Cleft Lip: Primary and
Secondary Deformities
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Historical background
Cleft lip
– 1st
repair
• Unidentified Chinese surgeon
• 390 AD
– 1st
description
∀ ∼1300 AD
• Strai...
Historical background
Cleft lip
– Millard
• 1955
• Concept:
– Lateral flap advancement into upper lip
– Downward rotation...
Embryology basics
Primary germ layers
– Ectoderm
• Cutaneous,
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Embryology basics
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Embryology basics
Facial development
– 4th
to 10th
week gestation
– Fusion of five processes:
• Unpaired frontonasal
proc...
Embryology basics
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Embryology basics
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Embryology basics
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Embryology basics
Facial development
– 6th
week
• Medial nasal processes migrate and fuse
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Embryology of CleftingEmbryology of Clefting
Facial DevelopmentFacial Development
Medial nasal processesMedial nasal proce...
Classification
Standardized
methods
– Key anatomic
structure
• Incisive foramen
– Primary
• Lip
• Premaxilla
• Alveolus
–...
Classification
Cleft of primary palate (cleft lip)
– Unilateral
• Incomplete
– Lip only
• Complete
– Primary palate
– Lip...
Classification
Cleft of primary palate (cleft lip)
– Bilateral
• Incomplete
– Lip only
• Complete
– Primary palate
– Lip,...
Classification
Standardized
methods
– Kernahan
• 1971
• “Striped Y”
– Incisive foramen
as focal point
• Position 7
– Hard...
Classification
Standardized
methods
– Millard modification
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Epidemiology
Cleft lip and palate
– Racial heterogeneity
• Asians
– 2.1 in 1000 live births
• Whites
– 1 in 1000 live bir...
Epidemiology
Relative incidence
– Fraser and Calnan
• 21% cleft lip
• 46% cleft lip and palate
• 33% cleft palate
• Left ...
Epidemiology
Associated factors
– Parental age
• Incidence increases with age
• Father’s age more significant
• Risk high...
Epidemiology
Associated factors
– Parental head topography
• Parents:
– Underdeveloped maxillae
– Flattened anterior surf...
Epidemiology
Associated defects
– Overall incidence of associated defects
29%
• CNS malformations
• Club foot
• Cardiac a...
Etiology
Categorize cleft deformity
– Malformation
• Morphologic defect of organ or body region
– Intrinsic error of morp...
Etiology
Categorize cleft deformity
– Syndromic
• More than one malformation
• More than one developmental field
– Non-sy...
Genetics
Associated syndromes
– Stickler
• Cleft palate alone
• Autosomal dominant
• Type 2 collagen gene mutation
• Myop...
Genetics
Associated syndromes
– Blepharo-cheilo-dontic syndrome
• Eyelids
– Euryblepharon
– Ectropion
– Lagophthalmia
• T...
Genetics
Non syndromic presentations
– Cleft lip +/- palate
• Different chromosome regions
• 6p23
• 2q13
• 19q13.2
– Clef...
Environmental agents
Chemical agents
– Animal model
– Alcohol
• No increased risk of cleft with low quantities of EtOH
• ...
Environmental agents
Folic acid
– Beneficial effect
– Reduced incidence of unilateral cleft lip and
palate with at risk m...
Environmental agents
Altitude
– Higher relative risk in highlands
• Also microtia
• Preauricular tags
• Branchial arch an...
Multifactorial model
Non mendelian inheritance
– Concept of genetic susceptibility
• Threshold determined by genetics and...
Genetic counseling
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Prenatal diagnosis
Ultrasound
– Late 1st
trimester/early second trimester
• 3.5 MHz scanner
– Cleft lip/nose at 15 weeks
...
Timing of surgery
Rule of tens
– 10 weeks of age
• Allow lip tissues to develop
– 10 lbs in weight
– Hgb 10 g/dL (100 in ...
Anatomy
Millard
– Critical anatomic features of unilateral
cleft lip:
• Cleft side
– Premaxilla outwardly rotated
– Later...
Anatomy
Millard
– Critical anatomic features of unilateral
cleft lip:
• Cleft side
– Lower lateral cartilage attenuated
•...
Anatomy
Millard
– Critical anatomic features of unilateral
cleft lip:
• Cleft side
– Skin curtain droops over alar rim
• ...
Anatomy
Millard
– Critical anatomic features of unilateral
cleft lip:
• Non cleft side
– Shortened philtral height
– Shor...
Anatomy
Muscular deformity
– Muscular bulge
• Haphazard arrangement of muscle fibers
– Transverse/oblique/anteroposterior...
Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Unilateral cleft lip
Evaluation and classification
– Three categories of unilateral cleft lip:
• Microform cleft lip
• In...
Unilateral cleft lip
Microform cleft lip (forme fruste)
– Presentation:
• Furrow or scar
• Transgresses vertical length o...
Unilateral cleft lip
Microform cleft lip
(forme fruste)
– Three characteristic
elements:
• Vermilion notch
• Band of fibr...
Unilateral cleft lip
Microform cleft lip
– Surgical management
• Usually indicated
• Vertical height equal on affected si...
Unilateral cleft lip
Unilateral incomplete cleft lip
– Varying degree of vertical separation of
the lip
– Intact nasal si...
