cleft lip & palatedental.subharti.org/oral_maxillofacial/cleft.pdf · cleft lip & palate dr...

CLEFT LIP

&

PALATE

DR Prajesh Dubey

Department of Oral and maxillofacial Surgery

Dr. Prajesh Dubey, Subharti Dental College, SVSU

Incidence & Prevalence

1:700 in live births

Males are affected more than females for CL+/- P, CL is more common in males while CP is more common in females

Prevalence of CL+/-P is 0.77 per 1000 live births (CL is 0.29 and CL+P is 0.48 per 1000 live births)

Unilateral > Bilateral

Left>Right


Aetiology (Multifactorial)

Genetic: MSX, LHX, goosecoid,DLX,IRF6 genes.

Environmental: viral, radiation, drugs e.g. antibiotics, steroids, insulin, anti-epileptics, Vitamin B6 and folic acid deficiency, anaemia, anorexia, stress, alcohol, smoking

Heredity

Maternal age

Consanguineous marriages


Embryology

Face develops between 4th and 8th weeks of I.U.L

Processes involved:

Frontonasal-LNP,MNP-Upper lip, Primary palate

Mandibular arch-maxillary-Secondary palate

CL develops when LNP fails to fuse with MNP

Primary palate cleft occurs when MXP-MNP fusion breaks down

Secondary palate cleft develops when palatal shelves fail to fuse


Anatomy of Cleft Lip

Cleft Lip Types


Hard Palate Anatomy


Soft Palate Anatomy


Anatomy of cleft palate

In cleft palate, the

aponeurosis of the tensor

veli palatini, instead of

attaching along the

posterior border of the hard

palate, is attached along

the bony cleft edges. All

the muscles that attach to

the palate insert onto the

aponeurosis of this muscle.

Thus, the overall length of

the palate is shortened


Disruption of levator sling


The Deformity

Clefts of the Palate


Some syndromes associated with

clefts

More than 200 syndromes include clefts

Cleft Palate :

Apert’s, Stickler’s

Treacher-Collins

Pierre-Robin

Cleft Lip +/- Palate:

Van der Woude’s

Waardenberg’s


Classification 1

Davis & Ritchie Classification(1922)

Group I: Pre-alveolar clefts (unilateral,bilateral

and median)

Group II:Postalveolar clefts

Group III: Complete alveolar

clefts(unilateral,bilateral and median)


Classification 2

Veau Classification (1931)

Group I: Cleft of soft palate only

Group II: Cleft of hard and soft palate

Group III: Complete unilateral cleft

Group IV: Complete bilateral cleft


Classification 3

International Classification(1967)

A. Group I: Cleft of anterior (primary) palate

a. Lip: Unilateral Rt/Lt-total or partial Bilateral

b. Alveolus: Unilateral Rt/Lt-total or partial Bilateral

B. Group II: Cleft of anterior and posterior(primary+ secondary) palate

a. Lip: Unilateral Rt/Lt-total or partial Bilateral

b. Alveolus: Unilateral Rt/Lt-total or partial Bilateral

c. Hard palate: Rt/Lt-total or partial


Classification contd.

C. Group III: Clefts of posterior (secondary) palate

a. Hard palate: Rt/Lt

b. Soft palate

D. Group IV: Rare facial clefts


Clinical Features of Cleft Lip

Loss of continuity of orbicularis oris

Alveolus defect- deviation,hypoplasia

Nostril defect-asymmetry,columella deviation etc.

Maxilla-vertical and horizontal hypoplasia

Dental abnormalities

In bilateral cases-projection of prolabium and premaxilla


Clinical features of Cleft palate Intact palate is necessary

for normal function of

speech and swallowing.

Soft palate function is

important for valve action

on Eustachian tube.

