This document provides information on cleft lip and cleft palate, including epidemiology, etiology, embryology, classifications, symptoms, problems, and treatment. It discusses that cleft lip and palate is a common birth defect affecting the lip, alveolus, and palate. Prenatal diagnosis and counseling is important. Treatment involves a multidisciplinary team and stages of presurgical nasoalveolar molding, lip and palate repair surgery, followed by postoperative care and long-term orthodontics and speech therapy. Surgical techniques aim to reconstruct the lip and palate while minimizing complications and achieving optimal function and appearance.

1. Dr Lamture Y.R.
Surgery department
J.N.M.C. Wardha
CLEFT LIP AND CLEFT
PALATE

2. Learning Objectives
 Intoduction
 Aetiology
 Embryology
 symptoms
 Classifications of cleft
 Treatment

3. Introduction
 Facial clefting is the second most common
congenital deformity (after clubfoot).
 Most common congenital malformation of the
head & neck
 Problems are cosmetic, dental, speech,
swallowing, hearing, facial growth, emotional

4. EPIDEMIOLOGY:
Cleft lip and palate is a global problem.(0.28-3.74/1000 live
births globally)
Least incidence in negro (0.4%) and maximum in
afghans(4.9%)
The incidence of oral clefts is seen more in males than in
females.
Cleft lip alone- more in males than female
Cleft palate- more in females than males

5. ETIOLOGY:
1.) Heredity:
Transmitted through a male as sex linked recessive gene.
Predisposition for cleft lip is 40% while only 18-20% for cleft palate.
It is transferred as:
a) Monogenic/ single gene disorder-conform to mendelian inheritance
b) Polygenic/ multifactorial inheritance- show familial tendency but not
mendelian inheritance
c) Chromosomal abnormalities:
- Down’s Syndrome
- Edwards Syndrome (trisomy 18)
-

6. 2.) Environmental Factors:
Usually occurs due to various influences during Ist trimester.
• Environmental terratogens:
-Cigarette smoking- 30% increase in cleft lip and palate and 20%
increase in cleft palate in smoking during pregnancy.
-Anti seizure drugs.eg: di-phenyl hydantoin and trimethadione.also
causes growth retardation, craniofacial dysmorphism, mental deficiency

7. MALNUTRITION:
Hypervitaminosis A: acute maternal exposure to 13-cis retinoic
acid during first trimester causes cell death in the pharygeal
arch leading to facial clefting. Vit A analogue used as an anti-
acne drug. Also proved by animal experiments.
Folic Acid: Deficiency of folic acid affects virtually every organ
system. It affect the neural tube- neural crest cell migration and
differentiation.
Anaemia
INFECTION DURING PREGNANCY:
Rubella infection during the first 3 months associated with
clefting.
PARENTAL AGE:
Shaw et al presented evidence that women above the age of 35
had a doubled risk of having a child with CLCP.
above 39- tripled risk.
Consanguineous marriages- increased risk of CLCP in child.

8. SYNDROMES WITH CLEFT LIP AND PALATE
Van der woude Syndrome
Treacher Collins Syndrome Autosomal Dominant
Stickler’s Syndrome
Roberts Syndrome
Appert Syndrome
Christian Syndrome Autosomal Recessive
Meckel Syndrome

9. EMBRYOLOGY
 The first pharyngeal arch (mandibular arch),
develops two prominences at the end of 4th
week
 The maxillary prominence
 The mandibular prominence

10. 4th week

14.  As the medial nasal prominences merge with the
maxillary prominence, they form an intermaxillary
segment.
(Intermaxilla
ry segment)

15. The intermaxillary segment gives rise to :-
1. philtrum of the upper lip.
2. The median part of the maxillary bone with its four
incisor teeth
3. The primary palate.