Unilateral cleft lip
Unilateral complete cleft lip
– Presentation:
• Separation of lip, nostril sill and alveolus
– Deriv...
Unilateral cleft lip
Unilateral complete cleft lip
– Alveolar (maxillary) segment
• Four positions
– Narrow with no colla...
Unilateral cleft lip
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Unilateral cleft lip
Unilateral complete
cleft lip
– Narrow with no
collapse
• Rotation advancement
lip and nasal repair
...
Unilateral cleft lip
Unilateral complete
cleft lip
– Narrow with collapse
• Ideal with presurgical
palatal orthopedic
exp...
Unilateral cleft lip
Unilateral complete
cleft lip
– Wide without collapse
• Molding appliance
– Maintain width
– Guide a...
Unilateral cleft lip
Unilateral complete
cleft lip
– Wide with collapse
• Presurgical appliance
– Expands collapse
– Mold...
Unilateral cleft lip
Unilateral complete cleft lip
– Lip adhesion
• Highly selected unilateral and bilateral wide
clefts
...
Unilateral cleft lip
Options for presurgical molding
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Unilateral cleft lip
Evolution of cleft lip repair
– 1st
principle
• Lengthen vertical height of cleft side to match
norm...
Unilateral cleft lip
Evolution of cleft lip repair
– 2nd
principle:
• Using lateral lip tissue in deficient medial
segmen...
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Unilateral cleft lip
Evolution of cleft lip repair
– 4th
principle
• Rotation advancement concept
• Millard
– Incision li...
Unilateral cleft lip
Evolution of cleft lip repair
– 5th
principle:
• Muscle reconstruction and preservation of lip
funct...
Unilateral cleft lip
Evolution of cleft lip repair
– 6th
principle:
• Restoration of the bony platform
• Presurgical orth...
Unilateral cleft lip
Evolution of cleft lip repair
– 7th
principle:
• Restoration of normal nasal anatomy
– Complex
– Top...
Unilateral
cleft lip
Millard repair
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Unilateral cleft lip
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Unilateral cleft lip
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Unilateral cleft lip
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Unilateral cleft lip
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Unilateral cleft lip
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Bilateral cleft lip
Complex surgical dilemna
– Multiple techniques described and
utilized
– No one technique clearly supe...
Bilateral cleft lip
Deformity
– Protruding premaxilla
• Lack of connection of premaxilla with lateral
palatal shelves dur...
Bilateral cleft lip
Deformity
– Short columella
• Skin over columella is short
• “absent columella”
– Prolabium
• Anterio...
Bilateral cleft lip
Incomplete bilateral cleft lip
– Near normal nose
– Normal premaxilla
– Simonart’s bands across nasal...
Bilateral cleft lip
Protruding premaxilla
– Main obstacle in bilateral clefts
• Multiple approaches described
• Lip repai...
Bilateral cleft lip
Protruding premaxilla
– Alternate techniques:
• Elastic bonnet
– Poor control of premaxilla position ...
Bilateral cleft lip
Construction of central lip vermilion
– Two general methods:
• Buccal mucosa
– Inferior aspect of pro...
Bilateral cleft lip
Construction of
central lip vermilion
– Two general
methods:
• Lateral vermilion
tissue
– Muscle rota...
Bilateral cleft lip
Skin paradigm
– How to best use
prolabial skin and to
attempt to lengthen
columella?
• Split prolabiu...
Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Bilateral cleft lip
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Secondary deformities
Introduction
– Factors in decreased need for revisionary
surgery:
• Improved primary techniques
• S...
Secondary deformities
Introduction
– Lip repair expectations
• Accurate skin, muscle and mucous
membrane union
• Proper r...
Secondary deformities
Approach
– Assess following variables:
• Anatomic elements
– Components to be preserved and altered...
Secondary deformities
Timeline
– Complete majority prior to school age
• Facilitate peer interactions
– Final revisions i...
Secondary deformities
Unilateral cleft lip
– Deficient tubercle
– Vermilion deficiency and irregularities
– Short upper l...
Secondary deformities
Unilateral cleft lip
– Deficient tubercle
• V-Y advancement
• Dermal graft
– Create tunnel along ho...
Secondary deformities
Unilateral cleft lip
– Vermilion deficiency
and irregularities
• Notch “whistle
deformity”
– Inadeq...
Secondary deformities
Unilateral cleft lip
– Vermilion deficiency
and irregularities
• Mucosal deficiency
– Z plasty
– V-...
Secondary deformities
Unilateral cleft lip
– Vermilion deficiency and
irregularities
• Loss of Cupid’s bow
– Unilateral G...
Secondary deformities
Unilateral cleft lip
– Vermilion deficiency and
irregularities
• Loss of philtral column
– Limited ...
Secondary deformities
Unilateral cleft lip
– Vermilion deficiency and
irregularities
• Lateral vermilion
deficiencies
– L...
Secondary deformities
Unilateral cleft lip
– Short upper lip
• Measure of distance from Cupid’s bow to
columella
– Failur...
Secondary deformities
Unilateral cleft lip
– Short upper lip
• Lip lengthening techniques
– Rotation advancement flaps
– ...
Secondary deformities
Unilateral cleft lip
– Short upper lip
• Most common after straight line repair
– Rotation advancem...