Speech, deglutition and

hearing is affected

Maxillary development is

retarded

Malocclusion Dr. Prajesh Dubey, Subharti Dental College, SVSU

Treatment

AIMS & OBJECTIVES

Normalized esthetic appearance of the lip 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


Treatment

Multi-disciplinary Approach Plastic surgeon

Maxillofacial surgeon

ENT surgeon

Speech therapist

Child psychologist

Trained nursing staff

Orthodontist

Prosthodontist

Pediatrician

Geneticist


Treatment

General Management Protocol

Immediately after birth- paediatric consultation, counselling,

feeding instructions, evaluation by geneticist, diagnosis of

life expectancy and tests

Within 1st few weeks of life- team evaluation including

hearing test

At 10-12 weeks- surgical repair of lip (3-6 mths in India)

Before 1 year to 18 mths: team evaluation and surgical

repair of cleft palate and placement of Grommets (pressure

equalization tubes)

3 mths. after palate repair: team evaluation and speech and

language assessment


Treatment

3-6 years: team evaluation, behavioural intervention, speech therapy, treatment of middle ear infection, fistula repair, soft palate lengthening, psychological evaluation

5-6 years: lip, nose revision if necessary, pharyngeal surgery

7 years: Orthodontic consultation

9-11 years: Alveolar bone grafting

12 years: Orthodontic treatment

15-18 years: Prosthetic rehabilitation for missing teeth

18-21 years: Orthognathic surgery, Rhinoplasty, final lip revision


Lip repair

Millard’s rule of 10:

10 weeks of age

10 gm % Hb

10 lb weight


Millard’s Rotation-Advancement

OTHERS: RANDALL-TENNISON Z-PLASTY, DELAIRE’S FUNCTIONAL

CHIELOPLASTY, NOORDORF’S MODIFICATION OF MILLARD’S TECHNIQUE


Bilateral Lip Repair

Straight Line Closure


Techniques of Palatal Repair

Langenbeck (1860)

Veau (1920)

Kriens (1969

Furlow’s double opposing Z-plasty


Langenbeck’s Technique


Veau-Wardill-Kilner “Push-back”

Technique


Krien’s Intravelar Veloplasty


Furlow’s Double-opposing Z-

plasty


Complete Palatal Repair


Soft Palate Repair


Alveolar Bone Grafting

1. Grafting achieves stability of the arch and prevents collapse of the alveolar segments.

2. Grafting provides room for the canine and lateral incisors to erupt into the arch.

3. Grafting restores continuity not only of the alveolus, but also of the maxilla at the piriform rim. This supports the ala and provides improved stability and support for the nose.

4. Grafting of the alveolar defect provides an opportunity for the surgeon to address any residual oronasal fistula


Alveolar Bone Grafting


Velopharyngoplasty

“Velopharyngeal insufficiency” (VPI) is defined as inadequate closure of the nasopharyngeal airway port during speech production.

The audible nasal air escape with resultant hypernasal speech that is associated with VPI is perhaps the most debilitating consequence of the cleft palate malformation.


Superiorly based pharyngeal flap


Orthognathic Surgery

Maxillary retrusion

requires advancement

of the maxillary base

anteriorly which is

usually done via a Le

Fort I osteotomy.


Orthognathic Surgery


Other Concomitant Treatments

Hearing assessment

Speech assessment and therapy

Orthodontics

Prosthetic replacement of missing teeth

General dental care


Orthodontic Intervention


Prosthodontic Intervention

1. FOR REPLACEMENT OF

MISSING TEETH

2. FOR CLOSURE OF PALATAL

FISTULA

3. FOR CORRECTION OF

SPEECH


General Dental Care


Fluoride Application


Routine Dental Treatment

Oral Prophylaxis

Treatment of Carious teeth

RCT

Extraction of malformed teeth

Crown and Bridge

Implants


Prevention

Parental Counselling

Genetic testing

High dose folic acid supplements


Conclusion

CLP is a distressing condition for the patient and

his family.

The condition requires multiple surgical

procedures from birth to maturity and frequent

outpatient visits.

The treatment presents serious challenges to

healthcare delivery systems and dedicated cleft

centres with a multi-specialty teams only can

provide complete and successful outcome.


THANK YOU


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