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Cleft class
- 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. Cleft Lip and Palate in Saudia Arabia
- 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. Embryology • Formation of the lip and palate takes place between the 5th and 10th week of fetal life
- 5. Embryology Failure of fusion of 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 Secondary palates
- 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 Ultrasound images of clefts of the lip can be visualized as early as 16 weeks
- 17. 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
- 18. Problems of individuals with clefts • Dental problems • Malocclusion • Feeding problems • Nasal deformity • Ear problems • Speech difficulties • Associated anomalies
- 19. 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
- 20. Malocclusion • Class III seen in most cases • Retruded maxilla
- 21. Feeding problems • Suckling and swallowing reflexes are normal • Have extreme difficulty producing the necessary negative pressure
- 22. Feeding problems • Specially designed nipples with enlarged openings • More frequent burping is necessary
- 23. 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
- 24. Ear problems • More predisposed 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 • Hearing loss at an early age is especially detrimental to the development of normal speech skills
- 28. • The levator veli palatini muscle functions to elevate the velum and enable appropriate speech production
- 29. 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
- 30. 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
- 31. Classification of Cleft lip and palate
- 35. Millard’s modified classification of Kernahan’s classification
- 37. Problems of individuals with clefts • Dental problems • Malocclusion • Feeding problems • Nasal deformity • Ear problems • Speech difficulties • Associated anomalies
- 39. 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)
- 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 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
- 44. Cleft lip repair • Unilateral • Millard Rotation – advancement lip repair • Tennison Randall Triangular flap lip repair • Bilateral • Mulliken lip repair
- 45. Millard rotation-advancement lip repair
- 46. Tennison Randall Triangular flap lip repair
- 47. Millard Rotation-advancement lip repair
- 48. Bilateral cleft lip repair
- 49. Bilateral cleft lip repair
- 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’s 2 flap palatoplasty • Von Langenbeck palate repair • Furlows double opposing z plasty
- 56. Bardach 2 flap palatoplasty
- 57. Bardach’s 2 flap palatoplasty
- 59. Furlow’s double opposing Z 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 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
- 62. 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
- 64. 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