Cleftlipandpalate
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This document provides an overview of cleft lip and palate, including a brief introduction. It discusses the incidence of clefts across different populations. It also covers the embryological development and classifications of clefts, as well as some of the problems individuals with clefts may experience like feeding and speech difficulties. The document outlines the various medical specialties involved in cleft treatment and describes some of the surgical procedures used like cheiloplasty and palatoplasty.
Cleftlipandpalate
- 1. CLEFT LIP AND PALATE Dr Sneha khadka MScD Orthodontics.
- 2. CONTENTS Introduction Incidence Classification Embryological Background Etiology Diagnosis Problems of individuals with clefts Treatment of Cleft Lip and Palate Specialties involved in the treatment of Cleft Lip and Palate Timings of surgical repair Cheilorraphy Palatorrhaphy Alveolar Cleft Grafts Secondary Surgical Procedures Valopharyngeal Insufficiency
- 3. INTRODUCTION What is Cleft Lip and Palate? Congenital abnormal space or gap in the upper lip, alveolus and palate.
- 4. INCIDENCE More common in south far Asians: 1 in 500 Less frequent in Africans: 1 in 2000 Prevalence in Europeans and Americans: 1 in 750
- 5. Boys are more affected than girls by 3:2 Cleft Lip and Palate occur twice as often in boys as in girls. Isolated Clefts of Palate are more often in girls. 75% of Clefts are Unilateral, rest are Bilateral. Left side is more involved than right side
- 6. Head and Neck of 4- Week Old Embryo Trigeminal nerve Facial nerve Glossopharyngeal nerve Vagus nerve EMBROYOLOGICAL BACKGROUND
- 7. Development of the Lip: Unpaired Frontonasal Prominence Medial and Lateral Nasal prominences 2 maxillary prominences 2 mandibular prominences
- 8. Fusion defects can occur anywhere between these prominences The defect in the fusion between the frontonasal and maxillary will lead to cleft lip
- 9. Development of Palate: We have two parts of two different embryonic origins: 1 ) primary palate : the triangular part of hard palate anterior to incisor foramen which originate from the premaxilla ( frontonasal prominences). --ddeevveelloopp bbeettwweeeenn 44tthh aanndd 88tthh wweeeekk ooff ggeessttaattiioonn 2 ) secondary palate : remaining part of the hard palate and all soft palate posterior to incisor foramen which comes from palatine shelves of the maxillary prominences --ddeevveelloopp bbeettwweeeenn 88tthh aanndd 1122tthh wweeeekk ooff ggeessttaattiioonn
- 11. Various theories have been given for its development. 1. Alteration in intrinsic palatal shelf force . 2. Failure of tongue to drop down. 3. Non fusion of shelves. 4. Rupture of cyst formed at the site of fusion.
- 12. CLASSIFICATION Early attempts at classification by Davies & Ritchie in 1922. Group I : prealveolar clefts- unilateral cleft lip. - bilateral cleft lip. - median cleft lip. Group II : post alveolar clefts – cleft hard palate - cleft soft palate - cleft hard and soft palate. - submucosal clefts.
- 13. Group III: alveolar clefts- unilateral - bilateral - median
- 14. Veau in 1931 Group I : clefts of soft palate only. Group II : clefts of hard and soft palate extending upto the incisive foramen. Group III: complete unilateral clefts involving soft palate, hard palate, alveolar ridge and lip on one side. Group IV: complete bilateral clefts of soft and hard palates, alveolar ridge and the lip.
- 15. Fogh-Anderson in 1942 studied incidence of CL(P) in Denmark a. Hare lip including alveolus as far back as incisive foramen b. Hare lip & CP c. Isolated clefts of palate as far forward as incisive foramen
- 16. KERNAHAN AND STARK’S CLASSIFICATION OF CLEFTS (1958) Clefts of primary palate only Unilateral (right or left) Complete Incomplete Median Complete (premaxilla absent) Incomplete (premaxilla rudimentary) Bilateral Complete Incomplete Clefts of secondary palate only Complete Incomplete Submucous Clefts of primary and secondary palate Unilateral (right or left) Complete Incomplete Median Complete Incomplete Bilateral Complete Incomplete
- 17. KERNAHAN STRIPED Y CLASSIFICATION ( 1971) LIP ALVEOLUS PRIMARY PALATE HARD PALATE SOFT PALATE INCISIVE FORAMEN
- 18. MODIFIED STRIPED Y ELSHAY CLASSIFICATION ( 1973) 13 R L 12
- 19. 1,5- Fusion line between the maxillary prominence and medial nasal prominence at nostril floor level. 2,6- Fusion line at the level of upper lip. 3,7- R/L alveolus . Fusion line between the maxillary prominence and intermaxillary segments. 4,8- Fusion between the primary and secondary hard palate. 9,10- Fusion between the palatal shelves of hard palate. 11- Represents the soft palate. 12- Posterior pharyngeal wall. 13- Premaxilla.
