Cleft Lip & Palate

Cleft Lip & PalateCleft Lip & Palate

الدكتور علي القصيراختصاص الجراحه

التجميليه والتقويميه

Facial clefting is the second most common congenital deformity (after clubfoot).

Affects 1 in 750 births Problems are cosmetic, dental, speech,

swallowing, hearing, facial growth, emotional

introductionintroduction

PrevalencePrevalence CL/P is more common than CP and varies CL/P is more common than CP and varies

by ethnicity.by ethnicity. CL/P CL/P

High in American Indians and Asians (1/500 High in American Indians and Asians (1/500 newborns)newborns)

Low in American blacks (1/2000 newborns)Low in American blacks (1/2000 newborns) Intermediate level in Caucasians (1/1000 Intermediate level in Caucasians (1/1000

newborns)newborns) More common in male More common in male

Isolated CP occurs in only 1/2500 newborns Isolated CP occurs in only 1/2500 newborns , does not display variation by ethnicity and , does not display variation by ethnicity and more common in female. more common in female.

Cleft LipCleft Lip Complete closure at 35 days Complete closure at 35 days

postconception:postconception: 7 weeks from the LMP. 7 weeks from the LMP. Lateral nasal, median nasal, and maxillary Lateral nasal, median nasal, and maxillary

mesodermal processes merge.mesodermal processes merge. Failure of closure can produce Failure of closure can produce

unilateral, bilateral, or median lip unilateral, bilateral, or median lip clefting.clefting.

Left side unilateral cleft is the most Left side unilateral cleft is the most common. common.

Cleft PalateCleft Palate Lack of fusion of the palatal shelves. Lack of fusion of the palatal shelves. Abnormalities in programmed cell Abnormalities in programmed cell

death may contribute to lack of death may contribute to lack of palatal fusion(?).palatal fusion(?).

Isolated disruption of palate shelves Isolated disruption of palate shelves can occur after closure of the lipcan occur after closure of the lip

Palatal closure is not completed until Palatal closure is not completed until 9 weeks post-conception. 9 weeks post-conception.

emberologyemberology Primary Palate- Triangular area of

hard palate anterior to incisive foramen to point just lateral to lateral incisor teeth Includes that portion of alveolar ridge

and four incisor teeth. Secondary Palate- Remaining hard

palate and all of soft palate

embryologyembryology Primary Palate Forms during 4th to 7th week of

Gestation Two maxillary swellings merge Two medial nasal swelling fuse Intermaxillary Segment Forms:

Labial Component (Philtrum) Maxilla Component (Alveolus + 4 Incisors) Palatal Component(Triangular Primary Palate)

embereologyembereology Secondary Palate

Forms in 6th to 9th weeks of gestation Palatal shelves change from vertical to

horizontal position and fuse Tongue must migrate antero-inferiorly

anatomyanatomy Hard Palate

Bones: Maxilla( Palatine Processes) + Palatine Bones(Horizontal Lamina)

Blood Supply: Greater Palatine Artery Nerve Supply: Anterior Palatine Nerve

AnatomyAnatomy

Soft Palate Fibromuscular shelf attached like a

shelf to posterior portion of hard palate Tenses, elevates, contacts Passavant’s

Ridge Muscles: Tensor Veli Palatini(CNV),

Levator Veli Palatini(Primary Elevator), Musculus Uvulae, Palatoglossus, Palatopharyngeus(CN IX and X)

EtiologyEtiology Several agents that are associated with Several agents that are associated with

an increased frequency of midfacial an increased frequency of midfacial malformation.malformation.

Genetics Genetics MedicationsMedications —phenytoin, sodium —phenytoin, sodium

valproate, methotrexate. valproate, methotrexate. With corticosteroids there is no evidence With corticosteroids there is no evidence

of an increase in malformations.of an increase in malformations. Possible association could not be excluded Possible association could not be excluded

EtiologyEtiology Cigarette smokingCigarette smoking

Noted with mothers of children with facial Noted with mothers of children with facial clefting, both CL/P and CP.clefting, both CL/P and CP.

Teratogenesis has been attributed to hypoxia as Teratogenesis has been attributed to hypoxia as well as a component of tobacco (cadmium).well as a component of tobacco (cadmium).

AlcoholAlcohol Associated with an increased risk of fetal facial Associated with an increased risk of fetal facial

clefting.clefting. Alterations in cell membrane fluidity or reduced Alterations in cell membrane fluidity or reduced

activity of specific enzymes such as superoxide activity of specific enzymes such as superoxide dismutase.dismutase.

Folate deficiencyFolate deficiency Contributes to a range of birth defects. Contributes to a range of birth defects. Evidence is emerging for a similar association Evidence is emerging for a similar association

with the development of CL/P.with the development of CL/P.

Cleft formationCleft 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

Unilateral incomplete

Unilateral complete

Bilateral complete

Incomplete cleft palate

Unilateral complete lip and palate

Bilateral complete

Examples of Cleft Palate Cleft of Back Soft Palate Cleft of Soft Palate Cleft of Soft and Hard Palate Cleft of Soft and Hard Palate and Cleft Lip

treatment

Feeding respiratory tract and ear infection Orthodontic Surgery

Surgery

Cleft lip repair =role of ten ( wt: 10 pounds, age :10 weeks and 10 gm /ds litter haemoglobin)

Cleft palate repair at 10 month to 18 months .

Cp repair before speeking