.2005.tb00076.x
18. KINZER, G. A. and KOKICH, V. O. (2005), Managing Congenitally Missing Lateral Incisors. Part II: Tooth-Supported Restorations. Journal of Esthetic and Restorative Dentistry, 17: 76–84. doi: 10.1111/j.1708-8240.2005.tb00089.x
19. KINZER, G. A. and KOKICH, V. O. (2005), Managing Congenitally Missing Lateral Incisors. Part III: Single-Tooth Implants. Journal of Esthetic and Restorative Dentistry, 17: 202–210. doi: 10.1111/j.1708-8240.2005.tb00116.x

Development of the maxilla
Begins during week 4
Cranial neural crest cells migrate and unite to mesenchymal cells from the mesoderm
failure of mesenchymal consolidation and differentiation
2 Maxillary prominences grow toward the middle forming the nasal prominences
Cleft Lip
An example patient with a congenitally missing lateral incisor after having two implants previously fail in the edentulous site. The patient did not want to undergo any more surgery for implant placement or grafting. (18)
The final preparation of the partial-coverage pin-ledge cantilever restoration (attach to only one adjacent tooth). The pins on the distal and in the cingulum as well as the groove on the mesial in the preparation enhance the resistance and retention form. (18)
During week 5, the maxillary processes appear
Failure of the two maxillary processes on the affected side to join with the right, left or frontal nasal medial processes
Upper lip and primary palate formed.(13)
The extensions of the retainer are determined by the occlusion and the translucency in the incisal one-third of the abutment. The restoration is bonded with resin cement. It is imperative that all eccentric contacts be removed from the pontic. (18)

Patients with cleft lip and/or palate should receive appropriate dental care. With proper dental care, children who have this condition can have healthy teeth.

Dental Care:
dental examinations
caries control
preventive and restorative treatment
referral to appropriate providers for
prosthetic dental treatment as needed
monitor missing, malformed, or malpositioned teeth

The dentist should recommend proper cleaning, good nutrition and fluoride treatment.

Appropriate cleaning with a small, soft-bristled toothbrush should begin as soon as teeth erupt.

Patients are often referred to a pediatric dentist due to the complex nature of this abnormality.

Coordination should be established with the dental-surgical team. (11)
Begins at the end of week 5 and completed during week 12
Palate divided into 2 parts
Anterior palate(primary)
originates from intermaxillary segment forms the median palatine segment(13)
Posterior (secondary)
originates from the maxillary prominences which form the lateral palatine processes (13).
Lateral palatine processes grow horizontally
Tongue moves inferiority and decreases in size
The two shelves fuse in a median plane with the lateral and median palatine process(13)
The two lateral palatine processes begin in the vertical position(13).
Two lateral shelves and the nasal septum meet with the nasal septum via fusion of the epithelium in a median plane forming the palate .
incisive foramen (13).
Cleft Palate
Cleft of the anterior or primary palate:
anterior to the incisive foramen and are caused by a failure of the lateral palatine processes to meet and fuse with the primary palate(12)

Canine substitution is the least invasive and most convenient option for patients already committed to undergoing fixed orthodontic treatment.
Maxillary prominences form
Upper cheeks and most of upper lip(13).
Canine Shape and Color
E. Orthodontic extrusion of the canines
F. Ideal length of the canines as lateral incisors
G. Cuspal equilibration completed
H. Composite restoration of mesioincisal corners
Ability to leave adjacent teeth untouched; particularly beneficial when dealing with young patients and un-restored dentition
Implants cannot be placed until facial growth is complete so monitoring eruption in these patients at an early age is important for optimal implant site development (18)

Left: As the permanent canine erupts adjacent to the central incisor, its large buccolingual width begins to develop the alveolar ridge in the edentulous area

Right: The canine is moved distally, leaving behind an adequate buccolingual width for implant placement
After the implant has been placed, osteointegration should be complete after 4-6 months
Left: Taken minutes after seating the screw-retained implant. The tissue blanching that is present is due to the pressure caused by the difference in the provisional’s subgingival contour compared with that of the healing abutment.

