Collection of data :-Collection of data :-Dina M. AboelataDina M. AboelataDina M. ElnoamanyDina M. ElnoamanyRania M. MatarRania M. Matar Arrangment Arrangment

:-:- Dina Sabry EsmailDina Sabry Esmail

Powerpoint :-Powerpoint :- Dina Hamdey Abdella Dina Hamdey Abdella

Presented Presented by:-by:-

Dina Gamal GhanemDina Gamal GhanemDina Hassan MustafaDina Hassan Mustafa

What is Cleft-What is Cleft-palatepalate? ?

Cleft palate is types of clefting Cleft palate is types of clefting congenital deformity caused by congenital deformity caused by abnormal facial development during abnormal facial development during gestation. gestation.

A cleft is a fissure or opening gap. A cleft is a fissure or opening gap. It is theIt is the non-fusion non-fusion of the body’s of the body’s

natural structures that form before natural structures that form before birth. birth.

Clefts can also affect other parts of the Clefts can also affect other parts of the face, such as the eyes, ears, nose, face, such as the eyes, ears, nose, cheeks and forehead. cheeks and forehead.

primary palateprimary palate-:-:

During the During the fifth weekfifth week the primary the primary palate forms by the growth and palate forms by the growth and fusion of the medial nasal, fusion of the medial nasal, lateral nasal, and maxillary lateral nasal, and maxillary processes processes

The maxillary process, derived The maxillary process, derived from the proximal half of the first from the proximal half of the first arch, grows to meet and fuse arch, grows to meet and fuse with the nasal processes with the nasal processes

secondary palatesecondary palate-:-:

During theDuring the sixth weeksixth week two two shelflike outgrowths from the shelflike outgrowths from the maxillary swelling to form the maxillary swelling to form the secondary palate.secondary palate.

The 2 palatal shelves initially The 2 palatal shelves initially are in a vertical position because are in a vertical position because of the interposed tongue.of the interposed tongue.

At At 7 weeks7 weeks With extension of the With extension of the head and mandibular growth, the head and mandibular growth, the tongue is withdrawn and the tongue is withdrawn and the palatal shelves become into a palatal shelves become into a midline for fusion and formation midline for fusion and formation of a hard and soft palateof a hard and soft palate

Anteriorly the shelves fuse with Anteriorly the shelves fuse with the triangular primary palate, the triangular primary palate, and the and the incisiveincisive foramenforamen is is formed at this junctionformed at this junction

secondary palatesecondary palateprimary palateprimary palate

Clefts of the primary palateClefts of the primary palate result from a failure of mesoderm to result from a failure of mesoderm to

penetrate into the grooves between the penetrate into the grooves between the medial nasal and maxillary processes, medial nasal and maxillary processes, which prohibits their from fusion with each which prohibits their from fusion with each anotheranother

Clefts of the secondary palateClefts of the secondary palate result from a failure of the result from a failure of the

palatine shelves to fuse with one palatine shelves to fuse with one anotheranother. . The cause for this is The cause for this is failure of the tongue to descend failure of the tongue to descend into the oral cavityinto the oral cavity..

Normal palate Cleft palateNormal palate Cleft palate

ClassificationClassification

Classification veauClassification veau-:-:

Classification system proposed in 1938Classification system proposed in 1938 Group I (A):-Group I (A):-

Defects of the soft palate aloneDefects of the soft palate alone Group II (B)Group II (B)

Defects involving the hard and soft palates Defects involving the hard and soft palates (not extending anterior to the alveolus)(not extending anterior to the alveolus)

Group III (C)Group III (C)

Defects involving the palate through to the Defects involving the palate through to the alveolusalveolus

Group IV (D)Group IV (D)

Complete bi-lateral clefts.Complete bi-lateral clefts.

Spina classificationSpina classification

Classification system proposed in 1974.Classification system proposed in 1974.

Pre-incisive foramen cleftsPre-incisive foramen clefts (lip +/- alveolus) (lip +/- alveolus) Uni-lateralUni-lateral Bi-lateralBi-lateral MedianMedian

Trans-incisive foramen cleftTrans-incisive foramen cleft (lip, alveolus, palate) (lip, alveolus, palate) Uni-lateralUni-lateral Bi-lateralBi-lateral

Post-incisive foramen cleftsPost-incisive foramen clefts (secondary cleft palate) (secondary cleft palate) Atypical (rare) facial clefts.Atypical (rare) facial clefts.

What aboute comlicationWhat aboute comlication??

((11))Feeding difficultiesFeeding difficulties

One of the most immediate concerns after One of the most immediate concerns after birth is feeding as cleft palate make birth is feeding as cleft palate make sucking sucking difficultdifficult or cause gagging or nasal regurgitatio or cause gagging or nasal regurgitatio

To overcome this problem by using a To overcome this problem by using a special special bottlebottle nipple or a small artificial palate nipple or a small artificial palate (obturator) that fits into the roof of the mouth(obturator) that fits into the roof of the mouth. .

