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CLEFT LIP,CLEFT PALATE AND MAXILLARY

SINUS-PART 2

Presented by-
Dr. AKASH RAUT
MDS 1st year 2
 CONTENTS

• Treatment plan
• Obturators
• Maxillary Sinus
• Conclusion
• References

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•Cleft lip and palate requires careful planning as it
should take into account all factors involved in total
health care.

•It requires a multidisciplinary approach.

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 Multidisciplinary cleft lip and palate
team
• Children born with cleft lip and palate have many
problems that need to be solved for successful
habilitation. The complexity of these problems
requires that numerous health care practitioners
cooperate in providing the specialized knowledge and
skills necessary to ensure comprehensive care. The
multidisciplinary cleft lip and palate team concept has
evolved from that need.

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MUTIDISCIPLINARY TEAM FOR CLEFT
MANAGEMENT

• I. DENTAL SPECIALITIES
1.Prosthodontist 2.Orthodontist
3.Oral surgery 4.Pedododontist
• II. MEDICAL SPECIALITIES
1.Plastic surgeon 2.Genetic
3.Psychaitry 4.Pediatrician
5.Otolaryngologist
• III. ALLIED HEALTH CARE FIELDS
1.Audiologist 2.Psychologist
3.Speech therapist 4.Nurse
5.Social Worker
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• Prosthodontist are one of member of multi
disciplinary cleft team.
• In the care of patient with cleft lip and palate
prosthetic treatment retains an important place.
• Prosthodontist must be able to diagnosis the
defect and provide a preventive, interventional
and rehabilitative treatment to reduce the
impact of the defect in patient quality of life.

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 TREATMENT PLAN

• Sequence of cleft treatment : The comprehensive

treatment of cleft patients

• Divided into 4 stages:

1.Maxillary Orthopaedic Stage
2.Primary Dentition Stage
3.Mixed Dentition Stage
4.Permanent Dentition Stage

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 Stage 1 : Maxillary Orthopaedic Stage

This lasts from birth to 18 months.

It includes management of feeding problems by
fabrication of feeding obturators, plate, nipples, pre-
surgical orthopaedics , surgical management of cleft lip
and surgical management of cleft palate

• Subdivided into 4 stages:

• Initial Obturator therapy
• Pre-surgical orthopaedics
• Surgical lip closure
• Surgical palatal repair
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• I. Initial Obturator Therapy (0-3 months):

• Appliance fabricated after making impression and

made of acrylic .

• It should be cleaned before and after each feed .

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• II. Pre-Surgical Orthopaedics (0-5months):

• Aim of this is to achieve upper arch form

that conforms to lower arch.

• Very anteriorly placed premaxilla presents

difficulty in surgery, the defect is corrected
first by retraction plate or pre-maxillary
retraction tape .

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• III. Surgical Lip Closure (3-9 months) :

• Best time for lip repair as it is not fully developed .

• Rule of 10 is an important criterion.
-Age > 10 week
-Hb > 10gm%
-Wt > 10 pounds

• Types of lip repair

-Millard repair
-Veau repair
-Tennison-Randall repair
-Rose Thompson repair
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• IV. Surgical Palate Repair (10-18months):
Repair of Palate
Too Early Too Late

Esthetics Esthetics
Growth Growth

• 2 Types of palatal repair:

• 1.Single step repair- Von Langenback repair and V Y pushback

palatoplasty. Done at 1½ year of age.

2.Two-stage repair: soft palate repaired at

18 months and hard palate at 4 years by
Schweckendiek procedure
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 Stage 2 : Primary Dentition stage

• 18 months to 5 years
• Includes-
1. adjustment of obturators
2. restortation of decayed teeth
3. maintanance of oral hygiene
4. evaluating the erupting dentition.

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• Treatment during the primary dentition stage of dental
development is initially focused on establishing and
maintaining oral health.
• Special care should be taken to keep these teeth free
from caries because food is often lodged in and around
the cleft defect
• An increase in the frequency of periodic recall
examinations, possibly to 3- to 4-month intervals,
enables the dentist to intercept areas of
decalcification.
• This preventive regimen is continued throughout all
subsequent stages in the management of the cleft.

