Chahat o.s.
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Contents
Introduction Definition Incidence Etiology Embryology Classification Problems
encountered Management
Introduction
Orofacial clefts are the most common oro-facial anomaly in newborn infants and the second commonest congenital abnormality.
Affecting approx one in every 800 births worldwide
Non “life-threatening” abnormality, Can have significant effect on maternal
bonding. A small proportion of oro-facial clefts may be
associated with a genetic syndrome.
Definition
A cleft lip or palate is an abnormal separation in the oral-facial region that happens because tissue of the mouth or lip does not form correctly in fetal development.
Incidence
For Clefts affecting the Lip only or Lip and Palate (CL[P]), males are more commonly affected than females (approx 2-1).
Clefts palate alone (CP) is found in approx 1 in 2000; females are more often affected than males.
CL[P] varies between different ethnic populations.
Etiology / Causes 1.GENETIC:- Mutated Inherited Genes (gene=top,
mutation=bottom) 2.ENVIRONMENTAL:- Teratogens :-Known risk in taking
certain types of drugs during pregnancy .
Link to maternal smoking. Alcohol use. Debate on the role of folic acid. 3.OTHER SYNDROMES:- Stickler’s syndrome, Patau and Down syndrome
Embryology
Primary Palate- Triangular area of hard palate anterior to incisive foramen to point just lateral to lateral incisor teethIncludes that portion of alveolar ridge and
four incisor teeth. Secondary Palate- Remaining hard palate
and all of soft palate
Embryology
Primary PalateForms during 4th to 7th week of GestationTwo maxillary swellings merge Two medial nasal swelling fuseIntermaxillary Segment Forms:
Labial Component(Philtrum) Maxilla Component(Alveolus + 4 Incisors) Palatal Component(Triangular Primary Palate)
Embryology
Secondary PalateForms in 6th to 9th weeks of gestationPalatal shelves change from vertical to
horizontal position and fuseTongue must migrate antero-inferiorly
Cleft Formation Cleft result in a deficiency of tissue Cleft lip occurs when an epithelial bridge fails Clefts of primary palate occur anterior to
incisive foramen Clefts of secondary palate occur posterior to
incisive foramen Secondary Palate closes 1 week later in
females Cleft of lip increases likelihood of cleft of palate
because tongue gets trapped.
Unilateral Cleft Lip Nasal floor communicates with oral cavity Maxilla on cleft side is hypoplastic. Columella is displaced to normal side Nasal ala on cleft side is laterally, posteriorly,
and inferiorly displaced Lower lat on cleft side -lower, more obtuse Lip muscles insert into ala and columella.
Palatal Clefts
Soft palate muscles insert on posterior margin of remaining hard palate rather than midline raphe.
Associated Dental AbnormalitiesSupernumery Teeth- 20%Dystrophic Teeth- 30%Missing Teeth- 50%Malocclusion- 100%
Classification DAVIS AND RICHIE (1922) ON ANATOMICAL
BASIS:- Group I- Pre alveolar clefts
(unilateral , bilateral and median.) Group II- post alveolar clefts Group III- complete alveolar clefts.
(unilateral , bilateral and median.)
VEAU (1931) CLASSIFICATION:- Group I:-clefts of soft palate only. Group II:-clefts of hard & soft palate. Group III:-complete unilateral cleft. Group IV:-complete bilateral alveolar
clefts.
FOGH ANDERSON CLASSIFICATION (1942):-
Divided intoGroup – 1:-
• LIP • Unilateral• Bilateral
Group – 2:- Lip + palate
UnilateralBilateralGroup – 3:-
• Palate extending upto the incisive foramen.
GMC JAMMU
Of those with CL[P]….. approx 30% involved the lip+/-alveolus, and 70% involved lip and palate
Of those with CP..... approx 30% involved the soft palate only
and 70% involved hard and soft palate
LAHSHAL CLASSIFICATION:- Given by Okriens in 1987.
L : LipA : AlveolusH : Hard PalateS : Soft PalateH : Hard PalateA : AlveolusL : Lip
Based on the fact that cleft of lip, alveolus and hard palate can be bilateral and clefts involving soft palate are usually unilateral.
Symptoms
Separation of the lip (picture)
Separation of the palate (roof of the mouth)
Nasal distortion Recurring ear
infections
Symptoms (cont.)
Failure to gain weight
Nasal regurgitation when bottle feeding
Poor speech Misaligned teeth Growth retardation
(picture)
PROBLEMS ASSOCIATED
Ear infectionstop picture (right=normal,
left=infected) Hearing loss Dental cavities Displaced teeth (bottom
picture) Poor speech Lip deformities Nasal deformities
Cleft Lip and Palate patients present a multitude of problems:
Functional Impairment• Feeding problems:-Suckling and
Swallowing• Speech• Hearing• Malocclusion• Respiratory infections• General physical development• Mental development.
