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Introduction
Incidence
Classification
Embryological Background
Etiology
Diagnosis
Problems of individuals with clefts
Treatment of Cleft Lip and Palate
Specialties involved in the treatment of Cleft Lip and Palate
Timings of surgical repair
Cheilorraphy
Palatorrhaphy
Alveolar Cleft Grafts
Secondary Surgical Procedures
Valopharyngeal Insufficiency
Introduction
What is Cleft Lip and Palate?
Congenital abnormal space or gap in the
Incidence
Incidence
Boys are more affected than girls by 3:2
Cleft Lip and Palate occur twice as often in
boys as in girls
Isolated Clefts of Palate are more often in girls
75% of Clefts are Unilateral, rest are Bilateral
Left side is more involved than right side
Embryological
Background
Glossopharyngeal
nerve
Vagus nerve
Trigeminal nerve
Facial nerve
Embryological
Background
Development of the
Lip:
Unpaired Frontonasal
Prominence
Medial and Lateral
Nasal prominences
2 maxillary
prominences
2 mandibular
prominences
Embryological
Background
Fusion defects can occur anywhere
Embryological
Background
Development of Palate:
We have two parts of two different embryonic origins:
1 ) primary palate : the triangular part of hard palate anterior to
incisor foramen which originate from the premaxilla ( frontonasal
prominences).
develop between 4th and 8th week of gestation
2 ) secondary palate : remaining part of the hard palate and all soft
palate posterior to incisor foramen which comes from palatine shelves
of the maxillary prominences
develop between 8th and 12th week of gestation
Embryological
Background
Various theories have been given for its
1.
2.
3.
4.
development.
Alteration in intrinsic palatal shelf force
Failure of tongue to drop down
Non fusion of shelves
Rupture of cyst formed at the site of fusion
Classification
We classify as the follows:
its combined (cl+cp) or isolated cleft(cl
or cp)?
is it unilateral or bilateral?
is it complete (if it cross the nasal
Classification Systems
Lip
Alveolus
Primary
Palate
Hard Palate
(Maxillary)
Hard Palate
(Palatine)
Soft Palate
Karnahans Classification
Millards Modification of
Karnahans Classifcation
Kriens LAHSHAL
L = Lip (right)
A = Alveolus (right)
H = Hard Palate
(right)
S = Soft Palate
(median)
H = Hard Palate
(left)
A = Alveolus
Capital
letter(left)
= complete
L = Lip (left)
cleft
Lowercase letter =
incomplete cleft
Examples
.
or - = normal
LA.l = complete right cleft lip and
alveolus, incomplete left cleft lip
LAHS = complete right unilateral cleft
lip, alveolus, hard, and soft palate
Prenatal
Diagnosis
Cleft lipcan be easily
diagnosed by performing
ultrasonography in the
second trimester
Diagnosing a cleft palate
with ultrasonography is very
difficult
Three-dimensional imaging
has been introduced to
prenatal ultrasonography
diagnostics of cleft
anomalies
Diagnosis
Advantages of Prenatal
Diagnosis:
1.
2.
3.
4.
5.
Etiology
Actually no one knows exactly what causes
clefts
Multiple factors may be involved, like:
Genetics (inherited characteristic) from one or both
parents .
Environmental factors
Drugs: corticosteroids (anti-inflammatory), phenytoin
(anticonvulsant), retinoid.
Infections: like rubella during pregnancy.