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 Stage 3 :Mixed dentition stage :
• 6 to 10 years of age
• The main problem encountered due to ectopic
eruption and malalignment .

• The procedures in this stage are : 1

1. Correction of cross-bite
2. Maxillary expansion
3. Secondary Grafting
2

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 Stage 4:Permanent Dentition

• 12 to 18 years of age
• During this stage the patient can be treated in
conventional manner.

• The treatment undertaken during this stage are

mainly fixed orthodontic treatment , correction of
skeletal and dental irregularities and cosmetic
repair.

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 PROSTHESIS INDICATIONS

IN UNOPERATED CASES OPERATED

CASES
1.Wide clefts with deficient soft palate 1. Patient with
2. Wide cleft of hard palate hyper nasality and
inadequate speech
3. Neuromuscular deficiency of soft
following push back
palate and pharynx
and pharyngeal flap
4. Patient at high anesthetic risk procedures.
5. Delayed surgery approach planned
(Zurich Approach)
6. Case Where combined prosthetic +
orthodontic appliance like expansion
prosthesis are to be used improve spatial
relations prior to surgery
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 PROSTHESIS CONTRAINDICATIONS

1- When surgical repair is feasible and when

surgical repair or closure of cleft will produce
anatomic and functional repair.
2- Mentally retarded patient incapable of
controlling and maintaining appliances.
3-Uncooperative patients.
4-Rampant caries and periodontal breakdown
situations
5-Experienced prosthodontist unavailable.

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 PROSHETIC TREATMENT OF CLEFT
PALATE PATIENTS

Pre – Surgical Intermedia Post-

Surgical te Surgical
Feeding aid Splints Obturators SpeechAids

Latex Stents
obturator
Acrylic Temporary
Obturator obturators

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 IMPRESSION TECHNIQUE

•The most important part of the oral rehabilitation

of a patient with cleft lip and cleft palate is the
impression making procedure.

•The making of the impression in an infant with a

cleft palate is a critical procedure.

•For an accurate and safe impression procedure, a

proper patient and dentist position are vital.

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• As soon as possible (usually within 2
weeks of birth), an impression is made of
the infant’s maxillary arch.

• Before taking impression, appropriate

emergency equipment, including forced
oxygen, suction, and standard airway
management equipment, should be
available.

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 OBTURATOR

• Obturator-latin verb,obturare- to close or shut off

• A maxillofacial prosthesis used to close a

congenital or acquired tissue opening, primarily of
the hard palate and/or contagious alveolar /soft
tissue structures(GPT-9)

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 CLASSIFICATION OF OBTURATORS

• ACCORDING TO RAHN AND BOUCHER

• A)The origin of Discrepancy :

• a. Congenital defect obturator

• b. Acquired defect obturator

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• B)The location of the defect

• a.Labial or buccal reflex obturator

• b.Alveolar Obturator

• c.Hard Palate Obturator

• d.Soft Palate Obturator

• e.Pharyngeal Obturator

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• C)The type of obturator attachment to the basic
maxillary prosthesis

• a.Fixed obturator

• b.Hinged or movable obturator

• c.Detachable obturator

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• D) The physiologic movement of the oral, nasal
and pharyngeal tissues adjacent to or functioning
against the obturator

• a. Static Obturator

• b. Functional Obturator

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 TYPES OF OBTURATORS
1. Fixed Pharyngeal (Suerson 1868)
• Extension of denture projecting into the pharynx at
about the level of the anterior arch of atlas & shaped
so it can be gripped by the pharyngeal wall
• Placed in fixed position within pharynx at site of
maximal muscle activity.
• most commonly used.

Palatal
extension
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2. Hinge Pharyngeal ( Delabarre & Snell 1820s)
• Pharyngeal section attached to posterior border of
denture by a hinge & its lateral borders are shaped to
be gripped by the remnants of the soft palate & be
raised and lowered with them.
-Relies on activity of superior pharyngeal constrictor.

