Cleft class

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Oral & Maxillofacial Surgery
Fifth Year

Published in: Health & Medicine

Cleft class

  1. 1. Clinical Oral Surgery Class 5th year, 2nd semester, 1.5.2012 Cleft Lip and Palate Dr. Faiyaz Ahmed Oral & Maxillofacial surgeon Images used in this presentation may be subjected to copyright. This presentation is to be used only for classroom educational purposes
  2. 2. Cleft Lip and Palate in Saudia Arabia
  3. 3. Objectives Development of cleft lip & palate Factors that cause cleft deformities Management of cleft patients Principles & techniques of cleft lip & palate repair Diagnose and classify cleft lip and palate Alveolar bone grafting Problems in cleft patients Time table and sequence of treatment
  4. 4. Embryology • Formation of the lip and palate takes place between the 5th and 10th week of fetal life
  5. 5. Embryology Failure of fusion of medial nasal process and maxillary process results in a cleft lip
  6. 6. Palate - Development • Palatal shelves rotate to the horizontal position • Fuse from anterior to posterior to form the palate by 12 weeks
  7. 7. Primary and Secondary palates
  8. 8. • UCLP - most frequent combination, seen more often in boys, hereditary incidence is fairly high, predominantly – left side • Isolated Cleft palate more frequently seen in girls, incidence 1 in 2000
  9. 9. Etiology • Multifactorial – Genetic predisposition – Environmental factors • • • • Diazepam Corticosteroids Phenytoin Folic acid deficiency
  10. 10. Ultrasound scan diagnosis Ultrasound images of clefts of the lip can be visualized as early as 16 weeks
  11. 11. Objectives Development of cleft lip & palate Factors that cause cleft deformities Management of cleft patients Principles & techniques of cleft lip & palate repair Diagnose and classify cleft lip and palate Alveolar bone grafting Problems in cleft patients Time table and sequence of treatment
  12. 12. Problems of individuals with clefts • Dental problems • Malocclusion • Feeding problems • Nasal deformity • Ear problems • Speech difficulties • Associated anomalies
  13. 13. Problems of individuals with clefts • Congenital absence of teeth. • The cleft usually extends between the lateral incisor and canine • Supernumerary teeth are left until 2 to 3 months before the ABG because these teeth, although nonfunctional, maintain the surrounding alveolar bone
  14. 14. Malocclusion • Class III seen in most cases • Retruded maxilla
  15. 15. Feeding problems • Suckling and swallowing reflexes are normal • Have extreme difficulty producing the necessary negative pressure
  16. 16. Feeding problems • Specially designed nipples with enlarged openings • More frequent burping is necessary
  17. 17. Nasal deformity • Alar cartilage on the cleft side is flared • Columella is pulled towards the non cleft side • Nasal revision may be the last corrective surgical procedure the cleft patient undergoes
  18. 18. Ear problems • More predisposed to middle ear infections • Chronic serous otitis media is common among children with cleft palate
  19. 19. Speech difficulties • VPI • Hypernasality • Compensatory articulations
  20. 20. Speech difficulties : articulation • Dental malformation, malocclusion, and abnormal tongue placement may develop before the palate is closed and thus produce an articulation problem.
  21. 21. Speech difficulties • Hearing loss at an early age is especially detrimental to the development of normal speech skills
  22. 22. • The levator veli palatini muscle functions to elevate the velum and enable appropriate speech production
  23. 23. Objectives Development of cleft lip & palate Factors that cause cleft deformities Management of cleft patients Principles & techniques of cleft lip & palate repair Diagnose and classify cleft lip and palate Alveolar bone grafting Problems in cleft patients Time table and sequence of treatment
  24. 24. Classification of clefts The typical classification system used clinically to describe standard clefts of the lip and palate is based on careful anatomic description. Clefts can be unilateral or bilateral; microform, incomplete, or complete; and may involve the lip, nose, primary palate, and/or secondary palates
  25. 25. Classification of Cleft lip and palate
  26. 26. Millard’s modified classification of Kernahan’s classification
  27. 27. Veau’s classification
  28. 28. Problems of individuals with clefts • Dental problems • Malocclusion • Feeding problems • Nasal deformity • Ear problems • Speech difficulties • Associated anomalies
  29. 29. Management Protocol for Cleft lip & Palate • Prenatal - Diagnosis & Psychological counseling • At Birth – Evaluation by cleft lip & palate team , Feeding advice. Naso alveolar molding • 3-6 months –Cleft lip repair ( Millard’s Rule of 10)
  30. 30. Naso alveolar molding • Done during the first 3 months to bring the cleft segments closer and facilitate lip repair
  31. 31. Rule of 10 • 10 gm% Hb • 10 pounds wt • 10 weeks old
  32. 32. The ideal cleft lip repair should provide a symmetrical Cupid’s bow, natural-appearing philtral columns, a philtral dimple , a well aligned continuous white roll and minimum visible scar in the line of the philtral column. There should be ample vermilion and mucosa with a slight central tubercle, a normally functioning orbicularis oris muscle with harmonious symmetry of the nostrils
  33. 33. Cleft lip repair • Unilateral • Millard Rotation – advancement lip repair • Tennison Randall Triangular flap lip repair • Bilateral • Mulliken lip repair
  34. 34. Millard rotation-advancement lip repair
  35. 35. Tennison Randall Triangular flap lip repair
  36. 36. Millard Rotation-advancement lip repair
  37. 37. Bilateral cleft lip repair
  38. 38. Bilateral cleft lip repair
  39. 39. • 9 mon –1 ½ years :-) Cleft palate repair • 5 years :-) assess speech; manage VPI • 5 – 8 years :-) interceptive orthodontics • 5 – 7 years :-) pharyngeal flap (if needed) • 7 – 8 years :-) maxillary expansion (if needed) • 8 –11 years :-) SABG • 16 –21 Orthognathic surgery and Rhinoplasty
  40. 40. Palate repair • Bardach’s 2 flap palatoplasty • Von Langenbeck palate repair • Furlows double opposing z plasty
  41. 41. Bardach 2 flap palatoplasty
  42. 42. Bardach’s 2 flap palatoplasty
  43. 43. Von langenbeck palatoplasty
  44. 44. Furlow’s double opposing Z plasty
  45. 45. • 9 mon –1 ½ years :-) Cleft palate repair • 5 years :-) assess speech; manage VPI • 5 – 8 years :-) interceptive orthodontics • 5 – 7 years :-) pharyngeal flap (if needed) • 7 – 8 years :-) maxillary expansion (if needed) • 8 –11 years :-) SABG • 16 –21 Orthognathic surgery and Rhinoplasty
  46. 46. SABG • Specific timing is based on the child’s dental development instead of chronological age • Timing is based on the development of the permanent maxillary canine • Root resorption and graft failure are common when bone grafts are placed after eruption of the canine
  47. 47. Goal of bone grafting • Provide bony matrix for the developing teeth • Create alveolar ridge continuity • Closure of any residual oronasal fistulas • Improve bony support for the nasal base on the cleft side
  48. 48. Objectives Development of cleft lip and palate Factors that cause cleft deformities Diagnose and classify cleft lip and palate Management of cleft patients Principles & techniques of cleft lip & palate repair Alveolar bone grafting Problems in cleft patients Time table and sequence of treatment

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