Beruflich Dokumente
Kultur Dokumente
PALATE
Presented by:
Khushbu Agrawal
Dept of Orthodontics
CONTENTS
Introduction
Incidence
Embryology
Aetiology
Predisposing factors
Classification
Diagnosis
Problems associated with clefts
Syndromes associated with clefts
2
Management of Cleft lip and palate
• Timing of treatment sequence
• Presurgical Orthopedic treatment
• Nasoalveolar molding
• Alveolar Bone grafting
• Role of Orthodontist
• Orthognathic surgery
• Prosthetic rehabilitation
• Recent advances
• Other specialities
Conclusion
References
3
INTRODUCTION
4
• Hippocrates (400 BC) and Galen (150 AD) mention cleft lip, but not
cleft palate in their writings
5
Kingsley (1880)
- oral deformities as a branch of mechanical surgery
H.K.Cooper,Sr (1930’s)
- Introduced the integrated team concept and formed the Lanchester
cleft palate clinic
- True integration starts with a meeting of the minds of the individuals
who first examine the patient together and then agree on a program
together
6
INCIDENCE
INCIDENCE
• Worldwide one in 600 (1:600)
• Birth prevalence of clefts between 27,000 and 33,000 clefts per year
Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189.
• Caucasian population, the prevalence of CL was 25%, CLP 50%,
and CP 25%
• In India alone the number of infants born every year with CLP is
28,600
78 affected infants are born every day, or 3 infants with clefts born
every hour
9
Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189.
• More common clefts are –
• Unilateral clefts
• Left sided
10
Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189.
EMBRYOLOGY
EMBRYOLOGY
• Development of facial structures starts at the end of 4th week
12
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
• In following 2 weeks –
• The 2 medial nasal processes fuse in midline – upper lip
13
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
• The maxillary and lateral nasal process separated by nasolacrimal
groove/duct
14
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
• Primary palate – maxillary and medial nasal process merge
15
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
16
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
• Secondary palate – formed from 2 outgrowths from maxillary
prominences – palatine shelves
17
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
Formation of clefts
18
Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
Formation of clefts
19
20
ETIOLOGY
AETIOLOGY
Ancient Folk explanations
• Aztecs – eclipses occurred because a bite had been taken
out of the moon
22
Early Chinese
• Eating rabbit “hare lip”
• Bad karma or wrong doings
Philippines
• Force to the fetal face
23
Genetic
Environ
mental
Multi
factorial
24
1] Genetic
2. Single gene
4. Mitochondrial
25
John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
2] Multifactorial because:
26
John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
2 unaffected parents with 1 child affected
Risk for future children:
4.4% for CL+/-palate
2.5% for CP only
1 parent affected
Risk for future children
3.2% for CL+/-palate
6.8% for CP only
1 parent affected with 1 child affected
Risk for future children
15.8% for CL+/-palate
14.9% for CP only
27
3] Environmental factors
• Viral infections
• Poor nutrition
• Teratogens like:
Rubella virus, Cortisone/ steroids, Mercaptopurine,
28
Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85
PREDISPOSING FACTORS
High maternal age
Diabetes
Toxemia
Reduced blood supply
Folic acid deficiency
Racial – mongoloids
Radiations
29
Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85
CLASSIFICATION
CLASSIFICATION
Bixler divided oral clefts into three groups
2. Familial
25% of CLP and 12% of isolated cleft palate
3. Isolated / non-familial
75% of CLP and 80% of isolated cleft palate
31
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Davis and Ritchie’s classification (1922)
32
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Group III: Alveolar process cleft (any cleft involving the alveolar
process)
1. Unilateral (right/left: complete/incomplete)
2. Bilateral (right: complete/incomplete; left: complete/incomplete)
3. Median (complete/incomplete)
33
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Victor Veau’s classification (1931)
A] Cleft lip
Class I : U/L notching of vermillion border, not extending into the lip.
Class II : cleft extending into the lip, but not including the floor of the nose.
Class III: extending into the floor of the nose.
Class IV: any b/l cleft of the lip, whether incomplete or complete.