The The upright sitting positionupright sitting position allows allows gravity to gravity to help the baby swallow the milk more easilyhelp the baby swallow the milk more easily

)2(Ear infections and hearing loss)2(Ear infections and hearing loss

Babies with cleft palate are especially susceptible to Babies with cleft palate are especially susceptible to middle ear infectionsmiddle ear infections. Ear infections are often due to a . Ear infections are often due to a dysfunction of the tube that connects the middle ear and dysfunction of the tube that connects the middle ear and the throat. the throat.

Over time, repeated ear infections can Over time, repeated ear infections can damage hearingdamage hearing, , but hearing loss may resolve with treatment. but hearing loss may resolve with treatment.

It's important for children with cleft palate to be It's important for children with cleft palate to be evaluated evaluated regularlyregularly by an audiologist. by an audiologist.

Most children with clefts have tubes inserted in their Most children with clefts have tubes inserted in their ears to drain fluids and help prevent infections. ears to drain fluids and help prevent infections.

((33))Dental problemsDental problems-: -:

If the cleft extends through the If the cleft extends through the upper gumupper gum, tooth development , tooth development will likely be affected. will likely be affected.

A pediatric dentist should A pediatric dentist should monitor tooth development and monitor tooth development and oral health from an early age.oral health from an early age.

((44))Speech difficultiesSpeech difficulties-:-:

Because both the lip and palate Because both the lip and palate are used in forming sounds, the are used in forming sounds, the development of normal speech development of normal speech can be affected. A speech can be affected. A speech pathologist can evaluate your pathologist can evaluate your child and provide speech child and provide speech therapytherapy..

((55))Psychological challengesPsychological challenges-:-:

Children with clefts may face social, Children with clefts may face social, emotional and behavioral problems emotional and behavioral problems due to differences in appearance and due to differences in appearance and the stress the stress ofof intensive medical care intensive medical care

How to manage that diseaseHow to manage that disease??

DiagnosisDiagnosis-:-:

prenatal ultrasoundsprenatal ultrasounds can detect a cleft can detect a cleft palate prior a child's birth. palate prior a child's birth.

By detecting the cleft abnormality during a By detecting the cleft abnormality during a pregnancy, the expecting parents can pregnancy, the expecting parents can have a prenatal consultation with a plastic have a prenatal consultation with a plastic surgeon.surgeon.

The symptoms of these abnormalities are The symptoms of these abnormalities are visiblevisible during the during the first examination after first examination after birth. birth.

Treatments for Children With Cleft Treatments for Children With Cleft PalatePalate-:-:

Children born with a cleft palate may Children born with a cleft palate may need the skills of need the skills of several medical several medical professionalsprofessionals to correct the problems to correct the problems associated with the cleftassociated with the cleft

Treatment usually requires a complex, Treatment usually requires a complex, lengthy lengthy treatment plantreatment plan lasting until lasting until adulthood (see table below).adulthood (see table below).

AgeIntervention

PrenatalBirth-1 month

Referred to cleft lip and palate team

Diagnosis and genetic counseling

Address psychosocial issues

Provide feeding instructions

Make feeding plan

1-15 monthsCheck feeding and growth

Repair cleft lip

Check ears and hearing

16-24 monthsAssess ears and hearing

Assess speech and language

Check development

2-5 yearsAssess , manage velopharyngeal insufficency

Assess development and psychosocial adjustment

6-11 yearsOrthodontic interventions

Alveolar bone graft

12-21 yearsJaw surgery, rhinoplasty

as needed

Orthodontic bridges implants as

needed

Aim of repairAim of repair-:-:

separate the oral and nasal cavitiesseparate the oral and nasal cavities, this , this separation involves the formation of a valve separation involves the formation of a valve that is necessary for normal speech.that is necessary for normal speech.

also the also the muscles muscles at the back of the palate at the back of the palate need to be put in their need to be put in their proper placeproper place across across the cleft so the child can learn to speak the cleft so the child can learn to speak normallynormally

Time of operationTime of operation-: -:

General agreement exists that surgical General agreement exists that surgical correction of a cleft palate should be correction of a cleft palate should be accomplished when patients are accomplished when patients are younger younger than 1 yearthan 1 year, before significant speech , before significant speech development occurs. development occurs.

The six advantages for early closure of palatal The six advantages for early closure of palatal defects:-defects:-

(1) better palatal and pharyngeal muscle development (1) better palatal and pharyngeal muscle development once repairedonce repaired

(2) ease of feeding(2) ease of feeding(3) better development of phonation skills(3) better development of phonation skills (4) better auditory tube function(4) better auditory tube function(5) better hygiene when the oral and nasal partition is (5) better hygiene when the oral and nasal partition is

competentcompetent(6) improved psychologic state for parents and baby.(6) improved psychologic state for parents and baby.