Secondary deformities
Unilateral cleft lip
– Short upper lip
• Millard repair
– Inadequate rotation
– Inadequate muscle r...
Secondary deformities
Unilateral cleft lip
– Long upper lip
• More common in triangular and quadrangular
repairs
• Unusua...
Secondary deformities
Unilateral cleft lip
– Tight upper lip
• Horizontal tightness across upper lip
• Z-plasty
• Restric...
Secondary deformities
Unilateral cleft lip
– Tight upper lip
– Abbe flap
• Brings lower lip pouting tissue
to upper lip
•...
Secondary deformities
Unilateral cleft lip
– Unfavorable scars
• 1st
scar often the best
– Often restraint between 8 to 1...
Secondary deformities
Unilateral cleft lip
– Unfavorable scars
• Revisional techniques
– Excision and closure
• Straight ...
Secondary deformities
Unilateral cleft lip
– Buccal sulcus abnormalities
• Adhesions/scars
– Z plasty
– Z-Y technique
• D...
Secondary deformities
Unilateral cleft lip
– Orbicularis oris derangement
• Secondary repair of muscle
– Orient fibers tr...
Secondary deformities
Bilateral cleft lip
– More commonly has secondary deformity
– Issues
• Scars
• Tight lip
• Wide lip...
Secondary deformities
Bilateral cleft lip
– Scars
• Same approach as unilateral
• Millard
– Revise scars on side at a tim...
Secondary deformities
Bilateral cleft lip
– Tight lip
• Often associated with severe clefts
– Innate shortage of lip tiss...
Secondary deformities
Bilateral cleft lip
– Tight lip
• Lip switch
– Abbe flap
– Midline placement
– Attempt recreation o...
Secondary deformities
Bilateral cleft lip
– Wide lip
• Classic
– Failure to reunite orbicularis oris muscle during
primar...
Secondary deformities
Bilateral cleft lip
– Short lip
• More common in bilateral clefts
– Greater tissue deficiency
• Z p...
Secondary deformities
Bilateral cleft lip
– Missing or misplaced landmarks
• Missing philtral landmarks
– Absent on prola...
Secondary deformities
Bilateral cleft lip
– Vermilion deficiency and
irregularities
• Paucity of central lip
• Whistle de...
Secondary deformities
Bilateral cleft lip
– Vermilion deficiency and
irregularities
– Lateral vermilion flaps
• V-Y advan...
Secondary deformities
Bilateral cleft lip
– Vermilion deficiency and
irregularities
– Lateral vermilion flaps
• Double pe...
Secondary deformities
Bilateral cleft lip
– Buccal sulcus
abnormalities
• Local flaps
• Skin grafts
– Needs splinting
– S...
Secondary deformities
Bilateral cleft lip
– Orbicularis oris deformities
• Proper muscle reconstruction
– Perioral and pe...
Secondary deformities
Bilateral cleft lip
– Lower lip changes
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Secondary deformities
Residual skeletal deformities
– Issues
• Maxillary hypoplasia
• Alveolar bone grafting
• Orthognath...
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Thank you
For more details please visit
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Cleft lip primary & secondary deformities /certified fixed orthodontic courses by Indian dental academy

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  • Good afternoon ladies and gentlemen
  • Cleft lip primary & secondary deformities /certified fixed orthodontic courses by Indian dental academy

    1. 1. Cleft Lip: Primary and Secondary Deformities INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. Historical background Cleft lip – 1st repair • Unidentified Chinese surgeon • 390 AD – 1st description ∀ ∼1300 AD • Straight line repair – Malgaigne • 1843 • Local flap closure – Mirault • Lateral flap to fill medial deficit • Basis of most modern techniques www.indiandentalacademy.com
    3. 3. Historical background Cleft lip – Millard • 1955 • Concept: – Lateral flap advancement into upper lip – Downward rotation of medial segment – Preserves Cupid’s bow and philtral dimple – Tension of closure at alar base • Reduces nasal flare • Improved alveolar molding • Most popular method for unilateral lip closure www.indiandentalacademy.com
    4. 4. Embryology basics Primary germ layers – Ectoderm • Cutaneous, www.indiandentalacademy.com
    5. 5. Embryology basics www.indiandentalacademy.com
    6. 6. Embryology basics Facial development – 4th to 10th week gestation – Fusion of five processes: • Unpaired frontonasal process – Nose and philtrum • Paired maxillary swellings – Cheeks and upper lip • Paired mandibular swellings – Lower face – Lower lip and chin www.indiandentalacademy.com
    7. 7. Embryology basics www.indiandentalacademy.com
    8. 8. Embryology basics www.indiandentalacademy.com
    9. 9. Embryology basics www.indiandentalacademy.com
    10. 10. Embryology basics Facial development – 6th week • Medial nasal processes migrate and fuse www.indiandentalacademy.com
    11. 11. Embryology of CleftingEmbryology of Clefting Facial DevelopmentFacial Development Medial nasal processesMedial nasal processes (green) migrate toward each other and fuse Inferior tips of medial nasal processes expand laterally to form the intermaxillary process Tips of maxillary swellings (yellow) grow to meet the intermaxillary process and fuse 66thth weekweek 7th week Failure of maxillary swellings to fuse with intermaxillary process = cleft lipFailure of maxillary swellings to fuse with intermaxillary process = cleft lip Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction www.indiandentalacademy.com
