21: Cleft lip and palate

21 Cleft lip and palate

Summary

Karen, a 9-year-old girl, is unhappy about the appearance of her teeth (Fig. 21.1). What is the cause and how will it be treated?

image

Fig. 21.1 Anterior occlusion at presentation.

History

Complaint

Karen does not like the crookedness and spacing of her upper front teeth. Her mother is aware that the bite of Karen’s side teeth is not correct also and feels that she moves her jaw to the side when she closes her teeth together.

History of complaint

Karen’s baby front teeth were also crooked and spaced. Her mother has noticed the problem with her bite for several months.

Medical history

Karen was born with a cleft lip and palate, which has been repaired.

Family history

There is no family history of cleft lip and palate.

image What is the prevalence of cleft lip and palate?

It affects about 1 in 750 live births among Caucasians but the prevalence varies between racial groups as well as geographically, and is increasing. Cleft lip only is found in about 9% of all clefts whereas cleft of the lip and alveolus comprises about 3% of all clefts. Complete unilateral cleft lip and palate is the most common type of cleft and represents 50% of all clefts.

image Is there a sex and side variation for cleft lip and palate?

Females are affected less frequently than males and the right side is involved less commonly than the left.

image How does this malformation occur?

Failure of fusion of the median and lateral nasal processes and the maxillary process at about 4–6 weeks of intrauterine life leads to a cleft of the primary palate (the upper lip and the alveolus in the anterior region as far posteriorly as the incisive foramen). Cleft of the secondary palate (hard palate from incisive foramen back and soft palate) is due to failure of the palatal shelves to elevate and fuse at about 8 weeks.

Genetic and environmental factors, e.g. steroid therapy, folic acid deficiency or anticonvulsant drugs, interact in the aetiology.

Key point

Cleft lip and palate:

• Prevalence 1 in 750 live Caucasian births.
• Aetiology due to genetic and environmental factors.

Karen has been attending a cleft clinic at the regional dental teaching hospital since birth.

image Why is this? What treatment will have been provided to date and what role have you to play as her general dental practitioner?

Due to the multidisciplinary care required, treatment is facilitated for the patient and family by coordinating management in a specialized centre by a team comprising an orthodontist, speech therapist, health visitor and clinical psychologist as well as plastic, ENT and maxillofacial surgeons.

Treatment until now is likely to have been as follows.

Neonatal period to 18 months

Parental counselling by a member of the Cleft Lip and Palate Association and /or clinical psychologist as well as reassurance of the future treatment by an orthodontist and member of the surgical team.

Advice and support to the parents by a specialized health visitor, particularly in relation to feeding. In this case, feeding problems are likely to have been modest as the cleft only involves the primary palate.

Planning of lip repair: this usually occurs at 3 months. In this case, closure of the alveolar defect may be undertaken at the same time. Where a palatal cleft exists, on average, this is repaired at around 9 months.

Primary dentition

First formal speech and hearing assessment at around 18 months and then speech therapy as required.
Regular speech and hearing assessments should be undertaken; consider closure of any palatal fistulae to assist speech development. Consider pharyngoplasty to reduce velopharyngeal incompetence at 4–5 years, thereby attempting to improve any nasal intonation to speech.
Consider lip revision at 4–5 years only if clearly indicated.

As a general dental practitioner your role is to:

Liaise with the cleft palate team.
Provide dietary advice and oral hygiene instruction to the parents, at regular intervals, from eruption of the primary incisors.
Consider the use of fluoride tablets if the level of fluoride in the local domestic water supply is below 1 ppm.
Attend to any dental treatment required.
Your particular aim in dental care is to promote and maintain excellent dental health for Karen, thereby avoiding the need for restorative treatment or enforced loss of primary teeth through dental caries.

Key point

Management of cleft lip and palate requires a team approach.

image What skeletal/dental/occlusal problems are commonly found with cleft lip and palate?

Skeletally, there is a tendency for the maxilla and mandible to be retrognathic, the upper facial height to be reduced and the lower facial height to be increased. A Class III skeletal pattern is common.
On the cleft side, 2 is either absent, of abnormal size and/or shape, hypoplastic or as two conical teeth on either side of the cleft.
A supernumerary or supplemental tooth may exist on either side of the cleft.
1 is often rotated and tilted toward the cleft and may be hypoplastic.
Eruption is delayed.
Tooth size elsewhere in the mouth is small.
Class III incisor relationship is common with crossbite of one or both buccal segments and a lateral open bite on the/>

Related posts:

  1. 27: Facial swelling and dental abscess
  2. 39: Gingival bleeding and enlargement
  3. 3: Absent upper lateral incisors
  4. 6: Palatal canines
  5. 30: The fractured permanent incisor root
  6. 38: Dentinogenesis imperfecta

Stay updated, free dental videos. Join our Telegram channel
Tags:
Jan 2, 2015 | Posted by in Orthodontics | Comments Off on 21: Cleft lip and palate

VIDEdental - Online dental courses
Get VIDEdental app for watching clinical videos