Right: Taken at the 6-week evaluation; the contour of the provisional has influenced the form of the tissue
Alveolar Bone Graft
Clefts of the anterior and posterior palate:
involve both the primary and secondary palate and are caused by failure of the lateral palatine processes to meet and fuse with each other, the primary palate, and the nasal septum(12)
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Carla S. Rogers. Oral Bio I face cavity. Department of DIagnostic and Biomedical Sciences. UTSD. 2013
Patient is 8 years old
Bone graft is ideal before tooth eruption(14)
Lateral incisors normally erupt 8-9 yrs
Alveolus is a component of the primary palate and may be absent if complete fusion of the maxillary prominences does not occur.
inadequate alveolar bone results in the absence of the alveolar process containing the tooth.
Procedure needed for nostril base augmentation(15).
Pediatric dentists, orthodontists, oral surgeons, speech pathologists work together as a team(14)

Graft Sources
illiac crest of the pelvis
cranial bone
mandibular symphysis
fill the "alveolar defect with autogenic spongy bone graft during mixed dentition period"(16).
allows union of the cleft bone fragments and separation of the nasal and oral cavity(16).
Feeding parenterally 2 days post-surgery(16).
Continue on mashed diet for 4 weeks(16).
The shape and color of the canine are important factors to consider for canine substitution to be considered esthetic. Naturally, the canine is a much larger tooth than the lateral incisor it will be replacing. (17)

With a wider crown and a more convex labial surface, a significant amount of reduction is often required for the orthodontist to achieve a normal occlusion and acceptable esthetics.

Things for the dentist to consider: type of malocclusion and amount of crowding, profile, canine shape and color, and lip level (17)
The final outcome for the missing space can be resolved without having to wait for completion of skeletal growth
It also saves the patient from having additional surgeries or restorative procedures, making it not only safer but also a more cost effective option
Evaluation of specific dental and facial criteria is necessary when selecting the appropriate patient for canine substitution.
After canines have been moved into position next to the centrals...
In Conclusion....
A child with cleft lip and palate with have a multidisciplinary team involved with his or her treatment. Team members are from different healthcare professions with specialized expertise such as a plastic surgeon, orthodontist, speech and language specialist, and genetic counselor.

Development of the maxilla begins during week 4 as cranial neural crest cells migrate and unite to mesenchymal cells.
Cleft lip occurs around week 5 if the maxillary processes fail to join with one another.
Cleft palate caused by failure of the lateral palatine processes to fuse with the primary and/or secondary palate in weeks 5-12.

In order to correct the nose and alveolus on the cleft side, Michael will need an alveolar bone graft to fill the void so the nasal and oral cavity will be separate.

Race can affect the likelihood of an individual having a cleft lip in palate with the trend as follows... Native Americans > Asians > Caucasians > African Americans

As a healthcare professional we need to be aware of trends in disorders like cleft lip and palate so we can educate our patients regarding likelihood of second children having the disorder as well as other factors that can have an effect like smoking and diet.

It is the general dentists responsibility to provide thorough dental exams, discuss caries prevention, and refer to the appropriate members of the multidisciplinary team as needed.

Oronasal fistulas are one of the most common complications following a cleft palate surgery as a result of post-op infections --> symptoms to be aware of include nasal regurgitation of food and speech problems like hypernasality.

A cleft child will require multiple procedures throughout adolesence in order to alleviate some of the daily struggles like feeding while also improving esthetics.
Cleft lip is repaired first around 3 months followed by the palate repair around 9 months; finishing surgeries can occur up into their 20's as growth is completed.

Three ways to replace a missing lateral are canine substitution, tooth-supported restorations, and a single-tooth implant.
The primary consideration among all these treatment options is conservation of tooth structure. Ideally, the treatment of choice should be the least invasive option that satisfies the expected esthetic and functional objectives.
If an individual does not meet the necessary qualifications to be considered for canine substitution then some form of restoration must be considered.
The orthodontist will create the necessary space for the partial denture and luckily, given the root and crown length of the canine, it makes a great abutment (supporting structure) for the restoration. (18)
Once the implant is uncovered, the abutment is placed on the implant so that the crown can be cemented (18)
Anterior Fistula
Large Fistula
Flap Necrosis
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