    12. 12. Classification Standardized methods – Key anatomic structure • Incisive foramen – Primary • Lip • Premaxilla • Alveolus – Secondary • Soft palate • Hard palate www.indiandentalacademy.com
    13. 13. Classification Cleft of primary palate (cleft lip) – Unilateral • Incomplete – Lip only • Complete – Primary palate – Lip, nasal floor, alveolus www.indiandentalacademy.com
    14. 14. Classification Cleft of primary palate (cleft lip) – Bilateral • Incomplete – Lip only • Complete – Primary palate – Lip, nasal floor, alveolus www.indiandentalacademy.com
    15. 15. Classification Standardized methods – Kernahan • 1971 • “Striped Y” – Incisive foramen as focal point • Position 7 – Hard palate • Position 8 – Soft palate • Position 9 – Submucous cleft www.indiandentalacademy.com
    16. 16. Classification Standardized methods – Millard modification www.indiandentalacademy.com
    17. 17. Epidemiology Cleft lip and palate – Racial heterogeneity • Asians – 2.1 in 1000 live births • Whites – 1 in 1000 live births • African Americans – 0.41 in 1000 Isolated cleft palate – Constant incidence • 0.5 in 1000 live births www.indiandentalacademy.com
    18. 18. Epidemiology Relative incidence – Fraser and Calnan • 21% cleft lip • 46% cleft lip and palate • 33% cleft palate • Left > right > bilateral – 6:3:1 www.indiandentalacademy.com
    19. 19. Epidemiology Associated factors – Parental age • Incidence increases with age • Father’s age more significant • Risk highest with both parents over 30 years – Seasonal incidence • No strong evidence – Birth order • No evidence – Social class • High incidence in low socio economic status • Poor nutrition www.indiandentalacademy.com
    20. 20. Epidemiology Associated factors – Parental head topography • Parents: – Underdeveloped maxillae – Flattened anterior surfaces – Trapezoidal/rectangular faces – Thin upper lips – Increased interorbital and intercoronoid process distance – Wide nasal cavity – Increased length of anterior cranial base www.indiandentalacademy.com
    21. 21. Epidemiology Associated defects – Overall incidence of associated defects 29% • CNS malformations • Club foot • Cardiac abnormalities – Highest with isolated cleft palate www.indiandentalacademy.com
    22. 22. Etiology Categorize cleft deformity – Malformation • Morphologic defect of organ or body region – Intrinsic error of morphogenesis – Disruption • Morphologic defect – Extrinsic breakdown of normal developmental process – Ie. infectious – Deformation • Abnormal form, shape or position caused by mechanical forces www.indiandentalacademy.com
    23. 23. Etiology Categorize cleft deformity – Syndromic • More than one malformation • More than one developmental field – Non-syndromic • One defect • Multiple anomalies as a result of a single initiating event or primary malformation www.indiandentalacademy.com
    24. 24. Genetics Associated syndromes – Stickler • Cleft palate alone • Autosomal dominant • Type 2 collagen gene mutation • Myopia, retinal detachment and glaucoma – Van der Woude’s syndrome • Autosomal dominant • Bilateral lower lip pits • Absence second molars www.indiandentalacademy.com
    25. 25. Genetics Associated syndromes – Blepharo-cheilo-dontic syndrome • Eyelids – Euryblepharon – Ectropion – Lagophthalmia • Teeth – Oligodontia – Conical crown form • Autosomal dominant www.indiandentalacademy.com
    26. 26. Genetics Non syndromic presentations – Cleft lip +/- palate • Different chromosome regions • 6p23 • 2q13 • 19q13.2 – Cleft palate alone • Recessive single major gene • ? 2q13/TGFA www.indiandentalacademy.com
    27. 27. Environmental agents Chemical agents – Animal model – Alcohol • No increased risk of cleft with low quantities of EtOH • Increased risk of clefting with higher quantities of EtOH – Dilantin • 10X higher risk of cleft lip – Smoking • Dose response relationship • Increased risk of clefting www.indiandentalacademy.com
    28. 28. Environmental agents Folic acid – Beneficial effect – Reduced incidence of unilateral cleft lip and palate with at risk mothers Isotretinoin – Accutane dysmorphic syndrome • Rudimentary external ears • Absent/imperforate auditory canals • Triangular microcephalic skull • Cleft palate • Depressed midface • Brain/jaw/heart anomalies www.indiandentalacademy.com
    29. 29. Environmental agents Altitude – Higher relative risk in highlands • Also microtia • Preauricular tags • Branchial arch anomaly complex • Constriction band • Anal atresia – Speculation • Chronic hypobaric hypoxia during embryologic and fetal development www.indiandentalacademy.com
    30. 30. Multifactorial model Non mendelian inheritance – Concept of genetic susceptibility • Threshold determined by genetics and enviroment – Defect clusters in families – Risk for first degree relatives = √population risk – Risk for second degree relatives = lower than first degree – Greater severity; increased recurrence – Increased number of affected relatives; increased risk – Risk of recurrence increased in relatives of less affected sex – Consanguinity increases risk www.indiandentalacademy.com
    31. 31. Genetic counseling www.indiandentalacademy.com