17. ANATOMY

18. Anatomy of lip

21. Cleft Anatomy
 Unilateral Cleft Lip
and alveolus
 lack of mesodermal
proliferation
 cleft of orbicularis
o medial portion to
columella
o lateral portion to
nasal ala
 cleft of alveolus

22. 2) Isolated Complete
Bilateral/Unilateral
Cleft runs entire length of lip to floor of nose
Abnormal muscle pull distorts nose extensively and creates wide
clefts between the lip segments

24. Symptoms
 Separation of the lip
 Separation of the
palate (roof of the
 mouth)
 Nasal distortion
 Misaligned teeth
 Recurring ear
infections

25. Symptoms (cont.)
 Failure to gain weight
 Nasal regurgitation
when bottle feeding
 Poor speech
 Growth retardation

26. PROBLEMS
 Upper airway
 Speech
 Feeding difficulty
 Ear infection

27. Airway Problems
 Cleft Palate patients
 e.g. Pierre-Robin Sequence
 Micrognathia
 , Cleft Palate,
 Glossoptosis
 CYANOSIS
develop airway distress from tongue
fall and touch pharanyx
lodged in palatal defect

28. FEEDING PROBLEM
 FEEDING IN HEAD ELEVATED POSITION
 FEEDING WITH SPCIAL CP BOTTLES OR
D/SYRINGE OR DROPPER
 AFTER FEED LAY BABY ON SHOULDER AND
SLAB ON BACK TILL RETCHING

30. Hearing problem
 ETD- Due to abnormal insertion of levator veli
palatini and salpingo pharyngeus muscle into
hard palate
 milk enter into eustachian tube and lead to serous
otitis media and infective otitis media and finally
ankylosis of oscicles
 30% develop permanent deafness

31. Speech Disorders
 Errors in Articulation: Fricatives, Affricates
 Velopharyngeal Competence- competence after
initial palate surgery
 Incompetence- nasal emission or snort
 Evaluation- Direct exam , Fiberoptic Exam

32. When to Operate
Generally (Rules of 10’s)
 Weight > 10 pound (4500 gm)
 Hb > 10 gm
 Age > 10 weeks
Cleft lips between 3-6 months
Cleft palate between 12-18 months (preferred before
speech devolops)

33. Treatment of CLCP: A brief Overview

35. Nagpur classification
 Group I - Cleft of lip
 Group I(A) - Cleft of lip & alveolus
 Group II - Cleft of palate
 Group II(S) - Submucous cleft of palate
 Group III - Cleft of lip & palate

36. DAVIS AND RITCHIE CLASSIFICATION (1922):
They classified congenital clefts based on the position of the cleft
in relation to the alveolar process.
Group I-Pre alveolar clefts Lip
clefts only with subdivisions for
unilateral, median, bilateral.
Group II-Post alveolar clefts
degrees of involvement of soft and
hard palate to be specified till the
alveolar ridge, submucous clefts
included.
Group III-Alveolar clefts is
complete clefts of palate, alveolus
ridge and lip with subdivisions for
unilateral, median, bilateral.

37. Classification
 Veau Classification - 1931
 Veau Class I: isolated soft palate cleft
 Veau Class II: isolated hard and soft palate
 Veau Class III: unilateral CLAP
 Veau Class IV: bilateral CLAP

38. II VEAU’S CLASSIFICATION
(1931):
 Group I - Cleft of
soft palate only
 Group II - Cleft of hard and
soft palate, extending no
further than the incisive
foramen thus involving the
secondary palate alone.

39.  Group III - Complete
unilateral cleft of soft and
hard palate, lip and
alveolar ridge
 Group IV - Complete
bilateral cleft of soft and
hard palate, lip and
alveolar ridge on both
sides.

40. III KERNAHAN’S STRIPED “Y”
CLASSIFICATION (1971):
 In this classification the
incisive foramen is taken as the
reference point
 “Y” logo are each divided into
three sections, representing the
lip, the alveolus and the hard
palate as far back as the incisive
foramen. The stem of the “Y” is
also divided into three parts,
representing varying degrees of
clefting of the hard and soft
palates.

