Cleft lip and Palate

Question 1

What is the prevalence of cleft lip and palate?

Answer 1

Racial variation with 1:600 live births caucasian, 1:1000 african american, and 1:500 inuit.

in WA 1:830 (cleft lip AND palate), 1:1000 cleft palate only. Slightly higher prevalence in aboriginal Australians.

Question 2

Are lip and palate clefts associated with syndromes typically?

Answer 2

Cleft lip and palate is not often associated with syndromes.

Question 3

How does the palate typically form?

Answer 3

week 4 is when the pharyngeal arches form

1st contributes to mandibular and maxillary components and around week 6 and 7 you have the formation of the primary palatal components maxillary processes and frontonasal prominence. Secondary palatal shelves fuse and by week 10 the palate formation is complete.

Question 4

How does cleft lip and palate form?

Answer 4

Failure of the palatal shelves to fuse is what leads to the formation of cleft lip and palate

Question 5

What are the classifications of cleft lip and palate?

Answer 5

Usually described with descriptive terminology. There aren’t distinct classes due to the diversity.

Question 6

What is the Pierre Robin Sequence?

Answer 6

Sequence of events leads to this manifestation:

Micrognathic mandible

Posterior displacement of the tongue

Question 7

What causes cleft lip and palate?

Answer 7

Often genetic aetiology (70% of all cases of CL/P and 50% of cleft palate are non-syndromic)

Environmental aetiology (1.3x higher odds in maternal smoking. Maternal alcohol, nutritional deficiencies, stress, maternal obesity, ionising radiation.

Question 8

Which genes are associated with cleft lip and palate?

Answer 8

MSX1 (involved in epithelial/mesenchymal interactions)

IRF6 (Related to connective tissue formation)

FGFR1 (involved in

Question 9

How did antenatal diagnosis change CLP treatment?

Answer 9

40 -> 71% increase in detection of CLP between 1996 - 2003 -> 2003 - 2012

This resulted in increase in terminated pregnancies.

Question 10

What is the aim of treating cleft lip and palate?

Answer 10

The ultimate aim of cleft surgery is that the patient look well, feed well, and speak well.

Question 11

What makes treatment difficult for cleft lip and palate?

Answer 11

Treatment is complex and there remains extensive disagreement on the timings of interventions, the interventions themselves, and the various techniques involved in surgical correction of the cleft.

Treatment is multidisciplinary.

Question 12

What is the treatment timeline for cleft lip and palate?

Answer 12

Short-term: Presurgical and surgical repair of the lip and palate. (birth up to about 3 months)

Medium term: Dental care, speech therapy, and surgical revisions.

Long term: Alveolar bone grafting and orthognathic surgery

Question 13

What does presurgical management of cleft lip and palate involve?

Answer 13

Most kids with CL/P don’t need appliances to feed necessarily and are often under the care of specialist teams.

Feeding instruction

Feeding appliances

Methods of repositioning and aligning the bony cleft segments prior to surgical closure of the lip

Pre-surgical orthopaedics

Question 14

What is the aim of pre-surgiical orthopaedics?

Answer 14

Repositioning and aligning the bony cleft segments prior to surgical closure of the lip.

Facilitate primary lip repair

Question 15

What appliances are used pre-surgically in CL/P?

Answer 15

Intraoral appliance

Extraoral traction (bonnet/strapping)

Question 16

How have impressions changes in modern times?

Answer 16

Digital impressions are now used instead and they are safe,, accurate, and faster than alginate.

Question 17

What issues arise in feeding that are caused by CL/P? How are they fixed?

Answer 17

Difficulty creating suction, poor seal

Abnormally arranged oral and velopharyngeal musculature

Inefficient feeding (increased feeding time, weight loss/ slow weight gain)

Special bottles or feeding syringes can be used.

Question 18

How is the palate repaired in CL/P?

Answer 18

Surgical techniques include:

Von Langenbeck palatoplasty

Furlow Z palatoplasty

VY pushback

Question 19

What ‘well-baby’ checks can be used for preventative dental care?

Answer 19

Monitor to improve the effectiveness of plaque control

Professional cleaning and topical fluoride application

Dietary assessment and counselling

Fissure sealants to teeth at risk of pit and fissure caries

Early diagnosis and management of pathology

Occlusal development

Fabrication of mouthguard

Question 20

What age should alveolar bone grafting and orthognathic surgery be used?

Answer 20

After 13 years of age

Question 21

What is the purpose of pre-surgical orthodontics?

Answer 21

To provide optimal arch alignment prior to bone grafting

Question 22

When is secondary alveolar bone grafting done?

Answer 22

Secondary alveolar bone grafting is performed after dental alignment and maxillary arch expansion

Question 23

What is done to retained primary dentition adjacent to the cleft prior to the bone grafting?

Answer 23

Retained primary dentition adjacent to the cleft are extracted at least 4 weeks before bone grafting to allow for adequate healing of keratinized mucosa

Question 24

How are periodontal and gingival tissues maintained in optimal condition before alveolar bone grafting?

Answer 24

Periodontal review and work-up to ensure gingival tissues are in optimal condition leading up to ABG, this includes regular use of chlorhexidine oral gel and mouthwash.

Question 25

What factors are considered prior to alveolar bone grafting?

Answer 25

Before secondary alveolar bone grafting we must ensure correct alignment of teeth

Removal of retained primary dentition to ensure adequate healing of keratinized mucosa.

Periodontal and gingival health in optimal condition.

Question 26

Where does bone come from for the alveolar bone graft?

Answer 26

ABG surgery conducted by means of iliac crest autogenous bone grafts in the majority of cases

Question 27

What should be done post op after alveolar bone grafting?

Answer 27

Strict post-op oral hygiene and perio maintenance

Post op clinical and radiological evaluation

Recommencement of ortho treatment approx 6 weeks after surgery