    32. 32. Prenatal diagnosis Ultrasound – Late 1st trimester/early second trimester • 3.5 MHz scanner – Cleft lip/nose at 15 weeks • 6.5 MHz transvaginal scanner – 12 weeks – Controversy • Termination of pregancy – Northern Israel – 23/24 abortions – 1/24 couple would terminate if faced with situation again • Variation in culture www.indiandentalacademy.com
    33. 33. Timing of surgery Rule of tens – 10 weeks of age • Allow lip tissues to develop – 10 lbs in weight – Hgb 10 g/dL (100 in our world!) – WBC less than 10,000 www.indiandentalacademy.com
    34. 34. Anatomy Millard – Critical anatomic features of unilateral cleft lip: • Cleft side – Premaxilla outwardly rotated – Lateral maxillary segment retropositioned – Inferior edge of septum dislocated out of vomer groove • Nasal spine in floor of nostril – Shortened columella www.indiandentalacademy.com
    35. 35. Anatomy Millard – Critical anatomic features of unilateral cleft lip: • Cleft side – Lower lateral cartilage attenuated • Medial crus lower in columella • Dome rests below opposite alar cartilage • Lateral segment flattened and spread across cleft at obtuse angle • Alar crease continues through rim of ala – Alar base rotated outwardly in a flare www.indiandentalacademy.com
    36. 36. Anatomy Millard – Critical anatomic features of unilateral cleft lip: • Cleft side – Skin curtain droops over alar rim • Reduces apparent height of columella – Deficient vestibular lining – Orbicularis oris ends upward at margin of cleft and inserts into alar wing • Incomplete cases muscle does not cross cleft – Short philtrum www.indiandentalacademy.com
    37. 37. Anatomy Millard – Critical anatomic features of unilateral cleft lip: • Non cleft side – Shortened philtral height – Shortened columella – Two thirds of Cupid’s bow, one philtral column and a dimple hollow preserved – Hypoplastic muscle between philtral midline and cleft www.indiandentalacademy.com
    38. 38. Anatomy Muscular deformity – Muscular bulge • Haphazard arrangement of muscle fibers – Transverse/oblique/anteroposterior – Orbicularis oris • Two well defined components – Deep orbicularis www.indiandentalacademy.com
    39. 39. Anatomy www.indiandentalacademy.com
    40. 40. Anatomy www.indiandentalacademy.com
    41. 41. Anatomy www.indiandentalacademy.com
    42. 42. Anatomy www.indiandentalacademy.com
    43. 43. Anatomy www.indiandentalacademy.com
    44. 44. Anatomy www.indiandentalacademy.com
    45. 45. www.indiandentalacademy.com
    46. 46. www.indiandentalacademy.com
    47. 47. www.indiandentalacademy.com
    48. 48. Unilateral cleft lip Evaluation and classification – Three categories of unilateral cleft lip: • Microform cleft lip • Incomplete cleft lip • Complete cleft lip – Associated nasal deformity: • Mild • Moderate • Severe www.indiandentalacademy.com
    49. 49. Unilateral cleft lip Microform cleft lip (forme fruste) – Presentation: • Furrow or scar • Transgresses vertical length of lip • Vermilion notch • White roll imperfections • Vertical lip shortness – Three characteristic elements: • Vermilion notch • Band of fibrous tissue from edge of red lip to nostril floor • Deformity of ala on notch side www.indiandentalacademy.com
    50. 50. Unilateral cleft lip Microform cleft lip (forme fruste) – Three characteristic elements: • Vermilion notch • Band of fibrous tissue from edge of red lip to nostril floor • Deformity of ala on notch side www.indiandentalacademy.com
    51. 51. Unilateral cleft lip Microform cleft lip – Surgical management • Usually indicated • Vertical height equal on affected side and normal side – Straight line repair • Elliptical excision • 2 layer closure • Vertical difference greater than 1-2mm – Rotation advancement repair www.indiandentalacademy.com
    52. 52. Unilateral cleft lip Unilateral incomplete cleft lip – Varying degree of vertical separation of the lip – Intact nasal sill • Simonart’s band – Corrected with rotation advancement repairs – Nasal repair carried out with primary repair www.indiandentalacademy.com
    53. 53. Unilateral cleft lip Unilateral complete cleft lip – Presentation: • Separation of lip, nostril sill and alveolus – Derivative of primary palate • Secondary palate often is involved • Position of alveolar segments critical www.indiandentalacademy.com
    54. 54. Unilateral cleft lip Unilateral complete cleft lip – Alveolar (maxillary) segment • Four positions – Narrow with no collapse – Narrow with collapse – Wide with no collapse – Wide with collapse • Wide – Alveolus position lateral to desired alar base position • Collapse – Lingual position of lateral maxillary segment www.indiandentalacademy.com
    55. 55. Unilateral cleft lip www.indiandentalacademy.com
    56. 56. Unilateral cleft lip Unilateral complete cleft lip – Narrow with no collapse • Rotation advancement lip and nasal repair • Static molding useful for maintaining ideal arch www.indiandentalacademy.com
    57. 57. Unilateral cleft lip Unilateral complete cleft lip – Narrow with collapse • Ideal with presurgical palatal orthopedic expansion – Start at 2 weeks – Continue until surgical intervention www.indiandentalacademy.com