41. V MILLARD’S CLASSIFICATION
(1977):
 A modification of Kernahan’s
striped “Y” classification.
 . The inverted triangles represent the
nasal arch the upright triangles
represent the nasal floor.

42. Striped Y
1 & 5 - Floor of nose on right & left
sides
2 & 6 - Lip
3 & 7 - Alveolar ridges
4 & 8 - Premaxilla to incisive foramen
9 & 10 - Each half of the hard palate
11 - Soft palate
12 - Congenital velopharyngeal
incompetence without obvious clefts
13 - Protrusion of premaxilla

43. Iowa Classification
Group I
Clefts of lip only
Group II
Clefts of palate only (2o)
Group III
Clefts of lip,
alveolus, palate
Group IV
Clefts of lip and
alveolus (primary
cleft palate and
lip)
Group V
Miscellaneous

45. LAHSHAL Classification
 Kriens (1989)
 Rt. Side of pt. is on lt. side of formula
 L - cleft lip of Rt. Side
 -L cleft lip of Lt.side
 Complete cleft-Capital letters
 Partial cleft – lower letters
 Microform - Asterisks

46. Cleft Variants
1) Isolated Incomplete
Intact skin/muscle between the lip and nose
Less distortion brought on by abnormal muscle
pull
Bilateral/Unilateral
Cleft Lip
Expressed in structures anterior to incisive foramen
- prepalatal alveolus, maxilla, lip, nasal
structures
Gaping cleft of alveolus/lip structures to
mere ‘scar’ (forme fruste)
Deficiency in skin, muscles, mucous membranes,
maxillary/nasal bones, nasal cartilages

47. 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

48. Cleft Variants
Isolated Cleft Palate
Complete/Incomplete
Soft Palate
-cleft can extend into the hard
palate to any extent
Hard
Palate
Primary Palate (CL)
Secondary Palate

49. Treatment
 Treatment involves
many things which
include plastic
surgery,
orthodontics, and
speech therapy

50. PRIMARY MANAGEMENT Antenatal Diagnosis
 Diagnosed By US 3D After 18
Weeks’ Gestation
 Parents Need Counseling
 Reassure The Parents
 Explain Functional Problems
 Advise On
 Feeding
 Timing Of Surgery
 Ideally, The Newborn Infant With
A Cleft Is Evaluated By Cleft
Team In 1st Weeks Of Life

51. PRESURGICAL MANAGEMENT1:Presurgical infant orthopedics:
 Appliances
latham appliance for collapsed alveolar
arch
2:Presurgical nasoalveolar molding :
objective of NAM :
 To align & approximate the alveolar
segment
 To correct the malposition of the nasal
cartilage & alar base on affected side
 To idealize the position of philtrum &
columella

52.  When a cleft lip is present, it may be difficult for the baby
to make a good seal around the nipple.
 Babies with cleft palate usually need special bottles and
techniques to feed properly.
 There are three types of bottles for feeding babies with
clefts –
 the Mead-Johnson Cleft Palate Nurser,
 the Haberman Feeder and
 the Pigeon Nipple:
FEEDING TECHNIQUES

53. Feeding obturator
 The feeding obturator is a prosthetic aid that is designed to
obturate the cleft and restore the separation between the
oral and nasal cavities.
 It creates a rigid platform
 The obturator also prevents the tongue from entering the
defect and interfering with spontaneous growth of the
palatal shelves.
 reduces nasal regurgitation,
 reduces the incidence of choking,
 also helps in the development of the
jaws and contributes to speech

54. Naso Alveolar Moulding-(PRESURGICAL NASO
ALVEOLAR MOULDING )
(Grayson etal, 1999)
 Nasoalveolar moulding is a nonsurgical method of
reshaping the gums, lip and nostrils before cleft lip and
palate surgery, reducing the severity of the cleft. Surgery is
performed after the molding is complete, approximately
three to six months after birth.
 Actively mould and reposition the deformed nasal cartilages
and alveolar processes and lengthen the deficient
collumella.