Langenbeck’s operationLangenbeck’s operation-:-:

1- Bare cleft edge1- Bare cleft edge

2- release incision in mucoperosteum2- release incision in mucoperosteum

3- close nasal mucosa at floor of the nose3- close nasal mucosa at floor of the nose

4- close mucoperiostium of hard palate 4- close mucoperiostium of hard palate

5- fracture ptyrigoid hamulus if needed to 5- fracture ptyrigoid hamulus if needed to relax the flap relax the flap

Before Before AfterAfter

What should be expected post-What should be expected post-operativelyoperatively??

Immediate postoperative Immediate postoperative airway airway management and management and pain pain management. management.

Diet in the postoperative period is generally limited to Diet in the postoperative period is generally limited to liquids and soft foodsliquids and soft foods that do not require chewing that do not require chewing

The use of The use of bottlesbottles is avoided because the nipples may is avoided because the nipples may interfere with the repair. The use of interfere with the repair. The use of spoonsspoons is also is also avoided for similar reasons.avoided for similar reasons.

Feeding is accomplished by using either a cup or a Feeding is accomplished by using either a cup or a Breck feeder (a red rubber catheter attached to a Breck feeder (a red rubber catheter attached to a syringe). syringe).

Normal diet and feeding may be resumed after 10-14 Normal diet and feeding may be resumed after 10-14 days, depending on the type of repair. days, depending on the type of repair.

Normal regimen for follow up Normal regimen for follow up carecare-:-:

Once discharged from the hospital, the patient Once discharged from the hospital, the patient should have should have follow-up visits at 7-10 days and at follow-up visits at 7-10 days and at 3 weeks3 weeks..

If a If a small fistula small fistula or a wound breakdown is noted or a wound breakdown is noted in this period, waiting at least 6 months prior to in this period, waiting at least 6 months prior to attempting closure is advised.attempting closure is advised.

This delay allows for maximal wound contracture This delay allows for maximal wound contracture and for reestablishment of the blood supply to and for reestablishment of the blood supply to the tissuesthe tissues

Complication of sugeryComplication of sugery-:-: Airway obstructionAirway obstruction Results from the Results from the tongue falling backtongue falling back into the into the

airway while the patient remains sedated from airway while the patient remains sedated from anesthetics. Placement of a anesthetics. Placement of a tongue traction tongue traction suturesuture helps in the prevention of airway helps in the prevention of airway obstruction.obstruction.

Airway obstruction can also be a problem Airway obstruction can also be a problem because of because of changes in airway dynamicschanges in airway dynamics, , especially those in children with a small jaw. especially those in children with a small jaw. placement and maintenance of a placement and maintenance of a tube in the tube in the tracheatrachea is necessary until palate repair is is necessary until palate repair is complete. complete.

BleedingBleeding

Because of the Because of the rich blood supplyrich blood supply of the of the palatepalate

Preoperative assessment of the hemoglobin Preoperative assessment of the hemoglobin level and the platelet count is important.level and the platelet count is important.

Specific medication injected into the area Specific medication injected into the area being operated on, such as Epinephrine, being operated on, such as Epinephrine, can help significantly decrease blood loss. can help significantly decrease blood loss.

Palatal fistulaPalatal fistula

Wound breakdown occur as a complication in the immediate Wound breakdown occur as a complication in the immediate postoperative period, or it can be a delayed problem.postoperative period, or it can be a delayed problem.

palate fistulas can be managed in 2 ways:-palate fistulas can be managed in 2 ways:-

1-In a patient without any symptoms, a dental prosthesis can 1-In a patient without any symptoms, a dental prosthesis can be used to close the defect with good results. be used to close the defect with good results.

2- patient with symptoms may require surgery. Closure of 2- patient with symptoms may require surgery. Closure of persistent fistulas should be attempted no sooner than 6-12 persistent fistulas should be attempted no sooner than 6-12 months aftermonths after

New Treatments for Cleft PalateNew Treatments for Cleft Palate-:-:

Recent advances is Recent advances is presurgical presurgical orthopedicsorthopedics

These are palatal plates which adjust the These are palatal plates which adjust the palate and alveolus to a more normal palate and alveolus to a more normal shape.shape.

Early interventions that reduce the need for Early interventions that reduce the need for surgeries as the child growssurgeries as the child grows

They are now viewed as They are now viewed as adjuvants for surgeryadjuvants for surgery

In conclusionIn conclusion::

Keep in mind that surgery to repair a cleft Keep in mind that surgery to repair a cleft palate is palate is only the beginning of the processonly the beginning of the process

FamilyFamily support support is critical for your child. is critical for your child. Love and understanding will help him or Love and understanding will help him or her grow up with a sense of self-esteem her grow up with a sense of self-esteem that extends beyond the physical defect.that extends beyond the physical defect.

ScOrPiOnE