    58. 58. Unilateral cleft lip Unilateral complete cleft lip – Wide without collapse • Molding appliance – Maintain width – Guide alveolar segments together • Lip adhesion www.indiandentalacademy.com
    59. 59. Unilateral cleft lip Unilateral complete cleft lip – Wide with collapse • Presurgical appliance – Expands collapse – Molds to reduce width of interalveolar space www.indiandentalacademy.com
    60. 60. Unilateral cleft lip Unilateral complete cleft lip – Lip adhesion • Highly selected unilateral and bilateral wide clefts • Temporarily brings lip margins together www.indiandentalacademy.com
    61. 61. Unilateral cleft lip Options for presurgical molding www.indiandentalacademy.com
    62. 62. Unilateral cleft lip Evolution of cleft lip repair – 1st principle • Lengthen vertical height of cleft side to match normal side • Rose Thompson – Straight line repair; curvilinear cleft side – Ideal for microform clefts www.indiandentalacademy.com
    63. 63. Unilateral cleft lip Evolution of cleft lip repair – 2nd principle: • Using lateral lip tissue in deficient medial segment – 3rd principle: • Retaining normal anatomic Cupid’s bow – Hagerdon, LeMesurier • Quadrangular flap – Tennison Randall • Triangular flap www.indiandentalacademy.com
    64. 64. www.indiandentalacademy.com
    65. 65. Unilateral cleft lip Evolution of cleft lip repair – 4th principle • Rotation advancement concept • Millard – Incision line follows natural anatomic position of philtral ridge – Avoid placement of scars across lower philtrum (different from quadrangular and triangular repairs) www.indiandentalacademy.com
    66. 66. Unilateral cleft lip Evolution of cleft lip repair – 5th principle: • Muscle reconstruction and preservation of lip function – Extensive dissections – Nicolau and delineation of layers of muscle • Deep and superficial orbicularis oris • Intertwined with paraoral/paranasal muscles www.indiandentalacademy.com
    67. 67. Unilateral cleft lip Evolution of cleft lip repair – 6th principle: • Restoration of the bony platform • Presurgical orthopedics – Passive – Active • Latham appliance • Bone grafting • Gingivoperiosteoplasty – controversial www.indiandentalacademy.com
    68. 68. Unilateral cleft lip Evolution of cleft lip repair – 7th principle: • Restoration of normal nasal anatomy – Complex – Topic unto itself (stay tuned for next week!) www.indiandentalacademy.com
    69. 69. Unilateral cleft lip Millard repair www.indiandentalacademy.com
    70. 70. Unilateral cleft lip www.indiandentalacademy.com
    71. 71. Unilateral cleft lip www.indiandentalacademy.com
    72. 72. Unilateral cleft lip www.indiandentalacademy.com
    73. 73. Unilateral cleft lip www.indiandentalacademy.com
    74. 74. Unilateral cleft lip www.indiandentalacademy.com
    75. 75. Bilateral cleft lip Complex surgical dilemna – Multiple techniques described and utilized – No one technique clearly superior – Compared to unilateral clefts: • Twice as difficult with result ½ as good www.indiandentalacademy.com
    76. 76. Bilateral cleft lip Deformity – Protruding premaxilla • Lack of connection of premaxilla with lateral palatal shelves during development – Absent nasal spine • Retruded area under base of septal cartilage • Recession of medial crura footplates • Lower lateral cartilage footplates drawn by lateral palatal shelves – Broad flat nasal tip www.indiandentalacademy.com
    77. 77. Bilateral cleft lip Deformity – Short columella • Skin over columella is short • “absent columella” – Prolabium • Anterior inferior extent of frontonasal process normally contributes skin between philtral columns • Wide and short • Hangs directly from nasal tip skin www.indiandentalacademy.com
    78. 78. Bilateral cleft lip Incomplete bilateral cleft lip – Near normal nose – Normal premaxilla – Simonart’s bands across nasal floor – Surgical management • Rotation advancement • Triangular flap • Similar to unilateral • Single or double stages • Can also use bilateral straight line technique www.indiandentalacademy.com
    79. 79. Bilateral cleft lip Protruding premaxilla – Main obstacle in bilateral clefts • Multiple approaches described • Lip repair/adhesion – Stages attempt at retracting premaxilla – Unpredictable – Closed under tension – Wide scars with repair – Lip adhesion • Inflammation www.indiandentalacademy.com
    80. 80. Bilateral cleft lip Protruding premaxilla – Alternate techniques: • Elastic bonnet – Poor control of premaxilla position relative to lateral segments • Premaxilla excision/setback at 1st operation – NOT a present day option – Discards permanent incisors – Severe midface retrusion • Pin retained premaxillary retraction devices – Allows for gingivoperiosteoplasty – Bone grows across small cleft • Nasoalveolar molding www.indiandentalacademy.com
    81. 81. Bilateral cleft lip Construction of central lip vermilion – Two general methods: • Buccal mucosa – Inferior aspect of prolabial skin – Forms central vermilion – Bulk • Strips of muscle across • Deepithelialized buccal mucosa from lateral lip – Most often inadequate bulk in central section • Whistle deformity – Dry versus wet lip problem www.indiandentalacademy.com