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• 3. Meatal (Schalit 1946)
- Extension of back of the denture , upwards at
right angles to denture so that it occludes
opening of posterior nares
- provides only static obturation & not
dependent on surrounding muscle activity
-obturator of choice when retention is a problem

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 FEEDING APPLIANCE

 An ancilliary prosthesis that closes the oral nasal

cavity , thus enhancing sucking and swallowing
 maintains the right and left maxillary segments
of infants with cleft palates in their proper
orientation until surgery is performed to repair
the cleft (GPT- 9)

Palatal plate on master Palatal plate with

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cast thread
• It facilitates feeding by –
• Reduces the nasal regurgitation .
• Reduces the incidence of choking and shortens
the length of time required for feeding.
• It restore the basic function of mastication ,
Deglutition , speech production until cleft lip
or palate can be surgically corrected.

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 FEEDIND PLATE

Intraoral view Extraoral view

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 SPEECH AID PROSTHESIS

• A removable maxillofacial prosthesis used to restore

an acquired or congenital defect of the soft palate
with a portion extending into the pharynx to separate
the oro-pharynx and naso-pharynx during phonation
and deglution , thereby completing the palato-
pharyngeal spincter .(GPT-9)

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 PALATAL LIFT PROSTHESIS
Gibbons and bloomer(1958)

A maxillofacial prosthesis that elevates the soft

palate superiorly and aids in registration of soft
palate functions that may be lost because of an
acquired ,congenital or developmental defect.
(GPT-9)
Definitive palatal lift prosthesis is usually made for
patients whose experience with diagnostic palatal
lift prosthesis have been successful.

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 MAXILLARY SINUS
Introduction
• Paranasal air sinus are air containing bone spaces
around the nasal cavity and lined by respiratory
membrane.
• 4 paired (bilateral) sinuses
• Maxillary
• Frontal
• Ethmoidal
• Sphenoidal

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MAXILLARY SINUS

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Also called the Antrum of Highmore OR Sinus
maxillaris.

Anatomic space located superior to posterior

maxillary alveolus.(GPT-9)

Is the pneumatic space that is lodged inside the body

of the maxilla and that communicates with the
environment by way of the middle nasal meatus and
nasal vestibule.

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DEVELOPMENT OF MAXILLARY SINUS

• Development of sinus starts at 12 weeks of IU life

• The maxillary sinus is the largest paranasal sinus and

lies inferior to the eyes in the maxillary bone.

• Filled with fluid at birth.

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 It grows according to a triphasic pattern in which

first phase -0 to 2.5 years

second phase-7.5 to 12 years
third phase -12 to14 years

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• The earliest phase of pneumatization is directed
horizontally and posteriorly, whereas the later phase
proceeds inferiorly toward the maxillary teeth.

• This development places the floor of the sinus well

below the floor of the nasal cavity.

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Pneumatization is enlargement of sinus by resorption
of alveolar bone that formerly served to support a
missing tooth or teeth and then occupies the
edentulous space.. A thin cortex remains over the
alveolar ridge to maintain normal contour

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 EMBRYOLOGY

• Horizontal shift of palatal shelves, fusion of shelves

with each other and with nasal septum separates
secondary oral cavity from two secondary nasal
chamber
• Influences expansion of lateral nasal wall(wall begins
to fold)
• This give rise to 3 chonchae and 3 subjacent meatuses.
• Superior and inferior meatuses remain as shallow
depressions along lateral nasal wall for first half of
IUL
• Middle meatus expands immediately into lateral nasal
wall. 44
• The course of development :-
1.Tubular at birth
2.Ovoid at childhood
3.Pyramidal in adulthood

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 ANATOMY
• Size :height-3.5cm ,width-
2.5cm ,depth(anterioposterior) -3.5cm
• Four sided pyramid
-Anterior
-Posterior
-Superior
-Inferior
• Base: formed by inferior part of lateral
wall of nasal cavity(medially)
• Apex: towards zygomatic bone(laterally)
• Roof :floor of orbit
• Floor :alveolar process of maxilla
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 BLOOD SUPPLY

Nerve Arterial Venous Lymphatic

Supply Supply Drainage Drainage
1. Anterior,mid 1. Infra – 1. Pterygoid plexus 1. Sub-
dle, posterior orbital of veins Mandibular
superior Artery 2. Facial Vein Lymph
alveolar 2. Facial artery Nodes
nerves. 3. Greater 2. Deep
2. Infra – orbital palatine cervical
Nerve arteries lymph
nodes

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 EPITHELIUM
• Pseudo stratified columnar ciliated
epithelim(schniderian membrane)
• Cells – Columnar ciliated cells
Goblet
Basal
Non-ciliated

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 DRAINAGE OF SINUS
• Mucous transported from nose and pns
to nasopharynx.
• Ingested and presented to GIT

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 FUNCTIONAL IMPORTANCE
• Warming and humidification of air.
• Contribution to olfaction.
• Lightening of skull.
• Resonance of voice.
• Assistance in regulation of IC pressure.
• Enhance facio-cranial resistance to shock
• Production of bactericidal lysozyme.

