Cleft lip and palate

1. Cleft Lip & Palate

2. Introduction
• Most common congenital anomaly of orofacial structures
• Commonly associated with other congenital conditions
• Incidence
• Cleft Lip + Palate  1:600 live births
• Isolated cleft palate 1:1000 live births
• Highest incidence Native Indian tribes USA (1:276)
1:300 to
1:2000

3. Typical distribution of cleft types
• Cleft lip + Palate = 45%
• Isolated Cleft palate = 40%  Females
• Isolated Cleft Lip = 15%

4. Aetiology
• Genetic Predisposition + Environmental Component
• History in 1° Relative  incidence 1:25 live birth
• Environmental factors
• Drugs- Steroids, Diazepam, Phenytoin
• Maternal Epilepsy

5. • Pierre Robin Sequence
Retrognathia + Glossoptosis + Isolated cleft palate

6. Anatomy
Cleft Lip
• Three muscular rings of Delaire
1. Nasolaial
2. Bilabial
3. Labiomental
• Unilateral cleft lip
• Nasolabial & Bilabial rings disrupted on one side
• Asymmetrical deformity

8. • Bilateral left lip
• More profound & symmetrical deformity
• Bilateral disruption of Nasolabial & Bilabial muscle rings
• Flaring of nose + Protrusive Premaxilla + Prolabium
• Prolabium: Area of Skin in front of premaxilla, devoid of muscle

10. Cleft Palate
• Primary Palate: Anterior to incisive foramen
Alveolus
Upper Lip
• Secondary Palate: Behind the Incisive foramen
Hard Palate
Soft Palate
• Clefting  Failure of fusion of two Palatine Shelves
• Soft palate alone
• Soft + Hard Palate

11. • Incomplete vs Complete Cleft Palate
Cleft of Hard Palate, attached with Nasal Septum & Volmer  Incomplete
Nasal Septum & Volmer are completely separated  Complete
• Soft Palate
Normal: Transverse orientation of muscle fibres + No attachment to hard
palate
Clefting: Anteroposterior alignment of muscle fibres + Insertion on Posterior
edge of Hard Palate

12. • Hard Palate
Normal: Three Anatomical & Physiological Zones
1. Palatal Fibromucosa  below the floor of
nose
2. Maxillary Fibromucosa Thick
3. Gingival Fibromucosa lateral & adjacent
to teeth

13. Management
Primary Management
• Antenatal Management
 Antenatal diagnosis  Clift Lip Maternal Gestational USG at 18 weeks
 Isolated Cleft Palate  can not be diagnosed
Helps is parental counselling
• Feeding
Feeding difficulty
Modified teats /soft bottels/ feeding plates

14. • Airway
Respiratory problem is uncommon
Life threatening Airway obstruction in Pierre- Robbin Squence
Can be managed with retained oropharyngeal airway

15. Surgery
• Goals-
Normal appearance
Normal speech
Normal facial development normal growth of facial structures + normal
dentition
• No hypoplasia of tissues in clefting muscular malalignment

16. Timing of Surgery – Basic Principles
• Cleft lip repair @ 5-6 month
• Soft Palate Cleft repair @ 5-6 month
• Hard Palate Cleft repair @ 15-18 month  Delayed repair gives time
to closure /narrowing of defect  minimization of dissection  less
scarring  Normal maxillary growth

18. Secondary Management/Rehabilitation
• Hearing
• Speech
• Dental development
• Facial Growth
• Revisional Surgeries  must be delayed at least 2 years after primary
surgery