34
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
35
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
B] Cleft palate
36
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
37
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Fogh-Andersen’s classification (1942)
38
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Kernahan and Stark’s classification (1958)
39
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
American Cleft Palate–Craniofacial Association (ACPA)
classification (1962)
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
3. Clefts of the prepalate and palate (alveolocheilopalatoschisis)
41
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Kernahan and Stark’s stripped Y classification (1971)
42
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Spina’s classification (1973)
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
Kernahan and Stark’s
stripped-Y:
Modification by Ehlsaky
(1973) and Millard
(1976)
44
Schuchardt and Pfeifer’s symbolic classification
left Right
Lip
Alveolus
Hard palate
Partial
Soft palate
Total cleft
45
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
LAHSHAL classification by Okriens (1987)
46
Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
DIAGNOSIS
DIAGNOSIS
• Prenatal ultrasound – 2D or 3D
• Prenatal counselling
48
Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
Ultrasound technique
49
Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
Transabdominal US
- Not reliable till gestational age of 15 weeks
- Done at 20 or more weeks of gestation
Transvaginal USG
- Earlier visualization (12 weeks)
- Better image resolution
- Greater specificity and sensitivity
50
Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
Babcock and McGahan (1997)
51
Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
Advantages of prenatal cleft diagnosis
52
Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
Disadvantages of prenatal cleft diagnosis
- Emotional disturbance
- Termination of pregnancy
53
Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
PROBLEMS ASSOCIATED
WITH CLEFT LIP & PALATE
Dental
Skeletal
Nasal
Feeding
Ear problems
Speech
Associated anomalies
55
*Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20
DENTAL
Crossbites
Taurodontism, dilacerations
56
*Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20
SKELETAL
Maxillary deficiency
Mandibular prognathism
Concave profile
57
*Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara, Dental Anomalies of Number in The Permanent Dentition of Patients
With Bilateral Cleft Lip: Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476.
FEEDING PROBLEMS
Oronasal fistulas
58
SYNDROMES ASSOCIATED
WITH CLEFT LIP & PALATE
SYNDROMES
Around 400 syndromes
Chromosomal anomalies
• Trisomy 13 (Patau)
• Trisomy 18 (Edward)
• Trisomy 21 (Down’s)
60
*Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
Inherited syndrome
• Sticklers (Autosomal dominant)
Non-inherited syndrome
• Pierre Robin Syndrome – triad of cleft
palate, glossoptosis, retrognathia
• Goldenhar syndrome
61
*Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
Teratogenic
• Fetal alcohol syndrome
62
*Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
MANAGEMENT OF CLEFT LIP
& PALATE
MULTIDISCIPLINARY MANAGEMENT
Dentist
ENT/
Surgeon
audiologist
Speech
Nursing
therapist
CLEFT
TEAM
Paediatrician Genecists
Psychologi Social
st worker
Ophthalmol
ogist 64
TIMING AND SEQUENCING OF CONSERVATIVE
SURGICAL-ORTHODONTIC TREATMENT (1980s)
65
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
66
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
Philadelphia Centre for research in Child growth-
Wilton Krogman (1947-71)
67
• Second stage – at birth
Pediatrician discusses the condition with the parents,
Surgeon carries out the closure of the hard palate 1:2 soft palate 1:6
69
• Sixth stage – 6-12 years
Surgical corrections - secondary closure /repair of palate, lip and the nose
70
Cleft Lip and Palate Patients Management in OSLO-
Norway (1948)
1. No preoperative orthopedics.
71
FISHMAN
72
PROFITT
73
74
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
Neonatal • Birth to 1 year
Deciduous • 1 to 6 years
dentition
Mixed • 6 to 12 years
deentition
Permanent • 12 years
dentition and adult
75
NASOALVEOLAR MOULDING
76
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• Grayson (1993) – first technique to correct the alveolus, lip and
nose in cleft infants
• Matsuo (1988)
- Research for cartilage moulding
77
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• Matsuo used a stent, silicone tubes to shape the nostrils
• Grayson (1999) adapted his nasal stent to extend from the anterior
flange of an intraoral molding plate.
78
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
Objectives:
• Reduction in the width of the alveolar cleft segments until passive contact
of the gingival tissues is achieved.
79
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
Procedure:
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• Prashanth (2013), Mishra (2010) obtained impression when the infant
was awake in a prone position on the dental chair, the child is held
on the lap of their parents with no anesthesia.
• Dubey (2011) made impression of the cleft region upper arch using
ice cream stick and impression compound.
81
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• Plate – clear self-cure acrylic, trimmed with a denture soft material
• 2–3 mm in thickness
82
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• The nasal stent is added to the intraoral molding plate when the
cleft alveolar gap is reduced to 5mm or less
83
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• Elastics used are 0.25 inch and it should be stretched about two
times the diameter for activation force of about 2 Oz
84
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
85
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
Complications and disadvantages:
86
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
Benefits:
• Short-term: the tissues are well aligned prior to primary lip and nose
repair
• Long-term:
• change in nasal shape is stable
*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
CLEFT LIP REPAIR
• Timing: 3 to 6 months
• 10 pounds (weight)
• 10 gm/dl (Hb)
88
Techniques:
89
PRESURGICAL ORTHOPEDIC TREATMENT
90
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
1920s -1930s – repair the defect by establishing an anatomical
continuity
Priority of treatment
- Improve speech ability
- Dental function
- Facial aesthetics
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
1950s – Two schools of thoughts
• Led by Pruzansky
Immediate • Did not favour PSOT
surgery • Palatal closure at 2-4 years of age
92
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
A Millard-Latham Procedure
93
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
Modified appliance – a premaxillary stainless steel
pin 7/10 mm in diameter is inserted through the
posterior stem of the premaxilla.
