Cleft lip Part-1

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

• Cleft lip and cleft palate comprise a form of birth defect.

• 2ND MOST COMMON BIRTH DEFECT

• A cleft lip is a separation of the two sides of the lip

• The separation often includes the bones of the upper jaw and/or upper gum

• A cleft palate is an opening in the roof of the mouth

Introduction

2

• It is a condition in which the two sides of the palate did not fuse, or join together, as the unborn baby was developing

• Cleft lip and cleft palate can occur on one side (unilateral cleft lip and/or palate), or on both sides (bilateral cleft lip and/or palate). Because the lip and the palate develop separately, it is possible for the child to have a cleft lip, a cleft palate, or both cleft lip and cleft palate.

Definition :

CLEFT LIP :-

• It is the birth defect which results in a unilateral or bilateral opening in the upper lip between the mouth & nose.

CLEFT PALATE :-

• It is the birth defect characterized by an

opening in the roof of the mouth caused

by lack of the tissue development

• Extends back as far as 400 bc.

• Hippocrates & Galen (400 BC and 150 AD respectively) mentioned cleft lips.

• In 390 BC a cleft lip was successfully joined in China

• In 1764, Le Monnier, a French dentist, successfully repaired a cleft velum.

• In 1816, Karl Ferdinand von Gräfe, a noted surgeon who was a pioneer in early German plastic surgery, is credited with performing the first velar repair.

HISTORY

5

Health Statistics in India & South Asia

The most important

basic need of people

– food.

India, along with

Bangladesh and

Nepal, have the

highest percentages

of undernourished

children (under the

age of 5) at close to

50%.2 Source: WORLD HEALTH ORGANISATION

6

Mortality RateRates of maternal deaths

during child birth provide

insight of conditions of

child birth and medical

aid available. More

significantly, they point to

the place of women in

society.

Nepal > India >

Pakistan>Bhutan

>Bangladesh.

Sri Lanka and Nepal,

have much lesser

maternal deaths and are

comparable to statistics

from China.

Source: WORLD HEALTH ORGANISATION

7

Cleft Statistics In India

Cleft Deformity is still not included in Disability Act of

India.So no government grants are provided.

General public awareness about the deformity, its

occurrence and cure is extremely low.

According to the report by Tata Institute of Social

Studies – 2000 in India:- Incidence of Cleft Lip &

Cleft Palate in India is 1: 800 live births. 8

Approximately 30,000 New Cleft Children are

born every year.

Only 25% of them get any form of treatment.

Rest 75% families remain untreated

So, Total treatment and rehabilitation is very low.

9

The approximate incidence of cleft lip and palate is

1.4 per 1,000 live births in India

Survey by Indian health ministry in 2010

One in every 700 births results in a cleft lip and/or

palate – many within families that have no history

of clefts

INTERNATIONAL CRANIOFACIAL INSTITUTE

INCIDENCE

10

CAUSES

Syndromes

AFFECTS GENOTYPE & PHENOTYPES

Genetic

Medication

1.Consanguinos marriage

2.Exposure to chemicals and viruses

Environmental

11

• lack of prenatal care during pregnancy,

• cigarette smoking

• lack of a balanced diet and

• the chronic use of non- prescribed drugs or substance abuse

Additional risk factors

12

Cleft Lip:

Failure of fusion of medial nasal process and maxillary processes

Cleft Palate:

Failure of fusion of palatine processes of maxilla

EMBRYOLOGY

Development of Lip – Normal & Abnormal

www.spreadingsmile.org 14

INTERMAXILLARY SEGMENT – formed by Median nasal process fusion at deeper level .

Composed of labial componentupper jaw componentPRIMARY PALATE portion of nasal septum

DEVELOPMENT OF PALATE – Normal & Abnormal

Palate develops from the primary palate & secondary palate

Secondary palate derived from maxillary prominences

Outgrowth of palatine shelves appear in sixth week & on each side of tongue

DEVELOPMENT OF PALATE – Normal & Abnormal

In 7th week palatine shelves attain horizontal position & fuse with each other to form secondary palate

Secondary palate fuse with nasal septum and posterior part of primary palate

Bone extend from maxilla to ossify hard palate

DEVELOPMENT OF PALATE – Normal & Abnormal

Posterior part of palatine process do not get ossified and extend posteriorly to form soft palate

The median palatine raphe indicates line of fusion of processes

DEVELOPMENT OF PALATE – Normal & Abnormal

Nasopalatine canal

persists in median

plane between

premaxilla and

secondary palate &

represented in adult

as incisive fossa.

DEVELOPMENT OF PALATE – Normal & Abnormal

Anatomy

Normal Musculature Incomplete Cleft

Complete Cleft

Muscles of Lip

• The main blood supply to the lip and nose area -facial artery.

• The facial artery -inferior / superior labial branches

BLOOD & NERVE SUPPLY

NERVE SUPPLY

Classification

• Davis and Ritchie classification 1922.

• Each of the following subgroups is further subdivided into the extent of the cleft (1/3, 1/2, etc).

• Group I – Prealveolar clefts• unilateral,

• median, or

• bilateral

• Group II - Postalveolar clefts • Hard palate alone,

• soft palate alone,

• soft palate and hard palate,

• or submucous cleft

• Group III – Alveolar clefts • unilateral,

• median

• or bilateral

Classification

• International Confederation of Plastic and Reconstructive Surgery classification

• This system uses an embryonic framework to divide clefts into 4 groups, with further subdivisions to denote unilateral or bilateral cases.