    82. 82. Bilateral cleft lip Construction of central lip vermilion – Two general methods: • Lateral vermilion tissue – Muscle rotates with lateral lip elements – Single scar at depth of Cupid’s bow – Scar mimics white roll – Good bulk www.indiandentalacademy.com
    83. 83. Bilateral cleft lip Skin paradigm – How to best use prolabial skin and to attempt to lengthen columella? • Split prolabium – Form philtrum and neocolumella • Millard fork flap technique www.indiandentalacademy.com
    84. 84. Bilateral cleft lip www.indiandentalacademy.com
    85. 85. Bilateral cleft lip www.indiandentalacademy.com
    86. 86. Bilateral cleft lip www.indiandentalacademy.com
    87. 87. Bilateral cleft lip www.indiandentalacademy.com
    88. 88. Bilateral cleft lip www.indiandentalacademy.com
    89. 89. Bilateral cleft lip www.indiandentalacademy.com
    90. 90. Bilateral cleft lip www.indiandentalacademy.com
    91. 91. Bilateral cleft lip www.indiandentalacademy.com
    92. 92. Bilateral cleft lip www.indiandentalacademy.com
    93. 93. Secondary deformities Introduction – Factors in decreased need for revisionary surgery: • Improved primary techniques • Specialized centers of excellence • Sophisticated presurgical orthodontics • Nasal correction simultaneously • Gingivoplasty • Nasal molding www.indiandentalacademy.com
    94. 94. Secondary deformities Introduction – Lip repair expectations • Accurate skin, muscle and mucous membrane union • Proper rotation of lateral orbicularis into horizontal position • Symmetric nostril floor and tip • Even vermilion border and cupid bow’s • Eversion of central upper lip • Minimal scar – Failure of above needs secondary repair www.indiandentalacademy.com
    95. 95. Secondary deformities Approach – Assess following variables: • Anatomic elements – Components to be preserved and altered • Residual deformities – Uncorrected – Recurrences – Iatrogenic • Realistic surgical goals – Choose procedure with most predictable results with fewest interventions www.indiandentalacademy.com
    96. 96. Secondary deformities Timeline – Complete majority prior to school age • Facilitate peer interactions – Final revisions in adolescence www.indiandentalacademy.com
    97. 97. Secondary deformities Unilateral cleft lip – Deficient tubercle – Vermilion deficiency and irregularities – Short upper lip – Long upper lip – Tight upper lip – Unfavorable scars www.indiandentalacademy.com
    98. 98. Secondary deformities Unilateral cleft lip – Deficient tubercle • V-Y advancement • Dermal graft – Create tunnel along horizontal length with orbicularis • Rotate medial edges of vermilion mucosal flaps inferiorly • Temporoparietal fascia flap www.indiandentalacademy.com
    99. 99. Secondary deformities Unilateral cleft lip – Vermilion deficiency and irregularities • Notch “whistle deformity” – Inadequate approximation of orbicularis www.indiandentalacademy.com
    100. 100. Secondary deformities Unilateral cleft lip – Vermilion deficiency and irregularities • Mucosal deficiency – Z plasty – V-Y advancement www.indiandentalacademy.com
    101. 101. Secondary deformities Unilateral cleft lip – Vermilion deficiency and irregularities • Loss of Cupid’s bow – Unilateral Gillies operation – Triangular skin excision above mucocutaneous line – Close horizontally – Modified Abbe flap www.indiandentalacademy.com
    102. 102. Secondary deformities Unilateral cleft lip – Vermilion deficiency and irregularities • Loss of philtral column – Limited surgical useful techniques – Subcutaneous rotation flap – Rollover muscle flap – Chondrocutaneous composite flap – Auricular cartilage graft – Muscle splitting technique • Vest over pants closure www.indiandentalacademy.com
    103. 103. Secondary deformities Unilateral cleft lip – Vermilion deficiency and irregularities • Lateral vermilion deficiencies – Lower lip vermilion flap – Centrally based cross lip flap www.indiandentalacademy.com
    104. 104. Secondary deformities Unilateral cleft lip – Short upper lip • Measure of distance from Cupid’s bow to columella – Failure to lengthen lip at primary repair • Initial shortening – 1st 2 months – Maximal at 6-8 weeks – Softens and relaxes subsequently – Resumes immediate post op appearance if muscle repair adequate www.indiandentalacademy.com
    105. 105. Secondary deformities Unilateral cleft lip – Short upper lip • Lip lengthening techniques – Rotation advancement flaps – Z plasties – V-Y forked flaps – Muscle advancements – Abbe flap www.indiandentalacademy.com
    106. 106. Secondary deformities Unilateral cleft lip – Short upper lip • Most common after straight line repair – Rotation advancement flap useful – Indications • Cleft philtral scar short • Cupid’s bow pulled up toward nostril • Wide nostril floor • Alar displacement laterally and downwards www.indiandentalacademy.com
    107. 107. Secondary deformities Unilateral cleft lip – Short upper lip • Millard repair – Inadequate rotation – Inadequate muscle repair • Consider rerotation and muscle repair • Triangular repair – Flattening of Cupid’s bow – Shift of vermilion tubercle to cleft side www.indiandentalacademy.com
    108. 108. Secondary deformities Unilateral cleft lip – Long upper lip • More common in triangular and quadrangular repairs • Unusual to have overrotation of rotation advancement flap • Horizontal excision at alar base – Full thickness www.indiandentalacademy.com