55. Naso alveolar mold

57. Surgical techniques:
 For unilateral cleft lip:
Modern accepted technique is the modified
Millards rotation & advancement repair
 For microform cleft lip:
Straight line repair
Modified Millard rotation – advancement
repair
 For bilateral cleft lip:
1,Manchester repair
2. bilateral millard repair

58. MANCHESTER REPAIR

59. Complications of lip repair
Unilateral cleft lip:
 Deficient tubercle
 Vermilion deficiency & irregularity
 Short upper lip or Long upper lip
 Tight upper lip
 Unfavorable scar
Bilateral cleft lip:
 Whistle deformity
 Nostril stenosis

60. complications
 Immediate
 Bleeding
 Delayed
 Fistula formation
 Failure of repair
 Speech problem
Immediate
Bleeding
Delayed
Fistula
formation
Failure of repair
Speech
problem

61. Bilateral incomplete cleft lip
bilateral millard procedure

62. bilateral millard repair
Bilateral complete cleft lip

63. unilateral Complete cleft lip

64. Incomplete cleft lip

65. POSTOPERATIVE CARE
 Soft arm restrain for 2 weeks
 Analgesics
 Feeding
 Suture line care
 Stitch removal
 Avoid oral suction

66. POSTOPERATIVE CARE
 Fluids for one week
 Water after every feed
 Semi solids for next two weeks and water after
every diet
 Solids are allowed after three weeks
 No need to remove stiches (vicryl)

67. Cleft Palate
 Affects 1/2500 living births
 More often in girls
 Heredity is less affects

68. Problems with cleft palate
Feeding
Hypernasal Speech
Midfacial hypoplasia
Hearing and middle ear problems
Additional anomalies (% 30)
Psychological problems

69. Goal of Palatal Repair
 Separation of oral and nasal
cavities
 Understanble speech
 Avoiding maxillary retrusion
 Preservation of hearing
 Good occlusion

70. Submucous Cleft Palate
 Anatomic problem
 Muscles are not fused middle of palate (muscular diastasis)
 notch at the back of the hard palate
 Bifid uvula
 persistentear disease
 swallowing difficulties
 Mostly asymptomatic
 % 15 velopharengeal insufficiency
 Short soft palate
 Limited motion
 Easy to get tired while speaking
 When light goes through nose, light can be seen from oral
side
 It is not necessary surgical treatment until child growth
enough to cooperate

71. •Treatment of Submucous Cleft
Palate
 Submucous cleft palate only requires surgery
if it is causing problems for the individual
 The most common reason for treating a
person with a submucous cleft palate is
because of abnormal, nasal-sounding speech

72. Surgical Repair- Cleft Palate
 Several Techniques-
 less scarring and less tension on palate
Scarring of palate may cause impaired mid-facial
growth(alveolar arch collapse, midface retrusion,
malocclusion)
Facial growth may be less affected if surgery is
delayed until 18 months, but feeding, speech,
socialization may suffer.

73. Surgical techniques
 Von langenback operation
 Veau, Wardill, Kilner push back palatoplasty
 Intravelar veloplasty
 Furlow z – plasty
 Bordeck palatoplasty

74. Palatoplasty Technique

75. “Double opposing Z Plasty”
Von Langenback
Method
Surgical treatment of isolated cleft palate

76. Secondary surgery for cleft lip and
palate
 Cleft lip revision
 malaligned vermilion
 Asymmetrical cupid’s bow
 Poor nasal tip projection
 Deviation of cartilaginous nasal septum
 Alveolar bone grafting
 Closure of palatal fistula, veloplasty,
pharyngoplasty
 Rhinoplasty

77. Take home message
 Common orofacial defect
 Counselling of parents
 Feeding techniques
 Look for other genetic syndrome like down’s

78. References
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79. Thank you