Cranio-Maxillo-Facial

Caranial & Facial Birth Defects
Temporo-Mandibular Joint Ankylosis

Cranial and Facial Birth defects

Cranio-Facial Microsomia

Cranio-facial microsomia has a wide clinical presentation, varying in extent, degree and combination of deformities of the jaws, ears, soft tissues of the face and the central nervous system.. It involves, to a variable degree, all the structures derived from the first and second Branchial Arches and the Otic Capsule. The primary deficiency of soft tissues and bones produce secondary effect on adjacent and otherwise normal structures and all this together adds up to the clinical picture.

Alveolar & Anterior Palatal Clefts

Alveolus is the trough that contains tooth buds. Cleft of primary palate extend  from incisive foramen to anterior surface of the lip. It crosses the alveolus between lateral incisor if present and canine.

Effect of Cleft Lip on Alveolus 

• Palatal segments are laterally displaced because of

  –    pull of aberrantly attached orbicularis oris muscle

  –    protrusion of tongue 

Effect of Lip Repair on Alveolus

• Palatal segments move together - molding

• Alveolar cleft reduces

• Three potential arch forms

  –    palatal segments approximate

  –    larger segment overlaps smaller segment

  –    segments move together but fail to make contact because of premature contact of inferior turbinate and nasal septum. 

Alveolar cleft - why close it?

• Why should we attempt to close the cleft if

  –    there is a satisfactory lip repair aesthetically

  –    there is understandable speech

  –    prosthetic dentistry can bridge the gap satisfactorily 

Alveolar cleft - when close it?

• In neonates - with lip repair

  –    interferes with mid face development

• In adults

  –    lack of support to adjacent  permanent teeth

  –    orthodontic closure

• Between 8 to 11 years 

Clinical problems

• Instability of maxillary segment

• Tendency of relapse after orthodontic treatment

• Need for fixed elaborate bridges

• Persistent oro-nasal fistula

• Nasal asymmetry

Rationale of closure of alveolar cleft

• To provide stability to the maxillary arch

• To close oro-nasal fistula and ant. palatal clefts

• To provide better periodontal support for teeth bordering the cleft

   1. To provide stability to maxillary arch

• Particularly in bilateral clefts with mobile premaxilla

• Prevents collapse of minor segment in unilateral clefts

• For future Lefort I advancement the maxilla is in one piece 

  2. To close oro-nasal fistula and anterior palatal clefts

• Brings bone graft on Pyriform rim which

  –    provides better platform for alar base

  –    improves nasal symmetry

  –    prevents inf. turbinate prolapse into the cleft

• Prevents irritating nasal regurgitation of fluids 

  3. To provide better periodontal support for teeth adj. to the cle

• Creates bony matrix through which teeth erupt

• Provides longevity to the teeth bordering the cleft

• Avoids permanent fixed Prosthodontic appliances

Bone grafting in infancy

• Primary bone grafting at the time of lip repair

• Inhibits mid face growth

  –    effects blood supply to developing bone

  –    subperiosteal dissection and subsequent scar formation

• Maxillary retrusion has 

  –    dento-alveolar component - orthodontic treatment helps

  –    skeletal / basal component- orthodontic treatment futile

Bone grafting in adolescence

• Advantages

  –   Maxillary growth is complete

  –   Occlusion is stable

• Disadvantages

  –   Periodontal and alveolar support for teeth bordering the cleft is not improved

  –   Lower rate of successful orthodontic closure

  –   Increasing need for prosthodontics

Secondary bone grafting

• Optimal age depends on radiological evaluation of lateral incisor and canine

• Bilateral clefts wait for premaxilla incisors for orthodontic reposition

• Unilateral clefts 9-11years

  –    canine root is half formed

  –    satisfactory canine migration

  –    sagittal and transverse growth of maxilla complete. Subsequent maxillary growth is vertical, by addition of alveolar bone, triggered by eruption of permanent dentition.

If cleft space is 5 mm. Or more, the alveolar bone gap is 10 – 12 mm. And this often proves too large for a successful bone graft. Some surgeons would prefer to do the bone grafting at 5 – 6 years as

• Lateral incisor erupts but without bone graft it lacks support

• Provides more room for erupting central incisors

• Surgery at this age however may well cause hindrance to mid face growth 

Pre Surgical Planning

• Pre op. Orthodontics

  –    Correction of crossbite

  –    Align anterior teeth

  –    Arch expansion - create actual cleft

• Evaluate soft tissue for adequate closure

• Evaluate bony cleft radiologically  

Surgery

• Nasal intubation

• Nasal layer closure

• Pack with adequate volume of bone

• Water tight tension free oral layer repair

• Gingival and not buccal flaps for oral layer  

Graft material

• Cancellous bone

  –    early revascularisation

  –    rapid healing of bone

  –    incorporates rapidly into alveolar bone

  –    responds to migration and orthodontic movement of teeth

  –    iliac crest commonest

  –    during harvest avoid heat and desiccation

• Cortical bone

  –    heals by creeping substitution

  –    slow process

  –    orthodontic migration difficult

• Lyophilized bone

  –    less osteogenic potential

  –    slow to revascularize

  –    poor substrate for tooth migration

Graft source

• Iliac crest – cancellous commonest

• Tibia - cancellous

• Ribs – cortical and cancellous

• Calvarial – cortical and cancellous

Post surgical Orthodontics

• Arch expansion device left for 3 months post op. in retention mode

• Appliance modified to keep it away from repair

• Surgical exposure of canine if required

• Orthodontic guidance thereafter

Sites of Alveolar Clefts - Tessier's Classification

0) - Between central incisors

1) - Between central and lateral incisors

2) - Lat. incisor missing

3 + 4) - Between lateral incisor and canine

5) - Premolar region

6) - Malar hypoplasia - no cleft

Temporo-Mandibular Joint Ankylosis

Temporo-Mandibular Joint Ankylosis
Pre-Operation	Post-Operation
Temporo-Mandibular Joint Ankylosis-Exerciser

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