    109. 109. Secondary deformities Unilateral cleft lip – Tight upper lip • Horizontal tightness across upper lip • Z-plasty • Restricts anteroposterior facial growth – Relative pouting lower lip • Correction with Abbe flap www.indiandentalacademy.com
    110. 110. Secondary deformities Unilateral cleft lip – Tight upper lip – Abbe flap • Brings lower lip pouting tissue to upper lip • Most often with bilateral repairs – Recreates philtrum • Rotate on intact labial artery and vein • 1/3 of lower lip can be harvested – Mental crease should not be violated • Division of pedicle after 10-14 days www.indiandentalacademy.com
    111. 111. Secondary deformities Unilateral cleft lip – Unfavorable scars • 1st scar often the best – Often restraint between 8 to 18 years best • Hypertrophic or widened scars – Present one month post op – Red, raised and firm – Taping • Revision • Pink scar – Yellow light laser • Dermabrasion www.indiandentalacademy.com
    112. 112. Secondary deformities Unilateral cleft lip – Unfavorable scars • Revisional techniques – Excision and closure • Straight line • Wave line • Z plasty • W plasty • Stair step technique – Philtral column • Epithelium is resected • Leave dermis for bulk www.indiandentalacademy.com
    113. 113. Secondary deformities Unilateral cleft lip – Buccal sulcus abnormalities • Adhesions/scars – Z plasty – Z-Y technique • Deepening of sulcus – STSG – Oral mucosal free grafts – Local mucosal flaps www.indiandentalacademy.com
    114. 114. Secondary deformities Unilateral cleft lip – Orbicularis oris derangement • Secondary repair of muscle – Orient fibers transversely across defect • Muscle layers – Superficial – Deep • Peripheral and marginal slips – Separate repair of different layers recommended www.indiandentalacademy.com
    115. 115. Secondary deformities Bilateral cleft lip – More commonly has secondary deformity – Issues • Scars • Tight lip • Wide lip • Short lip • Missing or misplaced landmarks • Vermilion deficiencies • Buccal sulcus abnormalities www.indiandentalacademy.com
    116. 116. Secondary deformities Bilateral cleft lip – Scars • Same approach as unilateral • Millard – Revise scars on side at a time • Avoid excessive tension – Bank excessive lip scar • Useful for columellar lengthening www.indiandentalacademy.com
    117. 117. Secondary deformities Bilateral cleft lip – Tight lip • Often associated with severe clefts – Innate shortage of lip tissue – Overresection of tissue at primary repair www.indiandentalacademy.com
    118. 118. Secondary deformities Bilateral cleft lip – Tight lip • Lip switch – Abbe flap – Midline placement – Attempt recreation of philtrum – Dimensions • 0.8-1.2 cm wide at vermilion border • 0.6-0.9 cm at base of columella • 1.7 cm high www.indiandentalacademy.com
    119. 119. Secondary deformities Bilateral cleft lip – Wide lip • Classic – Failure to reunite orbicularis oris muscle during primary surgery – Gradual widening of philtrum • Correction – Muscle realigning techniques – Removal of excess philtral skin www.indiandentalacademy.com
    120. 120. Secondary deformities Bilateral cleft lip – Short lip • More common in bilateral clefts – Greater tissue deficiency • Z plasty – Lengthens by reducing horizontal dimension • Can need Abbe flap www.indiandentalacademy.com
    121. 121. Secondary deformities Bilateral cleft lip – Missing or misplaced landmarks • Missing philtral landmarks – Absent on prolabium of bilateral clefts • Same as with unilateral secondary deformity repair www.indiandentalacademy.com
    122. 122. Secondary deformities Bilateral cleft lip – Vermilion deficiency and irregularities • Paucity of central lip • Whistle deformity – Thin central lip – Relative • Excessive vermilion laterally • Transverse wedge excisions – Tendency to contract • Bulky design of flaps necessary www.indiandentalacademy.com
    123. 123. Secondary deformities Bilateral cleft lip – Vermilion deficiency and irregularities – Lateral vermilion flaps • V-Y advancement www.indiandentalacademy.com
    124. 124. Secondary deformities Bilateral cleft lip – Vermilion deficiency and irregularities – Lateral vermilion flaps • Double pendulum flaps www.indiandentalacademy.com
    125. 125. Secondary deformities Bilateral cleft lip – Buccal sulcus abnormalities • Local flaps • Skin grafts – Needs splinting – Second choice with children • V-Y advancement of entire labial sulcus • Combination – Z plasty – VY advancement www.indiandentalacademy.com
    126. 126. Secondary deformities Bilateral cleft lip – Orbicularis oris deformities • Proper muscle reconstruction – Perioral and perinasal – Minimizes secondary skeletal deformities www.indiandentalacademy.com
    127. 127. Secondary deformities Bilateral cleft lip – Lower lip changes www.indiandentalacademy.com
    128. 128. Secondary deformities Residual skeletal deformities – Issues • Maxillary hypoplasia • Alveolar bone grafting • Orthognathic surgery • Palatal fistulas – anterior www.indiandentalacademy.com
    129. 129. www.indiandentalacademy.com Thank you For more details please visit www.indiandentalacademy.com

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