CLEFT LIP & PALATE

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandent...
Overview
Introduction
Basic Science
Timetable of Events
•
•
•
•

neonatal
toddler
gradeschool
teenage

Surgical Procedures...
Introduction
A TEAM APPROACH IS REQUIRED
•
•
•
•
•
•
•
•

pediatrician
surgeon
OMFS
dentist
ENT
psychiatrist
speech
nurse ...
Introduction
Most common congenital malformation of
H and N (1:1000 in US; 1:600 in UK)
Second most common overall (behind...
Epidemiology
Syndromic CLAP
associated with more than 300 malformations
Pierre Robin Sequence; Treacher-Collins,
Trisomies...
Syndromic CLAP
Single Gene Transmission
trisomies 21, 13, 18

Teratogenesis
fetal alcohol syndrome
Thalidomide

Environmen...
Epidemiology: continued
Isolated cleft palate genetically distinct
from isolated cleft lip or CLAP
same among all ethnic g...
Embryology
Primary versus secondary palate
divided by incisive foramen
primary palate develops 4-5 wks
secondary palate de...
Embryology: continued
Secondary palate
medial ingrowth of lateral maxillae with
midline fusion
always a cleft in normal de...
Classification
Veau Classification - 1931
Veau Class I: isolated soft palate cleft
Veau Class II: isolated hard and soft p...
Classification; continued
Complete Clefts
absence of any connection with extension
into nose
vomer exposed

Incomplete Cle...
Anatomy - Normal
Lip: “Cupid’s Bow”
Maxilla
primary/secondary
palates
soft palate
alveolus
maxillary tuberosity
hamulus

w...
Anatomy: palatal muscles
Superior constrictor
– primary sphincter

Tensor veli palatini
– tenses palate

Levator Veli pala...
Cleft Anatomy
Unilateral Cleft Lip
and alveolus
lack of mesodermal
proliferation
• cleft of orbicularis
– medial portion t...
Cleft Anatomy - The Nose
Ipsilateral LLC
flattened
rotated downward

Short columella
Bifid tip

www.indiandentalacademy.co...
Cleft Antatomy: continued
Bilateral Cleft
Lip/Alveolus/nose
duplication of
unilateral defect
premaxilla
orbicularis to ala...
Cleft Anatomy: continued
Clefts of the primary hard palate/alveolus
cleft alveolus always associated with cleft lip
cleft ...
Cleft Anatomy: continued
Clefts of secondary
palate
Failure of medial
growth maxillae
• fusion at incisive
foramen
• macro...
Multidisciplinary Approach
These are not merely surgical problems
Requires team approach throughout life
neonatal period
t...
The Neonatal Period
Pediatrician:
directs care
establishes feeding
complete clefts
preclude feeding
• breast feeding not
p...
The Neonatal Period
Presurgical
Orthodontics (Baby
Plates)
• Molds palate into
more anatomically
correct position
• decrea...
The Neonatal Period
Surgical Repair
Cleft Lip
In US - “the rule of tens” - 10 wks, 10 lbs, Hgb 10
Lip adhesion vs baby pla...
The Toddler Years
Priority: Speech
“Cleft errors of speech” in 30%
primary defects - due to VPI (hypernasality)
• consonan...
The Toddler Years
Growth hormone deficiency
40 times more common in CLAP
suspects when below 5% on growth chart

www.india...
The Grade School Years
Three primary issues
Orthodontics
poor occlusion
congenitally absent teeth

alveolar bone grafting
...
The Teenage Years
Midface retrusion
etiology - ?early palatal repair
surgical correction around age 18

Psychological deve...
Surgical Techniques
Cleft Lip Repair
unilateral
rotation-advancement
flap developed by
Millard
complications
• dehiscence
...
Surgical Techniques
Cleft Lip Repair
bilateral
bilateral rotation
advancement with
attachment to
premaxilla mucosa
complic...
Surgical Techniques
Velopharyngeal
Incompetnece
superior based
pharyngeal flap
sphincter
pharyngoplasty
• palatopharyngeus...
Surgical Techniques
Alveolar Bone
Grafting
iliac crest bone graft
complications
infected donor site
• hematoma

failed gra...
Surgical Techniques
Midfacial
Advancement
LeForte osteotomies
leave vascular pedicle
attached in back of
maxilla - prevent...
Surgical Techniques
Rhinoplasty
standard techniques
tip projection
alar rotation
columellar length

complications
alar ste...
Controversies:
Otologic Disease
>90% have COME
Robinson, et al
• prospective, 150 patients - 92%

