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cleft lip and palate
- 1. CLEFT LIP &PALATE EMBRYOLOGY & MANAGEMENT Dr SD Sanyal Wg Cdr RD Bavdekar Cl Spl Surg & Plastic surgeon
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- 5. Lip Formation of Stomatodaeum Appearanceof FN process & Mandibular arches Maxillary & Mandibular processes develop
- 6. Lip Formation of Nasalplacodes Medial and Lateral nasal processes form Both nasal processes fuse together & with the Maxillary process
- 7. Lip Upper lip isformed Lower lip is formed by the fusion of the B/L Mandibular processes
- 9. Palate Palatal processes arisefrom the maxillary processes Premaxilla develops from the FN process B/L Palatal processes fuse with post border of the Premaxilla
- 10. Palate B/L palatal processesfuse together in the midline Fusion proceeds ant to post Medial edge of the palatal processes fuse with the free end of nasal septum
- 11. Incidence • Cleft lipand palate 1:600 • Isolated cleft palate 1:1000 • Oriental (1:500) > black (1:2000) • Cleft lip alone: 15 per cent • Cleft lip and palate: 45 per cent • Iisolated cleft palate: 40 per cent • Cleft lip/palate predominates in males • Cleft palate alone more common in females • Unilateral cleft lip - left side in 60 %
- 12. Etiology • Familial • Protein& vit deficiency • Rubella infection • Radiation • Drugs : Steroids, Phenytoin, Diazepam • Syndromes - Downs
- 13. Muscle Rings ofFace
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- 18. LAHSHAL System • Describessite, size and extent, as well as type of cleft • Complete clefts of the lip, alveolus and hard and soft palate designated as capitals - L, A, H and S • Incomplete clefts recorded in lower case letters • Microform clefts documented with asterisks
- 20. DAVIS & RITCHIE •Three groups according to position of cleft in relation to alveolar process: • Group I – Pre alveolar clefts: - Unilateral cleft lip - Bilateral cleft lip - Median cleft lip • Group II - Post alveolar clefts: - Cleft hard palate alone - Cleft soft palate alone - Cleft soft palate and hard palate - Sub mucous cleft
- 21. DAVIS & RITCHIE •Group III-Alveolar clefts: - Unilateral alveolar cleft - Bilateral alveolar cleft - Median alveolar cleft
- 22. VEAU Classification • GroupI (A) - Defects of the soft palate only • Group II (B) - Defects involving the hard palate and soft palate extending not further than the incisive foramen, thus involving the secondary palate alone • Group III (C) – Complete unilateral cleft, extending from the soft palate to the alveolus, usually involving the lip • Group IV (D) - Complete bilateral clefts, resembles Group III but is bilateral. When cleft is bilateral, pre- maxilla is suspended from the nasal septum
- 23. Management • Primary management •Surgery • Secondary management
- 24. Primary Management Antenatal Diagnosis: •Antenatal diagnosis of cleft lip U/L or B/L : - US scan after 18 weeks of gestation • Isolated cleft palate : - Antenatal scan has no role • Plastic surgery referral & counselling
- 25. Primary Management Feeding : •Most babies feed well • Soft bottles • Modified teats • Feeding plates
- 27. Primary Management Airway: • Majorairway obstruction uncommon • During feeding and sleep • Intermittant episodes – Prone nursing • Persistant – Retained nasopharyngeal intubation • Labioglossopexy
- 28. Surgery • Aims: - Normalappearance of lip, nose and face - Normal speech - Dentition and facial growth within normal range
- 29. Surgery Millard Criteriae forcleft lip: -10 months of age - 10 weeks old - 10gm % Hb Cleft palate : -10 kgs weight - 10-18mths old - 10gm% Hb
- 30. Principles of cleftlip repair: - Proper pre-surgical skin markings - Full thickness skin incisions - 1: 200000 Adr -Skin incisions developed to restore tissues to normal position -Ms continuity achieved by sub- periosteal undermining over ant maxilla -Nasolabial ms anchored to pre- maxilla - Oblique muscles of orbicularis oris sutured to the nasal spine - Horizontal fibres of orbicularis oris are sutured to achieve a functional sphincter - Three layer repair - Horizontal Cupid’s bow - Continuity of whiteline - No vermilion notching Principles of cleft palate repair : - Mobilisation and re- construction of aberrant soft palate musculature - Closure of hard palate with minimal dissection and scar formation - O2 stage closure ensuring physiological anrrowing of the cleft
- 31. Timing of Surgery Cleftlip alone : - U/L: One operation at 3–6 months - B/L :One operation at 4–5 months Cleft palate alone : Soft palate only : One operationat 6 months Soft and hard palate:Two operations - Soft palate at 6 months - Hard palate at 15–18 months
- 32. Timing of Surgery Cleftlip and palate : • U/L : Two operations - Cleft lip and soft palate at 5–6 months - Hard palate and gum pad +/- lip revision at 15–18 months • B/L : Two operations - Cleft lip and soft palate at 4–5 months - Hard palate and gum pad +/- lip revision at 15–18 months
- 34. Secondary Management Hearing : •Serous Otitis Media • SNHL • Early audiological assessment – 1 yr • ABR & Tympanomometry • Role of Myringotomy & grommet insertion
- 35. Secondary Management Speech : •Initial assessment by 18 months • Velopharyngeal incompetence: - Hypernasal speech - Soft palate dysfn • Articulation defects: - Due to VP incompetence or poor dental occlusion • Speech: - Speech therapy and speech training devices
- 36. Secondary Management Dental : •Delayed development & eruption • Abnormal morphology • Hypo/hyperdontia • Regular dental check up • Flouride supplementation & use of fissure sealants • Dietary advice
- 37. Secondary Management Secondary surgery: • Orthodontic & orthognathic surgery • Alveolar bone grafts • Lip revision • Rhinoplasty
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