Cleft Lip and Palate Flashcards
cleft management - need to know
4
- multifactorial
- multidisciplinary
- dental team aspect
- caries risk
orofacial clefting (OFC) classed as
craniofacial nomaly
common
types of orofacial clefting
2
cleft palate
cleft lip with/without palate
what orofacial clefting type is this
cleft palate
what orofacial clefting type is this
unilateral cleft lip and palate
cleft palate causes
issues with speech mainly
less likley dental impact
cleft lip with/without palate causes
larger dental impact
classification systems for orofacial clefting
Kernahan and Stark 1958
* Cleft lip +/- Palate -> cleft Lip Cl or Cleft Lip and Palate CLP
* Cleft palate -> Cleft Palate CP
LAHSHAL – use
how to use LAHSHAL
Very descriptive on what cleft about
- What unilateral or bilateral cleft lip/palate goes through
- Lip
- Alveolus
- Hard palate
- Soft palate
Small letters not complete - notch in lip
LAHS
use LAHSHAL classification to classify this orofacial cleft
LAHSHAL
(bilateral cleft lip and palate exending form lip to soft palate on both sides)
nasal septum divides
Unilateral : Bilateral
cleft lip and palate
80%:20%
4:1 unilateral:bilateral
Bilateral has the bigger impact - growth, teeth, challenges with speech etc
Variety of shapes and sizes of clefts
describe
LAHS cleft lip and palate
describe
microformed cleft lip
l
describe
Extreme bilateral – premaxilla attached to nasal septum,
inferior turbinates (nose) visible
describe
bilateral cleft lip and palate
cleft lip and palate facts
1:700 live births
* 100 clefts births per year in Scotland approx.
70% sporadic
Cleft lip +/- palate: males> females (Scotland)
Cleft lip : males :females 3 :1 (Scotland)
Cleft palate: females > males (3:2 EU)
CLP> CP (England and Wales)
CP=CLP Scotland
number of live births per year wiht CLP
1 in 700
100 clefts per year scotland
sex ratio of cleft lip +/- palate (scotland)
males>females
sex ratio of cleft palate (EU)
females>males
3:2
ratio cleft lip to cleft lip and palate
Scotland
England and Wales
scotland - CP=CLP
eng and wales - CLP>CP
aetiology of cleft lip and palate
MULTIFACTORIAL
genetic and enviornmental
genetic factors that may contribute to cleft lip and palate
5
Syndromes
* More common in syndromes e.g. Aperts, Treacher Collins
Family history
* 5% chance next child will have
Sex ratio
* Males more common have CLP, females CP
Laterality
* Missing and ectopic teeth more common on left, alike clefting
Ethnic dist
no pure genetic link yet
sex ratio of cleft lip (scotland)
males :females 3 :1 (Scotland)
environmental factors that may contribute to CLP
5, 3 key
social deprivation
smoking
alcohol
anti-epileptics
multivitamins
effect of smoking ban in public areas on CP
reduction in cleft palate since smoking ban in public areas - passive smoking environmental aspect
5 areas impacted by UCLP
- Aesthetics
- Speech
- Other anomalies
- Hearing airway
- Dental
aesthetics impact of UCLP
Baby born with cleft
* Shock to parents if not picked up prenatal
Cleft nurses - 5 in Glasgow cover whole of Scotland
* see pt in 24hrs within baby born
* Reassure pt, talk through pathway, explain how to feed
- Aesthetics correction
- Primary surgery lips 6 months - no health reason, social interaction (parents can find hard the change in appearance)
- Primary surgery on palate 1 year
- cannot close before 6 months, as babies obligate nasal breathers, palate swells and cannot breath if closed earlier
- done at 1 year as that is when baby starts to babble more and want to try to develop sound and speech as normally as possible
how to feed baby with UCLP
- When cleft goes through palate - hard to feed, cannot suckle
- soft bottle as cannot breast feed
speech impact on UCLP
when cleft goes through palate, air can escape through nose when trying to speak
* hypernasal
* speech sounds different
* to make plosive soft pharynx blocks the pharynx – cannot happen in cleft palate - check
speech therapists assess their development
hearing airway impact of UCLP
more prone to glue ear and brachial arch discrepancies
ENT and audiologists
other anomalies tha can impact child with UCLP
40% have some form of cardiac anomaly
Scottish cleft care centralised in Glasgow- cardiac&airway service there
team members of Cleft Care Scotland team
7
Cleft nurse
Surgeon
Speech therapist
Dental team
ENT Respiratory
* Audiologist
* Airway consultant
Geneticist
Psychologist
what can parents refer to regarding there tx journey
national cleft pathway
UCLP pt journey
**
3 months - lip closure
6-12months - palate closure
8-10years - alveolar bone graft
12-15 years - definitive orthodontics
18-20years - surgery (lips, orthognathic (after end of growth))
UCLP pt journey
3 months
lip closure
UCLP pt journey
6-12months
palate closure
UCLP pt journey
8-10years
alveolar bone graft
UCLP pt journey
12-15years
definitive orthodontics
UCLP pt journey
18-20years
surgery (Lips, nose, orthognathic (after end of growth))
clinics part of cleft care scotland
- baby MDT (newborn)
- Children’s clinic - see every 6 months till 7years
- bone graft clinic
- transition clinic
- adult clinic
fit timescales of pt journey
5 dental impacts of cleft lip and palate
missing teeth
impacted teth
crowding
growth
caries
