Management of cleft lip & palate

Cleft lip & palate

Dr.Mohamed Rahil( Maxillofacial surgeon )

Tikrit dentistry college

introductionAre the most common major congenital Craniofacial abnormalityCleft lip present in approximately 1 in 700 live births male to female 2:1 while cleft palate present approximately 1 in 2000 live births and effects male to female 1:2

Embryology At approximately 6 weeks of human embryologic development the median nasal prominence fuses with the lateral nasal prominences and maxillary prominences to form the base of the nose , nostrils , upper lip, and premaxilla ,the confluence of this interior components becomes the primary palate , when this mechanism fails , clefts of the lip and /or maxilla occur

At approximately 8 weeks of the fetal life the palatal shelves elevate beside the tongue , then the tongue descend inferiorly and interiorly with the developing mandible , the vertical palatal shelves movie horizontally to fuse with the septum to form the intact secondary palate ,when the palatal shelves fails to fuse a cleft of the secondary palate occurs

Cleft lip

Cleft palate

Facial cleft

Etiology : multifactorial etiology

Chemical exposures Radiations Maternal hypoxia and habits ( smoking , alcohol )Teratogenic drugs (anti convulsing ,diazepam, hydrocortisone)Nutritional deficiencies (folic acid ,iron ) Vitamin abuse (vit . A)Physical obstruction

Hereditary Environmental

classification Unilateral Bilateral Microform Incomplete Complete And my involve the lip , nose , primary palate and /or secondary palate

Problems of individuals with cleft1.Esthetic2.Dental problems3.Malocclusion4.Nasal deformity5.FeedingEar problemsSpeech difficultiesAssociated anomalies

Treatment

Normalized aesthetic appearance of the lip and nose Intact primary and secondary palate Normal speech , language , and hearing Nasal airway patencyClass I occlusion with normal masticatory functionGood dental and periodontal health Normal psychosocial development The aim of Treatment

Treatment planning and timing

Feeding the child with a cleft palateInfant with cleft palate enable to form an adequate seal between the tongue and palate to create sufficient negative pressure to such fluid from a bottle , nasal regurgitation

Specialised nipples and bottles are necessary

splint

Mead Johnson/Enfamil Cleft Feeder Special Needs Feeder / Haberman Feeder

Pigeon Feeder Dr. Browns Natural Flow to relieve gas

procedureTime frameCleft lip repair

Cleft palate repair

Pharyngoplasty

Maxillary / alveolar reconstruction With born grafting

Cleft orthognathic surgery

Cleft rhinoplasty

Cleft lip revision After 10 weeks

Age 9 -18 months

Age 3 5 years or later based on speech development

Age 6-9 years based on dental development

Age 14-16 years in girls 16-18 years in boys

After age 5 years but preferably at skeletal maturity after arthognathic surgery when possible

Any time once initial remodelling and scar maturation s completed , best after age 5 years

Cleft lip repair

Pre surgical orthopedic

Techniques for lip repair

Rotation and advancement flap (millard technique )

Triangular flap

Cleft palate repair

Soft palate VS hard palate repair

Hard palate closureAdvantage of early closure Better feeding ,hygiene , development of phonation Preserve auditory tube function Improve psychological state for baby and his parents

Disadvantages of early closureDifficult surgery due to small structuresGrowth restriction of maxilla due to scar formation

Speech development

Velopharyngeal incompetence

Treatment of Velopharyngeal incompetence

Speech aid applaince

Pharyngeal flap, superiorly or inferiorly based flap

Sphincter pharyngoplasty

Posterior pharyngeal flap augmentation

Alveolar cleft graftTIME

AdvantagesProvide bone support for maxillaClosure of oronasal fistula Augmentation of alveolar ridge to facilitate implant , prosthesisCreation of base to support lip and ala of nose

procedureTime frameCleft lip repair

Cleft palate repair

Pharyngoplasty

Maxillary / alveolar reconstruction With born grafting

Cleft orthognathic surgery

Cleft rhinoplasty

Cleft lip revision After 10 weeks

Age 9 -18 months

Age 3 5 years or later based on speech development

Age 6-9 years based on dental development

Age 14-16 years in girls 16-18 years in boys

After age 5 years but preferably at skeletal maturity after arthognathic surgery when possible

Any time once initial remodelling and scar maturation s completed , best after age 5 years

Nasal repairPrimary Early Late

Orthognathic surgery

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