Cleft lip cleft palate 1.classification 2.management protocol for cleft patient 3.cleft lip management 4.cleft palate repair

1. CLEFT LIP &
PALATE
DR KAPIL G
PATIL

2. Introduction:
 Cleft lip & palate is the most common
congenital deformity.
 Clefts occur when the lip or palate does not
completely fuse during fetal development.
 Male to female ratio is 2:1.
 Two maxillary process & medial nasal process
forms the upper lip.
 Palate is formed by palatal shelves,maxillary
process& frontal process.

3.  Primary palate formed by fusion of medial nasal &
maxillary process.
 It is between the lateral incisors.
 Secondary palate formed by fusion of Palatine shelves in
midline.
 It consist of hard & soft palate.
 Palatal fusion occurs in anterior to posterior direction.

6. ETIOLOGY
 Exact cause is unknown.
 Multiple factors are involved like:
 Genetic(inherited characters) from one or both parents.
 ENVIRONMENTAL FACTORS:
 Exposure to radiation & chemicals.
 Viral infections during pregnancy.
 Excessive intake of alcohol,tobacco chewing & smoking.
 Maternal age- older the mother greater the chance of incidence.

7. CLASSIFICATION

8. KERNAHAN’S STRIPPED Y-
CLASSIFICATION

9. ELSAHY’S MODIFICATION OF STRIPPED Y
CLASSIFICATION

10. SYNDROMES ASSOCIATED WITH
CLEFT LIP & PALATE

12. PROBLEMS ASSOCIATED WITH CLEFT
PATIENTS
 Difficulty in feeding:- sucking is difficult both from bottle & breast
feeding due to lack of negative pressure.
 Difficulty with speech:- Hypernasal speech deformity with difficulty in
pronouncing certain constant sounds.
 Dental problems:- teeth in region of alveolar cleft are usually missing
most common are canine & lateral incisor.
 Supernumerary teeth or congenitally missing teeth, crowding or
displacement of teeth, constriction of maxillary arch & narrowing of
palatal vault.
 Hearing difficulty: Repeated ear infections are common.

17. MANAGEMENT PROTOCOL FOR
CLEFT PATIENTS
 Birth:- pediatric consultation
 First few weeks:- hearing test
 At 10-12 weeks:- surgical repair of lip
 1year to 18 months:- surgical repair of palate
 2years:- speech & language development
 3-6years:- soft palate lengthening
 5-6years:- pharyngeal surgery

18.  7-8years:- 1st phase of orthodontic treatment
 9-11 years:- Alveolar bone grafting
 12-14 years:- 2nd phase of orthodontic treatment
 15-18 years:- placement of implant
 18-21 years:- nasal revisional surgery

19. MANAGEMENT

22. CLEFT LIP MANAGEMENT
Surgical lip closure(3-9months)
“MILLARD’S RULE OF 10”
10 weeks of age.
10g haemoglobin.
10 pounds of weight.

23. MILLARD’S TECHNIQUE : “CUT AS U GO”
 TECHNIQUE: Two components are rotation & advancement.
 ROTATION: Non-cleft side of lip consist of major portion of cupid’s
bow.
 It includes part of median tubercle, philtrum & philtral dimple.
 The aim of rotation flap is to rotate all these components from
non-cleft side down to their normal position.
 The rotation incision provides flap C which is cut free from lip
base attached to columella.

24.  ADVANCEMENT:
 flap from cleft side is advanced &
placed into the gap of rotation flap
to fill it.
 It helps in reconstructing wide
nostrils.
 Scars are safely concealed under
the nostril along the natural philtral
line.
 Three layered closure of skin
,muscle & mucosa that
approximates normal tissue after
excision of cleft tissue.

25. E Millard's rotation advancement operation for the repair of unilateral cleft lip. (A) Points 2 1,3 mark
Cupid's bow incision from 3 to 4 allows for downward rotation of the lip (5) The distance between 3 and 4
should be equal to 3 and 4: (C) The incision between 3 and 4 creates the advancement flap: (D) The
incision from 4 to 5'mobilizes the flap to allow its advancement into the rotation gap: (E) Closure is started
by elevating the nostril, permitting small "C" flap to augment columella.

26. Surgical repair of unilateral cleft lip-Millard's procedure: (A) Initial markings; (B) Flap
raised on the noncleft side; (C) Skin incision on the cleft side; (D) Intraoral mucosal
suturing: (E) Muscular layer and skin suturing: (F) Cleft lip repair complete

27.  ADVANTAGES:
 Preserves cupids bow &
philtrum.
 Helps to improve nasal tip
symmetry.
 Helps in lip lengthening.
DISADVANTAGES:
 Difficult to use in wide clefts.
 May narrow the nostrils.

28. CLEFT PALATE REPAIR
Singel stage:-
Carried out at 1.5 year
1. Von langenbeck’s repair
2. Wardill & Kilner V-Y pushback palatoplasty

29. VON LANGENBECK’S PALATOPLASTY
 Bipedicle mucoperiosteal flaps are advanced medially to close the palatal
defect.
 Incisions are placed on either side of palate.
 Mucoperiosteal flaps are raised upto the junction of hard & soft palate.
 The cleft edges of soft palate are incised & the oral & nasal layers
separated.
 In hard palate nasal layer is identified, reflected & sutured.
 Hard palate approximated in two layers –nasal & oral layers.
 Soft palate is approximated in three layers– nasal ,muscular & oral layer.

30. (A) Langenbeck marking; (B) Closure of the palate with Langenbeck technique.

31. ADVANTAGES:
 Easy to perform.
 Requires less dissection.
DISADVANTAGES:
 Failure to provide palatal length.

32. V-Y PUSHBACK PALATOPLASTY
 Unipedicle mucoperiosteal flaps are
retrodisplaced for palatal closure.
 Main purpose is to achieve lengthening of hard
& soft palate.
 Incision is placed to enable V-Y type closure.
 Mucoperiosteal flaps are raised.
 Soft palate is incised & oral & nasal layers are
mobilized.
 Hard palate close in 2 layers.
 Soft palate is closed in 3 layers.
 Raw surface heals secondarily.

33. ADVANTAGES:
 Lengthens palate.
 Allows better speech than von
langenbeck’s procedure.
DISADVANTAGES:
 Failure to close alveolar part of
cleft.
 Fistulas may occur at the
junction of hard & soft palate.

35. ALVEOLAR BONE GRAFTING:
 A cleft in alveolar region usually results in missing lateral incisors
or canine.
 Time to place the bone graft is during eruption of permanent
canine(9-12 years of age) with 1/3rd or 2/3rd root formation.
 GOALS:
 Closure of oronasal fistula
 Provides adequate bony & periodontal support for eruption of
lateral incisor and canine.
 Maintain continuity of maxillary arch.
 Provides bony support & fullness to the base of nose.

36. Procedure:
 The bone can be harvested from mandible .
 Incisions are placed on either side of cleft.
 Nasal lining is identified, reflected & sutured.
 Palatal flaps are sutured which leaves a tear drop
shaped defect.
 Bone harvested is packed tightly into the defect.
 Buccal flaps are approximated.

37. Graft taken from symphysis for alveolar cleft closure Exposure of alveolar cleft

38. Bone graft packed into defect
Closure of alveolar cleft