CLEFT LIP and PALATE

EPIDEMIOLOGY of CLP

• Incidence– 1 per 1000– Mongoloid > Caucasian > Negro

• Gender ratio– 2 males : 1 female

• Site– 3% of CLP involved with syndromes– 66% of unilateral clefts on left side

CLEFT PALATE CLINICS

• Women’s and Children’s Hospital• Flinders Medical Centre• Accreditation - Medicare

CLEFT PALATE TEAM• Plastic Surgeon• General Surgeon - Neurosurgeon• Oral and Maxillofacial Surgeon• Orthodontist• Dentist• Geneticist• Speech Therapist• Psychologist• Social Worker - Counsellor• Nurses, administrators, students

EMBRYOLOGY

•Lip•Palate

Second, third and fourthbranchial arches

Mandibular archStomodeumMaxillary process

Nasal placodeFrontonasal process

Cardiac swelling

Eye

5 week old embryo

6 week old embryo

Frontonasalprocess

Nasal pitEye

Maxillary process

Mandibular arch

Cardiac swelling

Maxillary processes fuses with the lateral nasal process. If fusion does not occur - clefting results.

Primary palate

Nasal septumLateral palatal shelf

(Bent vertically)

7 week old embryo

Secondary palate is the first to form before the primary palate.If the primary palate is affected, the secondary palate would definitely be affected. Not vice verca.

Lateral palatal shelf

Nasal septum

Oronasalchamber

Coronal cross section of 7 week old embryo

Lateral palatal shelf

Nasal septum

Coronal cross section of 8 week old embryo

Tongue

- Palatal shelves rising up to fuse.They rise up from the back to the front. - However fusion occurs in the opposite direction (front to back)

Bifid uvula

AETIOLOGY of CLP• Genetics– Syndromes

• Environment–Drugs, medication–Diseases–Nutrition– Teratogens

thalidomide

No. of affected parents No. of affected siblings CL ± CP Isolated CP

- - 0.12% 0.05%- 1 4%-5% 2%-3%1 - 2% 1.7%1 1 13%-14% 14%-17%2 - 13%-14% 14%-17%- 2 13%-14% 14%-17%2 1 20%-25% 25%-50%2 2 15%-20% 50%

RISK OF GIVING BIRTH TO A CHILD WITH A CLEFT

CLASSIFICATION of CLP

A. Unilateral left incompletecleft lip

B. Complete cleft of hardand soft palate

D. Unilateral left complete cleft of lip, alveolar ridge andhard and soft palate

F. Complete bilateral cleft of primary and secondary palates

E. Complete bilateral cleft of lip and primary palate

C. Unilateral left complete cleft of lip and alveolar ridge

Kernahan and Stark’s (1958) classification based on the incisive foramen as the dividing point between clefts of the lip and alveolar ridge (primary palate)

and clefts of the palate (secondary palate)

lips are okay

PROBLEMS in CLP

• Aesthetics• Function

• Feeding • Swallowing• Dental

• Otolaryngological• Speech• Psychological• Growth

can cause inflammation of the ear

MANAGEMENT of CLP

• Surgery– Lip– Palate

• Speech• Dental• Orthodontic

- Usually at 4-5 y/o- May have a second surgery at 10 years to align the canines or allow to erupt

speech therapy - sound production

lip repair at 3months - "z plasty"

surgeon has difficulty in replicating the cupids bow

bilateral CLP with the premaxilla hanging down

Device helps to improve the posiition of the palatal shelves before surgery

SPEECH

• Soft palate function• Surgery• Velopharyngeal incompetence

DENTAL ANOMALIES in CLP

• Displaced teeth - ectopia, impactions• Missing teeth, supernumaries• Transposition• Crossbites• Occlusal plane cants• A- P relations• Midlines, smile line• Gingival contours• Oral hygiene

lateral incisiors are usually missing

Canine eruption Bone graftingbone grafting procedure at around 10 years old

maxillary hypoplasia, lack of development, Would need further surgery to advance the maxilla