This document provides information on cleft lip and palate, including definitions, classifications, embryology, problems, and management. It defines cleft lip and palate as an abnormal separation in oral-facial tissue that occurs due to incomplete formation during fetal development. Treatment requires a multidisciplinary approach from prenatal diagnosis through adulthood and aims to address functional, aesthetic, and developmental issues through procedures such as cheilorrhaphy, palatorrhaphy, and alveolar bone grafting. Successful management of cleft lip and palate patients presents ongoing challenges due to the variety of impairments and extended treatment time required.
3. Introduction
Orofacial clefts are the most common oro-
facial anomaly in newborn infants and the
second commonest congenital abnormality.
Affecting approx one in every 800 births
worldwide
Non “life-threatening” abnormality,
Can have significant effect on maternal
bonding.
A small proportion of oro-facial clefts may be
associated with a genetic syndrome .
4. Definition
A cleft lip or palate
is an abnormal
separation in the
oral-facial region
that happens
because tissue of
the mouth or lip
does not form
correctly in fetal
development.
5. Incidence
For Clefts affecting the Lip only or Lip and
Palate (CL[P]), males are more commonly
affected than females (approx 2-1).
Clefts palate alone (CP) is found in approx
1 in 2000; females are more often affected
than males.
CL[P] varies between different ethnic
populations.
6. Etiology / Causes
1.GENETIC:-
Mutated Inherited Genes (gene=top,
mutation=bottom)
2.ENVIRONMENTAL:-
Teratogens :-Known risk in taking
certain types of drugs during
pregnancy .
Link to maternal smoking.
Alcohol use.
Debate on the role of folic acid.
3.OTHER SYNDROMES:-
Stickler’s syndrome,
Patau and Down syndrome
7. Embryology
Primary Palate- Triangular area of hard
palate anterior to incisive foramen to point
just lateral to lateral incisor teeth
Includes that portion of alveolar ridge and
four incisor teeth.
Secondary Palate- Remaining hard palate
and all of soft palate
8. Embryology
Primary Palate
Forms during 4th to 7th week of Gestation
Two maxillary swellings merge
Two medial nasal swelling fuse
Intermaxillary Segment Forms:
Labial Component(Philtrum)
Maxilla Component(Alveolus + 4 Incisors)
Palatal Component(Triangular Primary
Palate)
9. Embryology
Secondary Palate
Forms in 6th to 9th weeks of gestation
Palatal shelves change from vertical to
horizontal position and fuse
Tongue must migrate antero-inferiorly
10. Cleft Formation
Cleft result in a deficiency of tissue
Cleft lip occurs when an epithelial bridge fails
Clefts of primary palate occur anterior to
incisive foramen
Clefts of secondary palate occur posterior to
incisive foramen
Secondary Palate closes 1 week later in
females
Cleft of lip increases likelihood of cleft of palate
because tongue gets trapped.
11. Unilateral Cleft Lip
Nasal floor communicates with oral cavity
Maxilla on cleft side is hypoplastic.
Columella is displaced to normal side
Nasal ala on cleft side is laterally, posteriorly,
and inferiorly displaced
Lower lat on cleft side -lower, more obtuse
Lip muscles insert into ala and columella.
12. Palatal Clefts
Soft palate muscles insert on posterior
margin of remaining hard palate rather
than midline raphe.
Associated Dental Abnormalities
Supernumery Teeth- 20%
Dystrophic Teeth- 30%
Missing Teeth- 50%
Malocclusion- 100%
13. Classification
DAVIS AND RICHIE (1922) ON ANATOMICAL
BASIS:-
Group I- Pre alveolar clefts
(unilateral , bilateral and median.)
Group II- post alveolar clefts
Group III- complete alveolar clefts.
(unilateral , bilateral and median.)
14. VEAU (1931) CLASSIFICATION:-
Group I:-clefts of soft palate only.
Group II:-clefts of hard & soft palate.
Group III:-complete unilateral cleft.
Group IV:-complete bilateral alveolar
clefts.
18. Of those with CL[P]…..
approx 30% involved the lip+/-alveolus, and
70% involved lip and palate
GMC JAMMU
19. Of those with CP.....
approx 30% involved the soft palate only
and 70% involved hard and soft palate
20. LAHSHAL CLASSIFICATION:-
Given by Okriens in 1987.
L : Lip
A : Alveolus
H : Hard Palate
S : Soft Palate
H : Hard Palate
A : Alveolus
L : Lip
Based on the fact that cleft of lip, alveolus and
hard palate can be bilateral and clefts
involving soft palate are usually unilateral.
