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Cleft class
This presentation discusses cleft lip and palate, including the embryology, causes, problems experienced by patients, classification systems used, and principles and techniques for management and repair. It focuses on the development of the lip and palate in utero, factors that can cause cleft deformities like genetics and environmental exposures. Management involves a multidisciplinary team and follows a timeline of prenatal diagnosis, birth evaluation, lip repair at 3-6 months, palate repair at 9-18 months, bone grafting at ages 8-11 years and other procedures.
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Cleft class
- 1. Clinical Oral SurgeryClass 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. Cleft Lip andPalate in Saudia Arabia
- 3. Objectives Development of cleftlip & 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. Embryology • Formation ofthe lip and palate takes place between the 5th and 10th week of fetal life
- 5. Embryology Failure of fusionof medial nasal process and maxillary process results in a cleft lip
- 9. Palate - Development •Palatal shelves rotate to the horizontal position • Fuse from anterior to posterior to form the palate by 12 weeks
- 10. Primary and Secondarypalates
- 12. • 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
- 13. Etiology • Multifactorial – Genetic predisposition –Environmental factors • • • • Diazepam Corticosteroids Phenytoin Folic acid deficiency
- 15. Ultrasound scan diagnosis Ultrasoundimages of clefts of the lip can be visualized as early as 16 weeks
- 17. Objectives Development of cleftlip & 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
- 18. Problems of individualswith clefts • Dental problems • Malocclusion • Feeding problems • Nasal deformity • Ear problems • Speech difficulties • Associated anomalies
- 19. Problems of individualswith 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
- 20. Malocclusion • Class IIIseen in most cases • Retruded maxilla
- 21. Feeding problems • Sucklingand swallowing reflexes are normal • Have extreme difficulty producing the necessary negative pressure
- 22. Feeding problems • Speciallydesigned nipples with enlarged openings • More frequent burping is necessary
- 23. Nasal deformity • Alarcartilage 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
- 24. Ear problems • Morepredisposed to middle ear infections • Chronic serous otitis media is common among children with cleft palate
- 25. Speech difficulties • VPI •Hypernasality • Compensatory articulations
- 26. Speech difficulties :articulation • Dental malformation, malocclusion, and abnormal tongue placement may develop before the palate is closed and thus produce an articulation problem.
- 27. Speech difficulties • Hearingloss at an early age is especially detrimental to the development of normal speech skills
- 28. • The levatorveli palatini muscle functions to elevate the velum and enable appropriate speech production
- 29. Objectives Development of cleftlip & 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
- 30. Classification of clefts Thetypical 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
- 31. Classification of Cleftlip and palate
- 35. Millard’s modified classificationof Kernahan’s classification
- 36.
- 37. Problems of individualswith clefts • Dental problems • Malocclusion • Feeding problems • Nasal deformity • Ear problems • Speech difficulties • Associated anomalies
- 39. Management Protocol forCleft 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)
- 40. Naso alveolar molding •Done during the first 3 months to bring the cleft segments closer and facilitate lip repair
- 41. Rule of 10 •10 gm% Hb • 10 pounds wt • 10 weeks old
- 42. The ideal cleftlip 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
- 44. Cleft lip repair •Unilateral • Millard Rotation – advancement lip repair • Tennison Randall Triangular flap lip repair • Bilateral • Mulliken lip repair
- 45.
- 46. Tennison Randall Triangularflap lip repair
- 47.
- 48. Bilateral cleft liprepair
- 49. Bilateral cleft liprepair
- 50. • 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
- 55. Palate repair • Bardach’s2 flap palatoplasty • Von Langenbeck palate repair • Furlows double opposing z plasty
- 56. Bardach 2 flappalatoplasty
- 57. Bardach’s 2 flappalatoplasty
- 58.
- 59. Furlow’s double opposingZ plasty
- 60. • 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
- 61. SABG • Specific timingis 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
- 62. Goal of bonegrafting • 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
- 64. Objectives Development of cleftlip 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