Muntz, et al.
• retrospe...
Controversies:
Timing of Repair
Early repair
Advantage: improved speech
• Rohrich, et. al; retrospective study. The earlie...
Controversies: VPI
Surgical Repair
Reserved for failure of speech pathology
Pharyngeal Flap - superiorly based
Advantage: ...
Controversies
Presurgical Nasal
Alveolar Molding
molds palate, alveolus
and nose
Advantage: excellent
early results
Disadv...
Conclusion and
Future Directions
Multidisciplinary approach
Not merely a “surgical problem”
Alveolar bone grafting
PSNAM
P...
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Cleft lip & Palate /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Cleft lip & Palate /certified fixed orthodontic courses by Indian dental academy

  1. 1. CLEFT LIP & PALATE INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Overview Introduction Basic Science Timetable of Events • • • • neonatal toddler gradeschool teenage Surgical Procedures Conclusion/Future Directions www.indiandentalacademy.com
  3. 3. Introduction A TEAM APPROACH IS REQUIRED • • • • • • • • pediatrician surgeon OMFS dentist ENT psychiatrist speech nurse coordinator www.indiandentalacademy.com
  4. 4. Introduction Most common congenital malformation of H and N (1:1000 in US; 1:600 in UK) Second most common overall (behind club foot) www.indiandentalacademy.com
  5. 5. Epidemiology Syndromic CLAP associated with more than 300 malformations Pierre Robin Sequence; Treacher-Collins, Trisomies 13,18,21, Apert’s, Stickler’s, Waardenburg’s Nonsyndromic CLAP diagnosis of exclusion www.indiandentalacademy.com
  6. 6. Syndromic CLAP Single Gene Transmission trisomies 21, 13, 18 Teratogenesis fetal alcohol syndrome Thalidomide Environmental factors materal diabetes amniotic band syndrome www.indiandentalacademy.com
  7. 7. Epidemiology: continued Isolated cleft palate genetically distinct from isolated cleft lip or CLAP same among all ethnic groups (1:2000, M:F 1:2) Isolated CL or CLAP different among ethnic groups American Indians: 3.6:1000 (m:f 2:1) Asians 3:1000 (m:f 2:1) African American 0.3:1000 (m:f 2:1) www.indiandentalacademy.com
  8. 8. Embryology Primary versus secondary palate divided by incisive foramen primary palate develops 4-5 wks secondary palate develops 8-9 wks Primary palate mesodermal proliferation of frontonasal and maxillary processes never a cleft in normal development www.indiandentalacademy.com
  9. 9. Embryology: continued Secondary palate medial ingrowth of lateral maxillae with midline fusion always a cleft in normal development macroglossia, micrognathia may provide anatomical barriers to fusion www.indiandentalacademy.com
  10. 10. Classification Veau Classification - 1931 Veau Class I: isolated soft palate cleft Veau Class II: isolated hard and soft palate Veau Class III: unilateral CLAP Veau Class IV: bilateral CLAP Iowa Classification - a variation of Veau Classification www.indiandentalacademy.com
  11. 11. Classification; continued Complete Clefts absence of any connection with extension into nose vomer exposed Incomplete Clefts midline attachment (may be only mucosal) ex: submucous cleft (midline diasthasis, hard palatal notch, bifid uvula) www.indiandentalacademy.com
  12. 12. Anatomy - Normal Lip: “Cupid’s Bow” Maxilla primary/secondary palates soft palate alveolus maxillary tuberosity hamulus www.indiandentalacademy.com
  13. 13. Anatomy: palatal muscles Superior constrictor – primary sphincter Tensor veli palatini – tenses palate Levator Veli palatini – elevates palate – dilates ET Salpingopharyngeus, palatopharyngeous, palatoglossus: minor contribution www.indiandentalacademy.com
  14. 14. Cleft Anatomy Unilateral Cleft Lip and alveolus lack of mesodermal proliferation • cleft of orbicularis – medial portion to columella – lateral portion to nasal ala • cleft of alveolus – alveolar bone graft www.indiandentalacademy.com
  15. 15. Cleft Anatomy - The Nose Ipsilateral LLC flattened rotated downward Short columella Bifid tip www.indiandentalacademy.com
  16. 16. Cleft Antatomy: continued Bilateral Cleft Lip/Alveolus/nose duplication of unilateral defect premaxilla orbicularis to alar cartilages bilaterally bifid tip extremely short columella www.indiandentalacademy.com
  17. 17. Cleft Anatomy: continued Clefts of the primary hard palate/alveolus cleft alveolus always associated with cleft lip cleft lip not necessarily associated with cleft alveolus by definition there is opening into nose www.indiandentalacademy.com
  18. 18. Cleft Anatomy: continued Clefts of secondary palate Failure of medial growth maxillae • fusion at incisive foramen • macroglossia Submucous vs. complete Vomer www.indiandentalacademy.com