21. Symptoms
Separation of the
lip (picture)
Separation of the
palate (roof of the
mouth)
Nasal distortion
Recurring ear
infections
22. Symptoms (cont.)
Failure to gain
weight
Nasal regurgitation
when bottle feeding
Poor speech
Misaligned teeth
Growth retardation
(picture)
28. MANAGEMENT
Successful treatment requires a MULTI
DISCLIPLINARY APPROACH
Starts with antenatal diagnosis and continues
till adulthood.
NORTHERN AND
YORKSHIRE CLEFT
LIP AND PALATE
SERVICES CRITERIA.
29. MANAGEMENT PROTOCOL
BEFORE BIRTH:-ANTENATAL
DIAGNOSIS,ULTRASONOGRAPHIST AND
OBSTETRICIAN.
IMMEDIATELY AFTER BIRTH:-PAEDRIATIC
CONSULATION,COUNSELLING,FEEDING
INSTRUCTIONS.(PRE SURGICAL
ORTHOPEDICS)
BIRTH-5 WEEKS:-MULTIDISCIPLINARY
MEETING.
6-10 WEEKS:-CLEFT LIP REPAIR,2-3 DAY
STAY,MILLARD RULE OF 10,REMOVAL OF
30. 12-16 WEEKS-REVIEW AND POST OP,
ENT
ASSESSMENT.
6-18 MONTHS-SURGICAL REVIEW.
18 MONTHS – 6 YEARS:-ENT AND PEDIATRIC
,DENTAL ASSESMENT.
6-12 YEARS:-LATE PRIMARY / EARLY MIXED:-
ENT,ORTHODONTIST,PEDODONTIST,
PLASTIC SURGEON,PSYCHOLOGIST.
12-18 YEARS:-LIP
REVISION,RHINOPLASTY,OSTEOTOMY,DENT
AL IMPLANTS.
20 YEARS:-LOCAL COLLECTION AND FULL
32. Pre surgical plates, moulding
plates, feeding plates…….
Dr. Christine Underhill 12th July 2008
33. TREATMENT
Primary management:-
Primary management is done by:-
• Millard rotational flap
• Langenback’s operation
• Wardill’s operation
Cleft palate only:-
• Soft palate only- one operation at 6
months
• Soft palate & hard palate -two operation
soft palate at 6 months hard palate
at 15-18 months.
34.
Cleft palate and cleft lip:-
• Unilateral:- 2 operation:-
• Cleft lip an soft palate at 5-6 months.
• Hard palate and gum pad with or
without lip at 15-18 months.
• Bilateral:- 2 operation:-
• Cleft lip and soft palate at 4-5 months.
• Hard palate and gum pad with or
without lip at 15-18 months
35. Cheilorrhaphy
Surgical correction of cleft lip deformity.
Early operative procedure used to correct cleft
deformities.
Cleft lip disrupts the important circumoral
orbicuralis oris musculature.
Objectives :-1.Functional-restore normal
function and arrangement of muscle.
2.Esthetic.-normal anatomic
structures,cupid bow and philtrum.
36. Surgical technique
Different for different types of clefts.
In unilateral cases,unaffected side serve as a
guide for lip length and symmetry.
Lips closed in linear fashion.
Restore symmetry not only to lip but also to
the nasal tip.
First and the most important steps in
correcting nasal deformity.
38. Palatorrhaphy
Performed in one operation,but occsaionally
performed in two also.
Two operations:-soft palate closure
(staphylorrhaphy) performed first followed by
hard palate closure(uranorrhaphy).
OBJECTIVES:-speech and degluttion
correction.
Surgical techniques includes:-Hard palate
closure
Soft palate closure.
44. Alveolar bone grafting (ABG)
Provides continuity of alveolar ridge.
Provides bone for canine to erupt .
Osseous support for adjacent teeth
Majority of canines erupt spontaneously…
others require surgical exposure often in
combination with orthodontics.
The erupting teeth often appear to then
stimulate the formation of new alveolar bone
45. Secondary surgical
procedures.
Performed after initial repair of cleft defects in
an effort to improve speech or correct residual
defects.
Commonly used technique to improve
velopharyngeal competence secondarily is the
palatal flat procedure.
Another technique is the placement of an
implants behind the posterior pharyngeal wall
to bring it anteriorly.
46. Conclusion
Cleft Lip and Palate are common congenital
deformities that often affect speech, hearing,
and cosmesis; and may at times lead to airway
compromise.
Oro facial clefts require a multidisciplinary
approach
Treatment extends over many years and risks
exhausting patient cooperation
Need to keep the patients best interests in
mind…