CLEFT LIP

AND PALATE

Ass.Prof. Abdullah Atef Hammuda Oral Maxillofacial Surgery

Faculty of Dentistry

Minia University

DEFINITION

A cleft is a congenital abnormal space or gap between two structures that normally fuse or merge

Can involve many structures of the orofacial region

Major congenital clefts affect the lip ,alveolar ridge, hard & soft palate

Submucosal clefts:

when mucous membranes are complete but underlying tissue is incomplete

FREQUENCY

• White population = 1 in 1000 live births. T

• Asian population = 2 in 1000 live births,

• Black population = < 0.5 in 1000 live births

• Male children > female children.

• Unilateral : bilateral = 9 : 1

• Left : right ration is 2: 1

• Combined cleft lip and palate = 50 % > isolated cleft palate (30%), > isolated cleft lip or cleft lip and alveolus (20%).

• the risk to subsequent siblings increases with the severity of the cleft.

ETIOLOGY

Familial tendencies

Tratogenic drugs

Deficiency/excess of V. A & deficiency of riboflavin

Traumatic stress

Infection, Radiation

Alcohol, drugs steroid , toxins, smoking ,

Mechanical obstruction by enlarged tongue

Relative ischemia to the area due to defective vascular supply

Syndromes: e.g. Van der Woude syndrome

EMBRYOLOGY

At 4 week IU of facial development Initially there are Five primary tissue masses:

Frontonasal process which give medial & lateral nasal processes

Two maxillary processes

Two Mandibular Processes

During 5th week of IU two

maxillary processes grow inwardly

from the sides

The medial nasal grow in

downward direction from above to

fuse with maxillary process and

form the upper lip

Upper lip formation

Failure of fusion of the medial nasal process and the maxillary process Cleft lip

The maxillary processes continue to grow in a medial direction & compress the medial nasal toward the midline

7 week embryo

Primary palate formation

6week embryo

7week embryo

The medial nasal process merge at the surface & deeper and form the primary palate

at the end of 6th week Two maxillary

processes grow inward to give lateral palatal

shelves

the lateral palatine processes (shelves)

grow medially then downward on either

side of the tongue

Tongue moved downward allow for

elevation of the palatine shelves to fuse

with each other

Secondary palate formation

7,5week embryo Ten week embryo

Two lateral palatal shelves grow toward each other and fuse

anteriorly with primary palate &at this point incisive foramen is

formed & continuo growing posteriorly to complete formation

of secondary palate

8,5 week

Failure of fusion of the palate shelves with the primary palate or with each other result in Cleft palate

CLASSIFICATION

(VEAU SYSTEM)

CLEFT LIP:

CLI vermilion border

CLII vermilion border &lip

CLIII vermilion border &lip &floor of the nose

CLIV Any bilateral cleft of the lip incomplete/ complete notching

CLASSIFICATION (VEAU SYSTEM)

• Veau I Cleft of the soft palate

• Veau II Cleft of the soft and hard palate

• Veau III Unilateral complete cleft

• Veau IV Bilateral complete cleft

Dental problems:

Abnormalities of teeth

In number (supernumerary , absence)

In size (microdontia or macrodontia)

morphology, eruption, classification

Enamel hypoplasia

Malocclusion class II retrusion of maxilla

Narrow dental arch lateral cross bite

operative trauma Limited growth of the maxilla

Problems associated with cleft lip & palate

Feeding : nasal reflux or regurgitation, Ineffective sucking

Ear problems: recurrent otitis media &hearing loss

Speech difficulties cleft of soft palate (hypernasality)

Nasal deformity lack of underlying bony support to the base of the nose

DIAGNOSIS

Physical examination

hard palate by palpation: absence of posterior nasal spine

Can be confirmed by occlusal radiograph

Soft palate: bifid uvula

Bluish line (translucent membrane)

Patient says (ah): soft palate furrow in the midline

Ulltlrasonography

MANAGEMENT

GOALS OF SURGICAL CARE FOR CLEFT

LIP PATIENTS

• Normalized esthetic appearance of the lip and nose

• Intact primary and secondary palate

• Normal speech, language, and hearing

• Nasal airway patency

• Class I occlusion with normal masticatory function

• Good dental and periodontal health

• Normal psychosocial development

IMPORTANCE OF TEAM WORK

• Successful management of CLP patients requires

coordinated care provided by a number of different

specialties including:

• oral/maxillofacial surgery,

• otolaryngology,

• genetics/dysmorphology,

• speech/language pathology,

• Orthodontics, prosthodontics, and others.

X-RAY CLEFT LIP AND PALATE

TREATMENT

Treatment of (CLP) include cleft & associated problem which implies : Feeding (obturators)

Hearing ,speech early audiologic & speech evaluation is recommended

Psychological support for the family & patient during protracted management

Treatment is done at different age-dependent phases

CL as early as possible (3 m) ,

rule of ten 10weeks 10pounds,10 mg per dl hg

CSP 1year of age to enhance normal speech

CHP 4-5 years of age allow more maxillary growth

Orthodontic :

Before primary dentition retract anterior displaced premaxilla segment

9 years of age expansion of the maxilla to correct relationship between the teeth

10 -11 years bone grafting one half to two third unerupted canine root has formed supporting base of the teeth

13 years full orthodontic alignment can start

Plastic surgery of (lip & nose and soft palate),

orthognathic surgery is often required later in life

TECHNIQUES OF CLEFT LIP CLOSURE

• A variety of techniques have been used to repair the cleft lip such as:

• Le Mesurier’s quadrilateral flap or rectangular flap (Saunders et al 1986),

• Millard’s rotation advancement flap (Tardy et al 1995),

• Z-plasty and modified-Z-plasty repair (Fernandes and Hudson 1993),

• Modified rotation advancement repair (lower one third triangular flap) (Lee, 1999),

• Utero-neonatal cleft lip repair (Steleniki et al 1999).

CLEFT LIP REPAIR “MILLAR”

PRE-POST OP. CLEFT LIP

PRE-POST OP. CLEFT LIP

Hard and Soft Palate Repair

Expansion vs. contraction

Surgery of Cleft Palate

Maxillary Alveolar Cleft

Bone Graft and PRP

Surgical Flap And Bone Grafting

RESEDUAL ALVEOLAR CLEFT REPAIR

INTRODUCTION

A residual alveolar cleft is an obstacle when

considering rehabilitation of the dental arch.

Their sequela include:

Teeth Malposition

Insufficient periodontal bone support and

periodontal inflammation.

• Wide exposure with proper flap design.

• Nasal floor reconstruction.

• Packing the defect with bone graft (autogenic,

Allogenic or Mixed),

• Closure of pre-existing oronasal fistula.

Surgical technique

Mixture of HA particles and symphyseal bone

Symphyseal bone graft.

Iliac crest bone graft

Iliac crest bone graft

Mixed

Preop. Postop.

1 year

Preop.

Postop.

CONCLUSION

Chin bone and iliac crest have comparable results

both clinically and radiographically.

Chin bone is superior regarding maintenance of

post-grafting alveolar crest height. However, it is

less in amount in comparison to the iliac crest.