MANAGEMENT Successful treatment requires a MULTI
DISCLIPLINARY APPROACH Starts with antenatal diagnosis and continues
till adulthood. NORTHERN AND
YORKSHIRE CLEFT
LIP AND PALATE
SERVICES CRITERIA.
MANAGEMENT PROTOCOL BEFORE BIRTH:-ANTENATAL
DIAGNOSIS,ULTRASONOGRAPHIST AND OBSTETRICIAN.
IMMEDIATELY AFTER BIRTH:-PAEDRIATIC CONSULATION,COUNSELLING,FEEDING INSTRUCTIONS.(PRE SURGICAL ORTHOPEDICS)
BIRTH-5 WEEKS:-MULTIDISCIPLINARY MEETING.
6-10 WEEKS:-CLEFT LIP REPAIR,2-3 DAY STAY,MILLARD RULE OF 10,REMOVAL OF SUTURES.
12-16 WEEKS-REVIEW AND POST OP, ENT ASSESSMENT.
6-18 MONTHS-SURGICAL REVIEW. 18 MONTHS – 6 YEARS:-ENT AND PEDIATRIC
,DENTAL ASSESMENT. 6-12 YEARS:-LATE PRIMARY / EARLY MIXED:-
ENT,ORTHODONTIST,PEDODONTIST,
PLASTIC SURGEON,PSYCHOLOGIST. 12-18 YEARS:-LIP
REVISION,RHINOPLASTY,OSTEOTOMY,DENTAL IMPLANTS.
20 YEARS:-LOCAL COLLECTION AND FULL TEAM REVIEW.
STAGE OF TREATMENT:- NEONATAL PERIOD-immediate counselling,
feeding , pre surgical orthopedics ,lip repair ,palate repair.
TODDLER PERIOD:-speech therapy , hearing/ear infections.
GRADE SCHOOL PERIOD:-orthodontic management , ABG ,psychological growth.
TEENAGE PERIOD:- orthognathic surgeries,
Rhinoplasty.
TREATMENT Primary management:-
Primary management is done by:-• Millard rotational flap• Langenback’s operation• Wardill’s operation
Cleft palate only:-• Soft palate only- one operation at 6
months• Soft palate & hard palate -two operation soft palate at 6 months hard palate at 15-18 months.
Cleft palate and cleft lip:-
• Unilateral:- 2 operation:-• Cleft lip an soft palate at 5-6 months.• Hard palate and gum pad with or
without lip at 15-18 months.
• Bilateral:- 2 operation:-• Cleft lip and soft palate at 4-5 months.• Hard palate and gum pad with or
without lip at 15-18 months
Cheilorrhaphy Surgical correction of cleft lip deformity. Early operative procedure used to correct cleft
deformities. Cleft lip disrupts the important circumoral
orbicuralis oris musculature. Objectives :-1.Functional-restore normal
function and arrangement of muscle. 2.Esthetic.-normal anatomic
structures,cupid bow and philtrum.
Surgical technique Different for different types of clefts. In unilateral cases,unaffected side serve as a
guide for lip length and symmetry. Lips closed in linear fashion. Restore symmetry not only to lip but also to
the nasal tip. First and the most important steps in
correcting nasal deformity.
Palatorrhaphy Performed in one operation,but occsaionally
performed in two also. Two operations:-soft palate closure
(staphylorrhaphy) performed first followed by hard palate closure(uranorrhaphy).
OBJECTIVES:-speech and degluttion correction.
Surgical techniques includes:-Hard palate closure
Soft palate closure.
Alveolar bone grafting (ABG)
Provides continuity of alveolar ridge. Provides bone for canine to erupt . Osseous support for adjacent teeth Majority of canines erupt spontaneously…
others require surgical exposure often in combination with orthodontics.
The erupting teeth often appear to then stimulate the formation of new alveolar bone
Secondary surgical procedures.
Performed after initial repair of cleft defects in an effort to improve speech or correct residual defects.
Commonly used technique to improve velopharyngeal competence secondarily is the palatal flat procedure.
Another technique is the placement of an implants behind the posterior pharyngeal wall to bring it anteriorly.
Conclusion Cleft Lip and Palate are common congenital
deformities that often affect speech, hearing, and cosmesis; and may at times lead to airway compromise.
Oro facial clefts require a multidisciplinary approach
Treatment extends over many years and risks exhausting patient cooperation
Need to keep the patients best interests in mind…