Cleft Lip and Palate Flashcards
What is cleft palate?
CP- cleft goes through soft and hard palate
Issues with speech but no dental impact generally
What is cleft lip?
A cleft which involves lip and may or may not involve palate
How are cleft lip and palate classified?
By LAHSHAL- letter added for every part the cleft passes through
L- lip
A- alveolus
H- hard palate
S- soft palate
H- hard palate
A- alveolus
L- lip
-> if all it would be bilateral cleft lip and palate
What proportion of CLP is made up by unilateral?
80%
-> Bilateral have bigger growth deficiency, speech/dental issues
How do cleft lips form?
Premaxilla attaches to nasal septum and everts/rotates out without attachment
How common is cleft lip and palate
1:700 live births
What is meant by sporadic in CLP?
No obvious aetiology
-> This makes up for 70% of cases
How does sex alter the prevalence of different cleft conditions?
CLP- m>f
CL- males:females is 3:1
CP- Females: males is 3:2
What are the genetic factors involved in aetiology of CLP?
Syndromes- apert’s, crouzons, TCS
FH- if one child born with cleft there is a 5% chance the next child will have one
Sex
Laterality- more common on LHS
Ethnicity
What are the environmental factors involved in aetiology of CLP?
Smoking
Alcohol
Social deprivation
Anti-epileptics
Multi-vitamin use
What is the role of the cleft nurse?
They come and see patient within 24 hours of baby being born
Difficult to feed if CP- difficulty suckling
Reassure patients- talk them through the pathway
Advise use of soft bottles- squirt milk in when lip move
What are the implications of CLP?
Aesthetic issues
Speech issues- issues with plosive sounds
Dental issues
Hearing/airway issues- more likely to suffer glue ear and ears may not properly form
Other- more likely to have cardiac abnormality
Why is primary surgery of CP done when the patient reaches one?
As babies are obligate nasal breathers at birth and closing palate earlier would cause swelling which blocks nose
What would happen to a patient’s speech if they never had cleft palate repaired?
It would have a hyper-nasal quality as air would escape through palate
Who are the members of the cleft care team in Scotland?
Surgeons
Cleft nurses
Dental team
Psychologist
ENT respiratory doctor
Speech therapist
Geneticist
What are the steps in the journey of the cleft patient?
3 months- lip closure
1 year- palate closure
-> done before baby starts to talk/babble to ensure palate is as normal as possible for this
8-10 year- alveolar bone graft
12-15 years- definitive orthodontics
18-20 years- Surgery (secondary)
What is fixed in secondary surgery?
Lips, nose, orthognathic issues
-> done when patient fully grown
Which clinics look after children with clefts?
Baby MDT- Newborns
Childrens clinic- 0-7 years
Bone graft clinic- 7-12 years
Transition clinic- 12-16 years
Adult clinic- 16+
What are the dental implications of CLP?
Missing teeth
Impacted teeth
Crowding
Growth
Caries
What are the features of missing teeth in CLP patients?
Whatever tooth associated with area of cleft is missing (Often lateral incisor)
-> Central closest to cleft is usually small and hyperplastic
Which historic treatment for CLP is no longer used?
Premaxilla which is not connected may be removed and soft tissue closure done
-> causes loss of these teeth
What are the causes of impacted teeth in patients with CLP?
Supernumeraries at cleft site- prevents teeth coming through
Jaw is small and crowding results- not enough room for eruption
What causes crowding in patients with CLP?
Scarring on repairing of cleft makes top jaw smaller- not enough room
Social demographic- poor attenders, high caries rate (deciduous teeth need to be removed leading to crowding)
What jaw relationship do patients with CLP tend to have?
Tends to be class III jaw relationship
-> Scarring in top jaw stops translation/growth of maxilla
-> Improves after bone grafting
*may be hesitant about fixing incisor relationship due to growth imbalance
Why do cleft patients have more caries?
Teeth are often hypoplastic
Teeth come through in strange positions/crowding can make it difficult to clean
Who are the members of the dental team involved in treatment of CLP?
Paediatric dentist
Orthodontist
Oral surgeon
Dental and Orthodontic therapists
Restorative dentists
What is the role of the paediatric dentist in treating patients with CLP?
Follow guidelines
-> FV application
What are the roles of restorative dentists in CLP?
Placing restorations to fix any spaces
Bridges etc
Over dentures may be good to provide aesthetic outcome
What is the main role of orthodontist in treating CLP patients?
Close spaces
What are the aspects of orthodontic treatment for CLP patients?
Pre-surgical orthopaedics
Expansion/bone grafting
Definitive Ortho
Orthognathic surgery
What is involved in pre-surgical orthopaedics?
Placing plate in child’s mouth to help them feed
-> encourages segments of cleft to get closer together
-> help speech development
*now been found to be not effective
What is the main issue with pre-surgical orthopaedic plates?
Difficult as you need to take an impression- creates hypoxia while alginate sets
What is lip strapping?
Using silicone straps to bring cleft segments together in babies
-> done by cleft nurses
Why is bone grafting to fix then cleft done at age 8-9?
So not to damage permanent successors
What is done before and after bone grafts in CLP patients?
Before:
Remove all supernumeraries around cleft site or any teeth interfering with cleft site- 3 months later do bone graft
After:
Close spaces
-> Canine may be modified to help it look like a lateral
How is the correct timing for bone grafting in CLP that will allow eruption of canine determined?
Timing is based off OPT radiograph taken at 7-8 years
Canine should be 50% formed
Root formation takes 4 years- so if 50% formed then it’ll be 2 years from then that it will erupt
Where do the grafts used to fix CLP come from? How are they harvested?
Grafts come from hip bone using coffin lid incision
Drip with LA
Patient discharged the same day
95-96% success rate- only fails if decay or infection
What percentage of the time do canines come into correct position replacing missing lateral in CLP patients?
60%
What may the aesthetic concerns be in patients with CLP?
Central incisor often hypoplastic
-> build up?
Lateral incisor may be absent- creating lack of symmetry as canine is next to central (if unilateral)
-> accept?
-> as lip line is often low on that side- modify canine with veneer or composite for aesthetic result
What are the options for fixing class III incisor relationship in different growth types in CLP patients?
Good growers- space closure, space opening with bridge (needs replacement)
Poor grower- line up teeth and leave relationship
Borderline- line up dentition and see what happens
What treatment can be done if the CLP patient is significantly class III? What are the issues in these patients?
Orthognathic
More difficult in cleft patients- more scarring and less flexibility in soft palate in cleft patients so moving the jaw can create a hole again