• Group I - Defects of the lip or alveolus

• Group II - Clefts of the secondary palate (hard palate, soft palate, or both)

• Group III - Any combination of clefts involving the primary and secondary palates

Classification

Iowa system classification:• Group –I These are defined as clefts of the lip only.

• Group-II These are defined as clefts of the palate only i.e. secondary

palatal clefts.

• Group-III These are defined as clefts of the lip , alveolus and palate i.e. complete

cleft lip and palate.

• Group-IV These are defined as clefts of the lip and alveolus i.e. primary cleft

palate and lip

• Group –V This classification is defined as miscellaneous and includes clefts

which

do not fit into any of the above categories.

• Veau classification• Classification system proposed in 1938.• Group I (A)• Defects of the soft palate alone• Group II (B)• Defects involving the hard and soft palates

(not extending anterior to the incisive foramen)

• Group III (C)• Defects involving the palate through to the

alveolus• Group IV (D)• Complete bilateral clefts.

Classification of cleft lip and palate

26

• Kernahan and Stark classification [2]

• Embryology-based classification system proposed in 1958 that designates the incisive foramen as the dividing line between the primary and secondary palates.

• The incisive foramen is a funnel-shaped opening through which neurovascular bundles pass. It is located in the hard palate behind the middle upper teeth (incisors). This structure is an important embryological landmark, which is used to define the boundary between the primary and secondary palate.

• Primary palate includes those structures anterior to the incisive foramen (lip, pre-maxilla, anterior septum).

• Secondary palate includes those structures posterior to the incisive foramen (lateral palatine shelves, soft palate, and uvula).

Classification of cleft lip and palate

27

Striped Y1 & 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 velopharyngealincompetence without obvious clefts

13 - Protrusion of premaxilla

28

Classification

INDIAN CLASSIFICATION Proposed by Dr. C. Balakrishnan in1975

• Group 1 Cleft lip only

• Group 1a Cleft lip and alveolus

• Group 2 Cleft palate only

• Group 3 Cleft lip and palate

30

Tessier classification

Tessier classification. Left: boney clefts, Right: Soft tissue clefts.

In 1976 Paul Tessier published a classification on facial clefts

based on the anatomical position of the clefts. The different

types of Tessier clefts are numbered 0 to 14. These 15

different types of clefts can be put into 4 groups, based on

their position[7]: midline clefts, paramedian clefts, orbital clefts

and lateral clefts. The Tessier classification describes the

clefts at soft tissue level as well as at bone level, because it

appears that the soft tissue clefts can have a slightly different

location on the face than the bony clefts.

Classification of cleft lip and palateBasic classification

31www.medlife.co.in

Classification

• Lahshal classification:

• Presented by Okriens in 1987

• LAHSHAL is a paraphrase of the anatomic affected by the

cleft.

L lip

A alveolus

H hard palate

S soft palate

H hard palate

A alveolus

L lip

Clinical features: Cleft lip- unilateral

NON CLEFT SIDE CLEFT SIDE

1.DEVIATION OF BASE OF NASAL SEPTUM,

COLUMELLA

2.OBICULARIS ORIS TERMINATE AT

THE BASE OF THE COLUMELLA

1. DEVIATION OF TIP OF NOSE.

2. ALAR CARTILAGE IS• PTOTIC• STRETCHED• ROTATED

3. LOWERING OF UPPERLATERAL CARTILAGE.4. EXCESSIVE MUSCLE EXISTS BENEATH THE

ALA NASI

SKIN OF NOSTRIL FLOOR• FINE GRAINED • FLAT• LIGHTLY HAIRED

SKIN OF LIP• FINE LINED• BULGING

THE WHITE ROLL : MUCOCUTANEOUS RIM , WHICH CONSIST OF THE CUTANEOUS INSERTION OF FIBERS OF THE EXTERNAL ORBICULARIS BAND

• SEEN EXTENDING JUST BEYOND THE MIDLINE ON MEDIAL SIDE• TENDS TO DISAPPEAR WITHINN 2-3 MM LATERAL TO CUPID BOWS PEAK ON

LATERAL SIDESTERILE MUCOSA :

MUCOSA LINING THE BORDER OF CLEFT , IT SHOULD BE REMOVEDA LINE DRAWN PERPENDICULAR FROM PEAK OF CUPID’S BOW ON MEDIAL & LATERAL SEGMENTS

• Nasal distortion

• Recurring ear infections

• Failure to gain weight

• Nasal regurgitation when bottle feeding

• Poor speech

• Misaligned teeth

• Growth retardation (picture)

• Ear infections

• Hearing loss

• Dental cavities

• Displaced teeth

• Social problems

Problems associated with cleft patients

35

Management

• Team Approach

• Cleft surgeon has a pivotal role

• Initial Head and Neck Examination

• Speech Disorders

• Ear Disease

• Airway Problems

• Surgical Repair

Head and Neck Exam

• Head- facial symmetry

• Otologic- auricle and canal development and location, pneumatic otoscopy, forks

• Rhinoscopy- identifies clefting, septalanomalies, masses, choanal atresia

• Oral Exam- cleft, dental, tongue

• Upper airway- phonation, cough, swallow

Thank You