Chahat o.s.

Cleft Lip and Palate

Dr.Chahat puri

Intern (H.D.C)

Sundernagar.(H.P.)

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.

KERNAHAN’S CLASSIFICATION

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.

Aesthetic Compromise

• Physiological implications

• Sociological implications

DIAGNOSIS.

ULTRASONOGRAPHY IN PREGNANT FEMALES MAY REVEAL THE PRESENCE OF CLEFTS.

Ultra Sound at 18th Week of Pregnancy

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.

12th July 2008Dr. Christine Underhill

Pre surgical plates, moulding plates, feeding plates…….

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.

A

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.

Hard palate closure(Von langenbeck operation)

Variations of langenbeck

Triple layered soft tissue flap

Wardill operation

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…

THANK YOU