Downloaded 19 times
Uploaded byDr. Haydar Muneer Salih
Cleft lip & palate
- Cleft lip and palate is a birth defect where the lip and/or palate do not fully form during development in utero. - The incidence of cleft lip and palate varies by race, with Asians having the highest rate at 1 in 500 live births. Males are more likely than females to be affected. - Treatment involves a multidisciplinary approach including surgery to repair the cleft, orthodontics, speech therapy and psychological support. The goal is to achieve normal appearance, speech and dental function.
More Related Content
![Lec 6 implant [autosaved]](https://cdn.slidesharecdn.com/ss_thumbnails/lec6implantautosaved-200124071351-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Cleft lip & palate
More from Dr. Haydar Muneer Salih
![lec 14 [Autosaved].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/lec14autosaved-230315142106-831cdef1-thumbnail.jpg?width=640&height=640&fit=bounds)
Cleft lip & palate
- 1. Cleft lip andpalate Dr. Haydar Munir Salih Alnamer BDS, PhD (Board Certified)
- 3. Epidemiology • The estimatedincidence of CLP ranges from 1:500 live births to 1: 2000 live births, the incidence is highest in Asians (1:500), the lowest incidence is in African-Americans (1:2000), but this racial variation is not observed in cases of isolated cleft palate (CP) with reported incidence of 1:2000 live births. • Males are predominant in CLP population, whereas isolated CP occurs more commonly in females. • Unilateral clefts are 9 times more common than bilateral clefts and they are more frequent on the left side than on the right.
- 4. Etiology • Clefts canoccur as part of a syndrome or as isolated clefts • Multiple genes have been implicated in the etiology of clefting, in addition to disturbances in growth factors or their receptors. • the environmental factors during pregnancy that have been established in the etiology of CLP include; smoking, alcohol, anticonvulsants, steroids, folic acid deficiency, hypoxia, retinoids, radiation, viral infections
- 5. Classification • Many classificationsystems were proposed for CLP starting in 1920s. Clefts need to be described rather than categorized and the description of CLP phenotypes should include: • 1. The laterality (unilateral/bilateral/median) and severity (complete/ incomplete) of the labial defect. • 2. Acknowledgment of an alveolar defect. • 3. Morphological characterization of the palatal defect;
- 7. Prenatal diagnosis • Recentadvances in ultrasound imaging have revolutionized prenatal diagnosis of facial clefts, ultrasound images of clefts of the lip can be visualized as early as 12-16 weeks (67%-93% detection rate), whereas diagnostic images of the palate are more difficult to acquire (7%-22% detection rate).
- 9. Clinical Manifestation • Inunilateral CL there is rotation and distortion of the vermillion with loss of Cupid's bow and philtral landmarks on the cleft side • In bilateral CL, the premaxilla grows independently of the maxillae on either side and may protrude considerably, particularly in complete clefts. The prolabium, consisting of soft tissues of the premaxilla without muscle fibers, also lacks Cupid's bow and philtral columns bilaterally.
- 13. Clinical Manifestation • Thespectrum of CP ranges from a submucous cleft to complete clefting of the primary and secondary palate. CP is primarily characterized by disorientation of palatal muscles which lead to feeding difficulties, velopharyngeal insufficiency, and speech problems.
- 14.
- 15. The Spectrum ofcleft Palate
- 16. Specific goals oftreatment • 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
- 17. The management ofCLP patients can be divided into: 1. Preoperative management. 2. Primary operative management. 3. Secondary operative management.
- 18. Preoperative management Feeding •One of the major concerns during this phase of management is feeding, this concern is not very critical in children born with isolated CL, as they can feed quite well and even have the opportunity to breastfeed in most instances. • Infants with cleft palate, on the other hand, can have difficulty in feeding due to the inability to form an adequate seal between the tongue and palate for creation of sufficient negative pressure to suck fluid from a bottle. Specialized nipples and bottles are necessary to improve feeding.
- 19. Specialized nipples andbottles
- 20. Pre-surgical orthopedics (PSO) •PSO entails using devices to mold the perioral structures of the infant with a CLP to reposition the nasolabial and maxillary segments closer to each other. It is mainly used in the first few weeks after birth and in the months prior to palate repair. • In the authors’ opinions, these techniques often have greater impact in cases of wide bilateral cleft lip and palate where manipulation of the premaxillary segment may make primary repair technically easier.
- 21. Pre-surgical orthopedics (PSO) Naso-alveolarmolding Lip taping
- 22. Treatment planning andtiming • The timing of CLP repair is controversial. The decision to surgically manipulate the tissues of the growing child should take into account the possible growth restriction that can occur with early surgery. • Historically the anesthetic risk-related data suggested that the safest time period for surgery in this population of infants could be outlined simply by using the "rule of lO's." This referred to the idea of delaying lip repair until the child was at least 10 weeks old, 10 pounds in weight, and with a minimum hemoglobin value of 10 g/dl.
