ORTHODONTICS IN CLEFT LIP & PALATE

by: Siti Farhanah binti Md Subandi Supervisor: Dr Rozita Hasan

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AIM OF MANAGEMENT
To allow the patient to : 1. LOOK WELL 2. SPEAK WELL 3. FUNCTION WELL

TIMING
Typical stages in mx: 1) Neonatal / first 18 months 2) Early mixed dentition 3) Late mixed dentition 4) Early permanent dentition 5) Late teens

Neonatal / first 18 months

Neonatal / first 18 months

Parental counselling & introduction to the

Cleft Lip & Palate Association (CLAPA)

Neonatal / first 18 months

- Offer feeding advice, establish preventive regimen & routine dental care

MAM orthodontic teats

Softplas bottles and spoon feeder

Interspace brush
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Neonatal / first 18 months

Pre surgical orthopaedics

- to align the displaced clefts segments

Lip repair at 3 months - some centres within days of birth Palate repair at 9-18 months

Neonatal / first 18 months

Pre Surgical Orthopedics

An infant with a CLP will have distorted mx arch at birth If distortion of arch form is extremely severe, surgical closure of the lip, which is normally carried out in the early weeks of life, can be extremely difficult
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Neonatal / first 18 months

Pre Surgical Orthopedicscont

Orthodontic intervention to reposition the segments & to bring the premaxillary segment back into arch may be needed to obtain a good surgical repair of lip Usu.would be done approximately at 10 wk

Currently remains useful in infant with extremely malpositioned segment, which occur almost exclusively in bilateral CLP
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Existing Devices 1. Passive Plates: These devices consist of a piece of acrylic that simulates a normal palate. 2. Molding Plates: These devices also consist of a piece of acrylic formed to fit the individual palate. 3. Latham: This device consists of two acrylic pieces that fit over the alveolar segments. 4. Nordin Device: This device is used for bilateral clefts. Like the Latham device, pieces of acrylic hold the alveolar segments. A ring of plastic encircles the premaxilla. 5. Jackscrew Device: This device consists of two acrylic pieces that fit over the alveolar segments. Latham . Passive Plates

. Jackscrew Device 11

Orthodontic mx in neonatal / 18 mo:

1. Parental counselling & introduction into CLAPA 2. Pre surgical orthopedics 3. Lip repair

4. Palate repair

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Early mixed dentition

5-6 years

8-9years

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Early mixed dentition

2 incisors may erupt into linguo-occlusion.

This should be corrected if possible but may be delayed until the next phase of development.

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Late mixed dentition

9-11years

12-13years

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Late mixed dentition

If an alveolar cleft is evident, 2 ALVEOLAR BONE GRAFT is routinely performed at age 910 years Cancellous bone from the iliac crest is placed in the alveolar cleft and will :
- facilitate eruption of the 2 canine - allow alignment of teeth adjacent to the cleft - promote orthodontic rather than prosthodontic repair - help stabilize the maxillary segments - assist closure of fistulae - improve vestibular anatomy
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Early 2 dentition

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Early 2 dentition

Tx indicated is dictated by the concerns of the pt & severity of skeletal discrepancy

Skeletal Discrepancy

Not severe
Conventional fixed appliance tx can be carried out

Severe skeletal pattern 3 Full correction requires

combination of orthodontics / orthognathic surgery in the late teens
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Late teens

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Late teens

If orthognathic surgery is indicated, the class

III incisor relationship is corrected by fixed

appliance tx to decompensate & coordinate

the dental arches prior to surgery.

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PRE SURGICAL & POST SURGICAL ORTHODONTICS

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PRE SURGICAL ORTHODONTICS

In adult CLP patients with excessive jaw discrepancies, orthognathic surgery is often indicated to correct their functional and esthetic problems. In most cases, orthodontic treatment using fixed appliances will be required both pre- & postoperatively. Pre surgical orthodontics usually takes between 12 & 18 months depending upon the complexity of the case.

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PRE SURGICAL ORTHODONTICS CONT

Aims of pre surgical orthodontics: a) General arch allignment b) Arch width correction c) Correction of anterior/posterior position of incisors d) Changes in overbite e) Correction of centrelines f) Create space for segmental surgery At this stage, the aim is to facilitate surgery & to create tooth positions that are likely to be stable postoperatively, rather than to obtain ideal cuspal relationships.
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POST SURGICAL ORTHODONTICS

Fine adjustments & final tooth position are achieved at this stage. Active tooth movement is not usually commenced until approximately 4 wk after surgery. Lighter round wires & elastic traction are utilized to detail the occlusion into a good interdigitation This phase of orthodontics should last for about 6 months.

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REFERENCES
An Introduction to Orthodontics, 2nd edition, 2001 Laura Mitchell W&H Orthodontic Notes, 6th edition, 2000, Malcolm L. Jones & Richard G. Oliver A textbook of orthodontics, 2nd edition, 1992, W.J.B. Houstan, C D Stephens, W J Tulley Contemporary Orthodontics, 4th edition, 2006, William R. Proffit, Henry W. Fields, JR., David M. Sarver Churchills pocketbooks Clinical Dentistry, 3rd edition, 2007, Ivor G. Chesnutt John Gibson

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