CLEFT LIP AND PALATE
Dec 22, 2015
Introduction
• A cleft is a congenital abnormal space or gap in the uppper lip, alveolus, or lip
• HARE LIP
Importance in dentistry
• Most common congenital anomalies to affect the orofacial region. These are deformities that involve the dental specialities throughout their protracted course of treatment.
• Special dental needs( anodontia or supernumery teeth)
• Malocclusion
Problems encountered in rehabilitation
• Parent counseling – explaination and reassurence • Prepare for protracted course of treatment - team approach
• Treatment must address Appearance Speech Hearing Mastication Deglutition
• Occurrence – 600 to 1000 live births • Boys: girl babies- 3:2• Commonly affect lip, alveolar ridge, hard and
soft palate• 3/4th unilateral • Left > right
Classification
Primary palate -anterior to incisive foremen • Lip-unilateral / bilateral• Alveolus-unilateral / bilateralSecondary Palate - posterior to incisive foremen Hard palate- Rt/Lt Soft palate
Classification
Davis and ritchie (1922)Group I; Pre alveolar clefts (uni, bi, median)Group II; Post alveolar cleftsGroup III; Complete alveolar clefts(uni, bi, median)
ETIOLOGY• HEREDITARY • ENVIRONMENTAL FACTORS
• Lack of complete knowledge of causes
• HEREDITARY– Genetic – 40%-CLEFT LIP– 18-20%-CLEFT PALATE
• ENVIRONMENTAL– Viral Infections
– Exposure to Radiation
– DRUGS-antibiotics, steroids, antiepileptic drugs
– Nutritional Deficiency of vit A, vit B, iron
– Excessive consumption of alcohol/smoking
– Consanguineous marriage-occurrance of congenital abnormalities
– Maternal age
Syndrome associated clefts
Dominant syndromes1. Vander woude’s syndrome2. Oral-facial-digital syndrome3. Velocardiofacial syndrome
Embryology Facial primordia-4th week- primordial stomodeum-5 facial primordiaSingle FNP(FRONTONASAL PROMINENCE)
Paired MXP(Maxillary prominence)
Paired MDP(mandibular prominence)
Median nasal process MNPLateral nasal process LNP
• FNP- FOREHEAD,DORSUM,APEX OF NOSE
• MXP-UPPER CHEECK,UPPER LIP,
• MDP-CHIN,LOWER LIP,LOWER CHEECK
• MNP-NASAL SEPTUM;merge-philtrum of upper lip,premaxilla,primary palate
• LNP-ALAE OF THE NOSE
• Primary palate-Median Palatine Process MPP DEVELOPS FROM INTER MAXILLARY SEGMENT only pre maxillary part of maxilla
• Secondary palate-lateral palatine process-mesenchymal projections frominternal aspect of MXP
FORMATION OF CLEFT • UCL- Failure of MXP merged MNP(on affected
side)
• BCL-Failure of MXP merged MNP
• CPP-Failure LPP(rt & lt ) MPP(rt/lt)
• CSP-Failure LPPrt LPPlt
Associated problems
• Dental problems• Skeletal Malocclusion • Nasal deformity • Feeding • Ear problems • Speech difficulties • Associated anomalies
Associated problems
• Dental problems– Affects development of teeth– Congenital absence of teeth– Presence of supernumerary teeth– Crowding or displacement of teeth– Morphologically deformed or hypomineralised– Cleft seen b/w-lateral incisor & canine
Malocclusion – class III malocclusion– Hypoplastic maxilla– Narrowing of palatal vault (Early palatal closure-(scar
contracture)- limits growth of maxilla)
Malocclusion
• Space maintainance • Orthodontic treatment
-aim to move abnormally positioned maxillary arches & pre maxilla to normal relationship.(before the first surgery-through-till after the last surgery)
Orthognathic surgery
- Flat tip of the nose- Short / absence of columella- Widening of alar base- Hypoplasia of septal cartilages
CheilorhinoplastyNasal revision – last corrective procedure
Nasal deformity
Feeding
• Bottle feeding – not possible sucking negative pressure is not created due to inadequate seal
• Specially designed elongated nipples • Use of eye droppers • Large syringes with rubber extension tubes
connected to them. • This method considerable amount of air
swallowed - frequent burping necessary
Ear problems
• Serous otitis media – suppurative • Chronic inflammatory changes – conductive
deafness not sensory neural loss
Speech difficulties
• Consonant sound retadation• P, b, t, d, k and g• Hypernasality • Dental malformation, malocclusion and
abnormal tongue placement may develop before the palatal closure and produce articulation problem
• Hearing problem further complicates ..
• Velopharyngeal incompetence – escape of air between nasopharynx and oropharynx
• soft palate is a valve - pharyngeal wall
Goal of surgical care • Normalized esthetic appearance of thelip and nose• Intact primary and secondary palate• Normal speech, language, and hearing• Nasal airway patency• Class I occlusion with normal masticatory• function• Good dental and periodontal health• Normal psychosocial development
Timing of surgical repairParents insist on correction of all defects as early as
possible and single surgery Multi disciplinary team approach• Feeding plate ?• Paediatric consultation • Nutrition consultation• Lip surgery 3 months• Palate surgery 1 year• Speech therapy / ENT• Orthodontics• Alveolar bone graft 8 – 9 years
Surgical Treatment Age Timing Considerations
1. Cleft lip repair 10 to 12 weeks
2. Cleft palate repair 9 to 18 months (Exact timing of repair is based on child’s speech/language age)
3. Pharyngoplasty for VPI 3 to 5 years
4. Alveolar Bone graft reconstruction 6 to 9 years
5.Orthognathic surgery 14 to 16 years for females,16 to 18 years for males
6.Dental implant placement 16 to 18 years
7. Lip/nasal revision After age 5 years (Varies widely depending
on clinical findings and psychosocial concerns.)
Definitive nasal surgery usually delayed until adolescence.
Lip repair
• Cheilorrhaphy • Timing • Rule of 10’s • child was at least 10 weeks old,• 10 pounds in weight, and• hemoglobin value of 10 dL/mg
• Surgical technique to elongate cleft margin to match normal length and symmetry
• Reorienting and reuniting the muscle • Three layer closure
• Lip closure in linear fashion causes scar contraction – notching at upper lip
• Rotation advancement repair – Millard technique• Cleft extending through floor of nose , the continuity
of nasal apparatus disrupted • Restore symmetry of lip and nose
Palatal closure
Palatal closure - around 18 monthsPalatorrhaphy one stage two stage (18-24 months and 4-5 years )Techniques Von langenbeck bipedicled repairVeau-wardill-kilner unipedicled repair
Palatorrhaphy
• to create a mechanism capable of speech and degluttition with out significantly interferring with subsequent maxillary growth
• Main goal - competent velopharangeal mechanism- Partitioning nasal & oral cavity
Palatorrhaphy
Aim is to obtain a long and mobile soft palate capable of producing normal speech
Three layer closure • Nasal mucosa• Muscle• Oral mucosa
Alveolar cleft grafts
Problems faced due to alv cleft • escape of oral fluids to nose • Drainage of nasal secretion into oral cavity• Eruption of teeth• Collapse of alveolar segments• speech
Alveolar bone grafting• Primary-time of lip/ palate closure before 2 yrs• Secondary
– Early06 to 7 yrs- performed at the time of maxillary lateral incisor eruption
– Late-9-11 yrs-just before canine eruption
• Grafting at the time of le fort I-osteotomy• Revision grafting
• Donor site– Ilium,calvaria,hydroxyapatite crystals….etc