missing teeth in UCLP
almost always missing where cleft goes thorugh (common lateral incisor)
central closes to cleft is often small and/or hypoplastic
crowding in UCLP
Supernumeraries coming through at cleft site
Jaw is small and compressed
* Crowded
* Scar tissue means less space for teeth -Impacted teeth
Deciduous decay leads to extractions, loss of space = crowding permanent
facial growth in UCLP
Class III growth discrepancy common
Top jaw not grown forwards
* Scarring stops translocation
* Fine till bone graft and then growth of maxilla stops whilst mandible continues
Affect ortho tx
* Incisor relationship
caries occurence in UCLP
challenging to reduce
* sociodemographic
* hypoplastic teeth
* hard to clean - access, misalligned
6 people in dental team for cleft care
Paediatric dentist consultant
Dental therapist
Orthodontist
Orthodontic therapist
Restorative dentist consultant
Oral surgeon
paediatric dentist in cleft team concern is
prevention of decay (SIGN guidelines, SDCEP, duraphat etc)
restorative dentist in cleft team concern is
aesthetics
majority is to disguise fact had cleft - space open and restoraitve tx
* some aim for simple closure so minimal maintenance
* discuss with pt
can be more complicated e.g. malocclusion
unilateral cleft, 3 erupted, RBB for 2 and composite build up 1
4 stages in orthodontist care of UCLP pt
Pre-surgical orthopaedics
Expansion/ Bone grafting
Definitive orthodontics
Orthognathic surgery
pre-surgical orthopaedics
2 aspects
Dento-alevolar moulding - Rare
* Plate fits inside child’s mouth
* Theory was Help them feed, speech develop - encourage segments together. RCT say not
* Impression of baby - hard
* Fill mouth with alginate - obligate nasal breather so cannot breath - hypoxia risk
Lip Strapping
* Silicone between sticky tape
* Sometimes done
expansion/bone grafting role
if teeth done right then makes ortho tx easier
as teeth come through in right place to be aligned
key for expansion/bone graft
timing of placement
* Aim is for tooth to come through as otherwise will be lost in 3 year
* time around teeth developing by cleft site
* wait at least till 8/9 - earlier will damage underlying teeth
radiological assessment for expansion/bone graft UCLP
OPT at 7-8 years
No justification for CBCT – doesn’t offer anything that OPT wouldn’t tell you
Want canine to be 50% formed
* Root takes 4 years to form
Here – crown is just formed so another 2 years till graft
Usually around 9 years for graft
process for expansion/bone graft for UCLP
remove all supernumeries and deciduous teeth around site
bone graft is from hip bone (aim for it to be at least 3 months prior to eruption, 50% formed on OPT)
pt discharged on the day
radiogical assessment of graft 6 months post op
clinical assessment
* aim is for canine to erupt through bone graft site
* 60% erupt in corect place
defintive orthodontics for UCLP
3 things to consider
bone graft
growth
dental aesthetics
defintive orthodontics considerations re bone graft
did it work?
is ther ebone to move teeth around in? (too thin then limited ortho option)
defintive orthodontics considerations re child growth UCLP
how are they growing?
possible to push teeth to correct incisor relationship or not?
not really any health benefit of class I incisor relationship over class III
defintive orthodontics considerations re dental aesthetics for UCLP
Restorative like symmetry
* If try to open space where bone graft placed, possible to lose graft but gain symmetry
Central incisor in CLP by cleft site
* 10-20% smaller than other central
* Slightly hypoplsatic
* Options to mask with composite
* Veneer or build up
* Some find better as if open gap and replace with RBB or implant – more expensive maintenance
Unilateral CLP
* Find nose asymmetry and lip line more noticeable than masked canine
classes of growers
**
defintive ortho tx
good growers
poor growers
boderline growers
good growers
UCLP def ortho
don’t become class III incisor relationship
space closure with composite build up OR space opening and bridge replacement
poor growers
UCLP def ortho
line up teeth with definitive ortho (leave in Class III incisor relationship)
pt tends to be concerned with upper arch aesthetics rather than lower arch so accept camouflage
boderline growers
UCLP def ortho
line up dentition and see where you get to
tricky
when is orthognathic surgery used for UCLP pts
When significant class III incisor malocclusion
Number of aspects with cleft make it more difficult
* Mainly speech concerned – scarring of soft palate from previous surgery make it less flexible, so when increase space that it needs to close over to reach pharynx can make plosives harder
how long is pt in cleft care
life long
dental prevention for UCLP
early is key
dentist see more than cleft care to enforce prevention
dental teams for cleft care
made of many people
* Paediatric dentist consultant
* Dental therapist
* Orthodontist
* Orthodontic therapist
* Restorative dentist consultant
* Oral surgeon
lothian, glasgow, grampian, tayside, inverness
refer to for advice
cause of clefts
multifactorial (genetics and environment)
cleft care team is
multi-disciplinary
cleft care scotlands website - refer for advice, any age of pt