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CLINICAL EXAMINATION
INSPECTION :
•Middle third of the face should be inspected for the
presence of
asymmetry, deformity, swelling, erythema , ecchymosis or
hematoma.
EXTRAORAL PALPATION :
Include palpation of the facial wall of the sinus above the
premolar where the bone is thinnest.

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 APPLIED ANATOMY
• Teeth with roots in close approximation to sinus-
maxillary 2nd molar followed by maxillary 1st and 3rd
molar.
• Unerupted tooth in maxillary tuberosity –potential
line of weakness.
• Acute sinusitis-pus formed inside antrum increases
intra antral pressure,inflammation,occlusion of lining
mucosa,compression of nerves.
• Periapical infection of tooth in close relation to
antrum –oroantral fistula.
• Any tumor of sinus may present as swelling of
cheeks,palate ,buccal mucosa.
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• Excessive tumor development,involving orbit-alterations in pupil and
strabismus with diplopia.
• Wall of sinus very thin in canine region-diagnostic aspiration(cad well
luc operation)
• Fractures of middle third of face-fracture of sinus
• Sinus grafting is usually required before or in conjunction with implant
placement to gain adequate bone height for implants of adequate length
in this region.
• Procedures such as sinus lift procedure can be made use of .

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 RADIOLOGICAL FEATURES

• IMAGING TECHNIQUES-
• Conventional-IOPA,Waters view
• Specialized-Orthopantomogram
• Advanced-CT scan,MRI scan

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 DISEASES
• Maxillary sinusitis-inflammatory
acute
subacute
chronic
odontogenic
• Oroantral fistula
• Traumatic haematoma
• Iatrogenic-tooth or root displaced into sinus
• Tumor-carcinoma of maxillary sinus
• Antral rhinoliths
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 2)Overextention of dental
1)A root tip of the maxillary
material like sealers,
first molar accidentally
cements ,Gp or silver
pushed into the sinus at the
cones
time of tooth extraction.

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3)Oro-antral communication
 MANAGEMENT
• Oroantral fistula -flaps
gold foil
polyglycolic acid or vicryl mesh
cadwell luc operation
• Traumatic haematoma-neo-synephrine 0.25%
surgery
oxified cellulose
• Tooth displaced into sinus- powerful suction
packing of roller gauge
surgical approach
• Antral rhinoliths-surgical
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 CONCLUSION

 Rehabilitation of the congential cleft palate patient may

be successful only if a warm, sympathetic approach is
made towards the patient by team of specialists
familiar with the possibilites and limitations of
medical,surgical,phonetics,pyschological,dental and
prosthetic therapy.
 A prosthodontist plays a vital role and works hand in
hand with various specialists to provide the best
possible treatment line with a single minded approach
to minimize the physical,social and emotional hardship
of a person with an orofacial cleft .

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It is not mere survival from disease alone but a return to
normal functioning life is a goal
When nature has provided insufficient tissue for successful
surgical closure, the prosthesis becomes the method of choice.
Many cleft patients with deficient maxillary development find
that the speech appliance combined with an anterior denture
enables them for the first time in their lives to speak
intelligently, to eat normally and to have an esthetically
acceptable appearance

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 REFERENCES

• John Beaumer111,Mark T Marunick,Salvatore

J.Esposito,Maxillofacial Rehabilitation 3rd edition
• Nikhil Marwah,Textbook of pediatric dentistry,3rd
edition
• GS Kumar,Orbans Oral Histology and
Embryology,12th edition
• BD Chaurasia’s,Human Anatomy,5th
edition,volume1
• S M Balaji,Textbook of oral and maxillofacial
surgery
• S.I Balajhi,Orthodontics,The Art and Science,6th
edition 62
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