- 23. Procedure Timing CL repairAfter 10 weeks CLP repair 9-18 months Pharyngeal flap or Pharyngoplasty 3-5 years or later based on speech development Maxillary / alveolar reconstruction with bone graft 6-9 years based on dental development Cleft orthognathic surgery 14-16 years in girls, 16-18 years in boys Cleft rhinoplasty After age 5 years but preferably at skeletal maturity: after orthognathic surgery when possible Cleft lip revision Anytime once initial remodeling and scar maturation is complete but best performed after age 5 years
- 24.
- 25.
- 26. The Delair technique Detailsof the incision design showing The small amount of mucosal resection.
- 27.
- 28. Muscle surgery ismore important than skin surgery. This photo shows good muscle reconstruction and passive coaptation of the skin Complete and watertight Closure of the nasal floor
- 29.
- 31. Bilateral cleft repair Orbicularisoris dissection
- 32. Bilateral cleft repair Suturingthe lateral lip mucosa to premaxilla segment
- 33.
- 34. Bilateral cleft repair Suturingthe orbicularis oris muscle
- 35.
- 36. Surgical procedures forCleft Palate • CP repair requires the mobilization of multilayered flaps to reconstruct the defect in a layered fashion by first closing the nasal mucosa and then the oral mucosa, the surgeon must also reconstruct the musculature of the velopharyngeal mechanism. • Therefore, the soft palate is closed in three layers by approximating the nasal mucosa, velar musculature, and the oral mucosa. The hard palate portion is closed in two layers using nasal mucosa flaps and then oral mucosa flaps
- 37. Separate the oralmucosa from nasal mucosa Release the abnormal levators muscle Attachment to hard palate
- 38. Closure of nasalmucosa Closure of levator muscles Closure of oral mucosa
- 39. Complications • Immediate postoperativecomplications include breakdown of the repair due to tension, palatal ischemia, secondary pressure, secondary trauma, or bleeding. • Other long-term complications include midface growth deficiency, velopharyngeal incompetence, recurrent fistula, and sleep apnea.
- 40.
- 41. Alveolar bone grafting Goalsof alveolar bone reconstruction: • To provide bone support and adequate attached gingival width for teeth adjacent to the cleft. • To close the remaining oronasal fistula. • To improve support of the nasal alar base and lip on the affected side(s). • To allow normal eruption of the permanent teeth in the cleft area and providing sufficient bone for the placement of dental implants, where needed.
- 42. Alveolar bone grafting Goalsof alveolar bone reconstruction: • To create an appropriate ridge form to allow for optimization of orthodontic care and dental alignment. • To allow for stabilization of the premaxillary segment and to provide continuity of the maxilla as a whole. • To improve nasal symmetry. • To provide support for the upper lip. Timing of the alveolar bone reconstruction was one of the most controversial issues.
- 43. Primary (early) grafting •which was defined as that performed simultaneously with lip repair or as grafting performed before the palate is repaired at age younger than 2 years. This "early''-phase bone grafting has been associated with reports of moderate to severe long-term maxillary growth restriction.
- 44. Secondary (delayed) grafting;which can also be divided into: • Early secondary; before the eruption of the permanent incisor teeth (3-6 years). The literature does not support early secondary grafting. • Secondary (mixed dentition); before the eruption of the maxillary canine, (6-12 years), it can also be divided into early secondary (6-8 years) and late secondary (8-12 years). Ideally the patient is between the ages of 8 and 12 years with a maxillary canine root that is one half to two thirds developed, some authors advocated the early secondary grafting (6-8 years) to preserve the lateral incisor especially if present in the posterior segment.
- 45. Late grafting • after12 or 13 years of age, after the eruption of the permanent canine
- 46. Common presenting problems •Discharge and smell from the nose. • Oral food/fluids leaking from the nose. • Poor speech. • Inability to suck up a straw or blow up balloons. • Poor appearance of the incisor teeth. • Missing or supernumerary teeth within the cleft area. • Difficulty cleaning teeth in the cleft area. • Poor facial appearance.
- 47. Alveolar bone grafting pre-operativeorthodontic treatment • Orthodontic treatment may be required to align the maxillary arch in preparation for the bone graft. This usually involves expansion of the arch in a transverse diameter and results in opening up the alveolar cleft to some degree
- 48. Alveolar bone grafting surgicalprocedure
- 49.
- 50. Bone graft thedefect
- 51. Closure of oralmucosa
- 52. Iliac crest; isthe most commonly used bone in bone grafting
- 53. Postoperative care • Antibioticsusually start before the incision and continue postoperatively for 7-10 days along with chlorhexidine mouth wash, excellent oral hygiene and good nutrition are encouraged, patients and parents are instructed to liquid and soft diet for 2-3 weeks and to avoid any trauma to the operative site.
- 54. Complications • Wound dehiscencewhich is managed by debridement and antimicrobial mouth washes with or without systemic antibiotics. • Infection which is managed by conservative debridement, daily irrigation and packing with oral antibiotics. • Persistent fistula which may require subsequent procedures.
- 55.