Cleft Lip and Palate Flashcards by Zach Geddes

What is cleft palate?

CP- cleft goes through soft and hard palate
 Issues with speech but no dental impact generally

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What is cleft lip?

A cleft which involves lip and may or may not involve palate

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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

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What proportion of CLP is made up by unilateral?

80%

-> Bilateral have bigger growth deficiency, speech/dental issues

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How do cleft lips form?

Premaxilla attaches to nasal septum and everts/rotates out without attachment

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How common is cleft lip and palate

1:700 live births

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What is meant by sporadic in CLP?

No obvious aetiology

-> This makes up for 70% of cases

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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

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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

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What are the environmental factors involved in aetiology of CLP?

Smoking

Alcohol

Social deprivation

Anti-epileptics

Multi-vitamin use

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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

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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

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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

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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

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Who are the members of the cleft care team in Scotland?

Surgeons
Cleft nurses
Dental team
Psychologist
ENT respiratory doctor
Speech therapist
Geneticist

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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)

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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