  19. 19. Multidisciplinary Approach These are not merely surgical problems Requires team approach throughout life neonatal period toddler grade school adolescence young adulthood www.indiandentalacademy.com
  20. 20. The Neonatal Period Pediatrician: directs care establishes feeding complete clefts preclude feeding • breast feeding not possible • a soft, large bottle with large hole is required • a palatal prosthesis may be required www.indiandentalacademy.com
  21. 21. The Neonatal Period Presurgical Orthodontics (Baby Plates) • Molds palate into more anatomically correct position • decreases tension • may improve facial growth • Grayson, presurgical nasal alveolar molding (PSNAM) www.indiandentalacademy.com
  22. 22. The Neonatal Period Surgical Repair Cleft Lip In US - “the rule of tens” - 10 wks, 10 lbs, Hgb 10 Lip adhesion vs baby plates Cleft Palate Varies from 6-18 months - most around 10 mo Early repair may lead to midface retrusion Early repair improves speech www.indiandentalacademy.com
  23. 23. The Toddler Years Priority: Speech “Cleft errors of speech” in 30% primary defects - due to VPI (hypernasality) • consonants are most difficult sounds (plosives) secondary defects - due to attempted correction • glottic stops, nasal grimace Velopharyngeal insufficiency diagnosed by fiberoptic laryngoscopy or BaSw surgical repair after failed speech therapy - usually around age 4 www.indiandentalacademy.com
  24. 24. The Toddler Years Growth hormone deficiency 40 times more common in CLAP suspects when below 5% on growth chart www.indiandentalacademy.com
  25. 25. The Grade School Years Three primary issues Orthodontics poor occlusion congenitally absent teeth alveolar bone grafting fills alveolar defect - around age 12 psychological growth considered standard of care www.indiandentalacademy.com
  26. 26. The Teenage Years Midface retrusion etiology - ?early palatal repair surgical correction around age 18 Psychological development counseling standard of care Rhinoplasty usually last procedure performed, around age 20 www.indiandentalacademy.com
  27. 27. Surgical Techniques Cleft Lip Repair unilateral rotation-advancement flap developed by Millard complications • dehiscence – infection • thin white roll – excess tension www.indiandentalacademy.com
  28. 28. Surgical Techniques Cleft Lip Repair bilateral bilateral rotation advancement with attachment to premaxilla mucosa complications • dehiscence • thin white roll www.indiandentalacademy.com
  29. 29. Surgical Techniques Velopharyngeal Incompetnece superior based pharyngeal flap sphincter pharyngoplasty • palatopharyngeus complications • continued VPI • stenotic side ports www.indiandentalacademy.com
  30. 30. Surgical Techniques Alveolar Bone Grafting iliac crest bone graft complications infected donor site • hematoma failed graft • dehiscence • palatal prosthesis www.indiandentalacademy.com
  31. 31. Surgical Techniques Midfacial Advancement LeForte osteotomies leave vascular pedicle attached in back of maxilla - prevents necrosis complications • malocclusion • infection • necrosis www.indiandentalacademy.com
  32. 32. Surgical Techniques Rhinoplasty standard techniques tip projection alar rotation columellar length complications alar stenosis www.indiandentalacademy.com
  33. 33. Controversies: Otologic Disease >90% have COME Robinson, et al • prospective, 150 patients - 92% Muntz, et al. • retrospective, 96% Pathology: ETD (controversial) abnormal muscular attachment Huang, et al. - Cadaveric study • palatal repair restores ET function. ?Midface growth? www.indiandentalacademy.com
  34. 34. Controversies: Timing of Repair Early repair Advantage: improved speech • Rohrich, et. al; retrospective study. The earlier the repair, the better speech. Disadvantage: worsening midface retrusion • Rohrich, et. al; people with unrepaired palates have less midface retrusion www.indiandentalacademy.com
  35. 35. Controversies: VPI Surgical Repair Reserved for failure of speech pathology Pharyngeal Flap - superiorly based Advantage: time tested, severe cases Disadvantage: passive obturator Sphincter Pharyngoplasty (palatopharyngeus rotation flap) Advantage: active sphincter Disadvantage: new technique www.indiandentalacademy.com
  36. 36. Controversies Presurgical Nasal Alveolar Molding molds palate, alveolus and nose Advantage: excellent early results Disadvantage: no long term results Grayson, et al. www.indiandentalacademy.com
  37. 37. Conclusion and Future Directions Multidisciplinary approach Not merely a “surgical problem” Alveolar bone grafting PSNAM Pharyngoplasty vs. pharyngeal flap www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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