- 20. MILLARD’S MODIFICATION OF KERNAHAN’S CLASSIFICATION
- 21. KKrriieennss ““LLAAHHSSHHAALL”” L = Lip (right) A = Alveolus (right) H = Hard Palate (right) S = Soft Palate (median) H = Hard Palate (left) A = Alveolus (left) L = Lip (left) Capital letter = complete cleft Lowercase letter = incomplete cleft “.” or “-” = normal Examples LA….l = complete right cleft lip and alveolus, incomplete left cleft lip LAHS = complete right unilateral cleft lip, alveolus, hard, and soft palate
- 22. Microform Cleft: May look like -a little dent in the red part of the lip. -a scar from the lip up to the nostril. Muscle tissue underneath the cleft can be affected and may require surgery Submucous Cleft Palate: Midline deficiency or lack of muscular tissue Often a submucous cleft palate is associated with a bifid or cleft uvula Posterior nasal spine is almost always missing Speech Problems are common
- 23. ETIOPATHOGENESIS Clefts of lip and palate may be isolated deformities or may be part of a syndrome. Non syndromic clefts are multifactorial in origin.
- 24. Multiple factors may be involved, like-- Genetics (inherited characteristic) from one or both parents . Environmental factors. -Drugs: corticosteroids (anti-inflammatory), phenytoin (anticonvulsant), retinoid. -Infections: like rubella during pregnancy,viral infections. -Alcohol consumption, smoking, hypoxia during pregnancy, some of dietary and vitamins deficiencies (like folic acid and vitamin A deficiency),stress, mechanical disturbances. Maternal Age.
- 25. Drugs Phenytoin Genetic predisposition Non syndromic Maternal illness Polygenic inheritance clefts smoking Alcohol
- 26. Some of the more common syndromes associated with CL/P Chromosomal Trisomy 13 Trisomy 18 Velocardiofacial syndrome (22q11 deletion) Non-Mendelian Pierre Robin syndrome CHARGE association Goldenhar syndrome Teratogenic Fetal alcohol syndrome Fetal phenytoin syndrome Fetal valproate syndrome Mendelian disorders Ectrodactyly-eetodermal dysplasia-clefting syndrome (AD) Gorlin syndrome (AD) Oto-palato-digital syndrome (XL) Oral-facial-digital syndrome (XL) Smith-Lemli-Opitz syndrome (AR) Stickler syndrome (AD) Treacher Collins syndrome (AD) Van der Woude syndrome (AD) Unknown de Lange syndrome Kabuki syndrome
- 27. PROBLEMS ASSOCIATED WITH CLEFT LIP AND PALATE Feeding Dental problems Nasal Deformity and Esthetic Problems Ear Problems Speech Difficulties Associated Anomalies
- 28. FEEDING DIFFICULTIES Cleft lip= makes it more difficult for an infant to suck on a nipple Cleft Palate= may cause formula or breast milk to be accidently taken up into the nasal cavity Inability to create negative pressure inside oral cavity Frequent regurgitations Upper respiratory tract infections
- 29. DENTAL PROBLEMS Local Dental Problems: Congenitally Missing teeth, Hypodontia, Hyperdontia, Oligodontia Presence of natal and neonatal teeth Anamalies of tooth morphology like microdontia, macrodontia etc Fused teeth Enamel Hypoplasia Poor periodontal support, early loss of teeth Gemination, Dilacerations Orthodontics Problems: Class III tendency Anterior and Posterior Cross bite Spacing and crowding
- 30. NASAL DEFORMITY AND ESTHETIC PROBLEMS Facial Disfigurements. Poor nasal shape. Scar marks of surgeries. Poor lip function during speech. Poor dental alignment and smile.
- 31. EAR PROBLEMS Middle ear disease - 22% to 88% . Conductive hearing loss and chronic suppurative otitis media may result. Repeated tympanostomy tube placement.
- 32. Speech Problems: Hearing loss hampers proper development of speech Velopharyngeal Insufficiency. Poor pronunciation of Bilabial, Labiodental, Linguoalveolar sounds
- 33. PRENATAL/POSTNATAL DIAGNOSIS Intrauterine - Sonographic diagnosis - Karyotyping Post partum - Clinical - Radiographic (intra and extraoral, laminography, pantography) - Additional aids (speech and sound recording, measurement of nasal and oral pressures, psychiatric examination)
- 34. PRENATAL, PERINATAL AND POSTNATAL PARENTAL COUNSELLING Requisites Accurate information should be given by an expert in the field Support must be available soon after diagnosis Parents and members of family given opportunity to express concern and emotional response
- 35. Give a clear view of how the baby is likely to look. Discussion on pregnancy termination based on accurate information . Promote early adjustment and acceptance of the baby by the parents and family. Long term dependence on counselor should be avoided and normalization of family life should be encouraged.
Editor's Notes
- #13: +Classification is an important part of treat ment planning. It should be neither be too detailed not be inaccurTE And inadequate due to oversimplification and it should facilitate the intra and interdisciplinary communication necessary to devIntrauterine Sonographic diagnosis Karyotyping Post partum Clinical Radiographic (intra and extraoral, cineradiography, laminography, pantography) Additional aids (speech and sound recording, measurement of nasal and oral pressures, psychiatric examination)
- #18: proposed Symbolic classification cleft lip and palate using a striped y having numbered block. Stippling of affected area is done and in case of submucosal cleft , the section is cross hatched.
- #22: Describes site, size. Extent and type of cleft.
- #23: OTHER TYPES OF CLEFT