Alcohol consumption, smoking, hypoxia during
pregnancy, some of dietary and vitamins deficiencies
(like folic acid and vitamin A deficiency)
Maternal Age
GENETICS
CL/P
CP
Nonsyndromic Cleft
Pierre Robin Sequence is the
most common associated
nonsyndromic anomaly
is a relative term describing the
small size of the lower jaw ) and
Glossoptosis (is a medical
condition and abnormality which
refers to the downward
displacement or retraction of the
tongue)
Syndromic Cleft
Common Syndromes
Stickler (25% of syndromic CP)
autosomal dominant type 2 collagen gene
Pierre Robin, ocular/hearing/joint
malformations
Feeding Difficulties
Cleft lip= makes it more difficult for an
Dental Problems
Local Dental Problems:
Congenitally Missing teeth, Hypodontia, Hyperdontia,
Oligodontia
Presence of natal and neonatal teeth
Anamalies of tooth morphology like microdontia, macrodontia
etc
Fused teeth
Enamel Hypoplasia
Poor periodontal support, early loss of teeth
Gemination, Dilacerations
Orthodontics Problems:
Class III tendency
Anterior and Posterior Cross bite
Spacing and crowding
speech
Poor dental alignment and
smile
Ear Problems
Middle ear disease - 22% to 88%
Conductive hearing loss and chronic
Speech Problems:
Hearing loss hampers proper development of
speech
Velopharyngeal Insufficiency (VPI)
Abnormal air
Poor pronunciation of Bilabial, Labiodental,
Linguoalveolar sounds
Schedule of Treatment
Birth:
Initial Assessment
Pre-surgical assessment
3 Month:
9-18 month:
Palate Repair
2 Year:
Speech assessment
3-5 Year:
8-9 Year:
Initial interventional
Orthodontics
Preparation for alveolar bone
grafting
10 Year:
12-14 Year:
Definite Orthodontics
16 Year:
17-20 Year:
Orthognathic Surgery
Feeding
Cleft lip= makes it more difficult for an infant to suck on a
nipple
use special nipples to allow the baby to latch
properly (either pump or use formula)
Pigeon Feeder
Dr. Browns Natural Flow to relieve gas
Special
Presurgical Orthopeadics:
1. Reduces the size of cleft; Aids in Surgery
2. Partial obturation aids in feeding
3. Parental Reassurance at a crucial time
Maxillary Strapping
Nasoalveolar Moulding Appliances (NAM)
Require orthopedic
repositioning of the nasal
cartilages, columella, nasal tip,
and lateral wall of the vestibule
prolabium can be of
variable size
3. The columella is
deficient/almost
nonexistent
collapsed
Protrusive maxilla
imperative to be
repositioned
Premaxillary orthopedics
Latham Appliance
Rule of Ten
Primary repair- repaired at approximately 10
weeks
The surgeon usually uses the Rule of Ten
The child weighs 10 pounds
The child has a hemoglobin of at least 10
grams
The child has a white count of no higher than
10,000
The child is at least 10 weeks of age
Surgical Techniques
Cleft Lip Repair
unilateral
rotationadvancement flap
developed by Millard
complications
dehiscence
infection
excess tension
Surgical Techniques
Cleft Lip Repair
bilateral
bilateral rotation
advancement with
attachment to
premaxilla mucosa
Orthodontic Treatment of
Transitional
Dentition
Secondary Bone
Grafting
Done before eruption of the permanent
canine
Usually when the root of the canine is 1/3 to
2/3 formed
Usually between ages 8-10
In CLP dental age is usually behind
chronological age
*Allogeneic
Graft resorbs, remodels, may contribute to osteoinduction and
osteoconduction
**Alloplast
Bone grows into, around alloplast
No active osteoinduction but some osteoconduction
Teeth do not erupt through alloplast
*Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary alveolar clefts in
humans- A preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987
**Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect in a primate
model. J Oral Maxiilofac Surg 47:946-952, 1989
Orthognathic Surgery
Midfacial
Advancement
LeForte osteotomies
leave vascular
pedicle attached in
back of maxilla prevents necrosis
Rhinoplasty
Rhinoplasty
standard techniques
tip projection
alar rotation
columellar length
Age =17-20
Surgical Management of
Velopharyngeal Insufficiency
Major Goals of Surgery
Close the gap or hole between the roof of
the mouth and the nose.
Reconnect the muscles that normally make
the palate work.
Make the repaired palate long enough so
that when the muscles are working, the
palate can perform its function properly.
Velopharyngeal Insufficiency
VPI
palatoplasty
Prosthetic Management
of VPI
Thank You!