94
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
CHANGING SURGICAL CONCEPT FROM 1920S TO
1950S
95
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
• Graber, Slaughter and Brodie (1950s-1960s) – negative reports on
surgical procedure done at an early age
96
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
• Melvin Moss (1968) – functional matric theory – septal cartilage
grows as a secondary response
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
CLAIMED BENEFITS OF PSOT
98
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
• Berkowitz (1978) – “State of art”
99
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
CONSERVATIVE TREATMENT – THE BEST APPROACH
100
*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184
CLEFT PALATE SURGERY TIMING AND SPEECH
OUTCOME
1970s
*Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191
1980 – 1990s
• Ross (1987) – slightly better facial growth if surgery done in the first
year of life
102
*Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191
SURGERIES FOR CLEFT PALATE
1. Von Langenback
3. Furlow’s technique
103
BONE GRAFTING FOR ALVEOLAR CLEFT
DEFECTS
BONE
GRAFTING
Primary Secondary
bone bone
grafting grafting
*Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
OBJEVTIVES FOR SURGICAL GRAFTING:
• Stabilization of segments
105
*Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
BONE GRAFTING AND ORTHODONTIC TOOTH MOVEMENT
106
*Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
SURGICAL MANAGEMNT OF ALVEOLAR CLEFT
• Ideal timing:
- 9 to 11 years of age
- Before canine eruption, canine root is 1/3rd formed (Bergland et al)
107
*Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
108
ROLE OF ORTHODONTIST
109
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
A] NEONATAL MAXILLARY ORTHOPAEDICS
110
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
B] ORTHODONTIC-ORTHOPAEDIC TREATMENT IN DECIDUOUS
DENTITION
- Functional shift
111
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204
• Turvey (1982) believe that orthodontic treatment in the deciduous
dentition, although possible, is contraindicated
112
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
C] ORTHODONTIC TREATMENT DURING THE MIXED DENTITION
• Bone grafting:
• 5 to 6 years of age
113
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204
• Orthodontics – 6 months before grafting
114
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
Expansion appliances for cleft palate patients:
7. Quad helix
115
Protraction Facemask Therapy:
• 12-15 months
116
D] ORTHODONTIC TREATMENT DURING THE PERMANENT
DENTITION
117
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
TREATMENT BY ORTHODONTICS ALONE
1. Tooth alignment
118
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
TREATMENT BY ORTHODONTICS COMBINED WITH
ORTHOGNATHIC SURGERY
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
• Unilateral clefts – 2 piece Le Fort I osteotomy
120
*Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14
• Bilateral clefts – 3 piece Le Fort I osteotomy
121
*Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14
• Post-surgical orthodontic – 4 to 6 months
122
*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
PROSTHETIC REHABILITATION FOR CLEFT PALATE
PATIENTS
123
*Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19
Restorative treatment options in permanent dentition
• Partial overdenture
• Implant prosthodontics
124
*Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19
VELOPHARYNGEAL IMPAIRMENT
125
1. Speech therapy
• Obturators
3. Surgical
126
*Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19
RECENT ADVANCES
• Non-life threatening defects like cleft lip, cleft palate, Pierre Robin
syndrome, Treacher-Collins syndrome, craniofacial microsomia
• Feto-endoscopic approach
127
*Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607
ADVANTAGES
128
*Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607
CONCLUSION
• Oral clefts are the second most common congenital anamoly, having
multifactorial origin
129
CONCLUSION
• Role of orthodontists
130
REFERENCES
• Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra
Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–9.
• Allori AC et al. Cleft lip and palate classification: Then and Now. Cleft
Palate–Craniofacial Journal 2016;53(1)
• Graber Vanarsdall and Vig. Orthodontics: Current Principles and
Techniques. Elsevier 2012.
• John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification,
etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
• Inderbir Singh. Human embryology. Macmillan India. Seventh edition 2001.
• Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85
131
REFERENCES
1. Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
2. Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate
Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20
3. Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara,
Dental Anomalies of Number in The Permanent Dentition of Patients With Bilateral Cleft Lip:
Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476.
4. Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
5. Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate
Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod
1996;2:169-184
6. Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech
Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod
1996;2:185-191
132
7. Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
8. Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-
196
9. Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-
204
10. Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod
1996;2:205-14
11. Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod
1996;2:215-19
12. Dalston R. Velopharyngeal Impairment in the orthodontic patients. Semin Orthod
1996;2:220-7.
13. Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new
perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607
14. Chang J. Fetal plastic surgery: a review and preview. © Chang www.thefetus.net/
133
THANK YOU
THANK YOU
134