Cleft Lip And Palate PDF

Nermeen Mostafa Cleft Lip And Palate Esthetic units of the upper lip Anatomy of the velum 1|Page  Nermeen Mostafa A cleft is a congenital abnormal space or gap in the upper...

Nermeen Mostafa Cleft Lip And Palate Esthetic units of the upper lip Anatomy of the velum 1|Page  Nermeen Mostafa A cleft is a congenital abnormal space or gap in the upper lip, alveolus, or palate. The problems encountered in the rehabilitation of patients with cleft deformities are unique. The treatment must address patient appearance, speech, hearing, mastication, and deglutition. Oral clefts commonly affect the lip, alveolar ridge, and hard and soft palates. Three-fourths of clefts are unilateral deformities; one-fourth are bilateral. The left side is involved more often than the right when the defect is unilateral. Cleft lip may occur without clefting of the palate, and isolated cleft palate may occur without clefting of the lip The cleft can be: - Complete or incomplete - Unilateral or bilateral - Microform (intact functional layer) Problems of Individuals with Clefts 1. Dental Problems - A cleft of the alveolus can often affect the development of the primary and permanent teeth and the jaw itself. - The most common problems may be related to congenital absence of teeth and, ironically, supernumerary teeth - The cleft usually extends between the lateral incisor and the canine area. These teeth may be absent because of their proximity to the cleft. It’s more common in bilateral cleft 2. Malocclusion - Individuals affected with cleft deformities, especially those of the palate, show skeletal discrepancies between the size, shape, and position of their jaws - Missing or extra teeth may partially contribute to the malocclusion. However, retardation of maxillary growth is the factor most responsible for the malocclusion. In general, the operative trauma of the cleft closure and the resultant fibrosis (i.e., scar contracture) severely limit the amount of anteroposterior maxillary growth and development that can take place. 2|Page  Nermeen Mostafa 3. Lip & Nasal Deformity Deformity in lip & normal nasal architecture is commonly seen in individuals with cleft lips 1. Notch in the vermillion border of the lip. 2. Deviation of the nasal columella 3. Flaring of the ala of the nose 4. Flattening of the alar base Surgical correction of nasal deformities should usually be deferred until all clefts and associated problems have been corrected. 4. Feeding The musculature is undeveloped or not properly oriented to allow the sucking to be effective (absence of seal). This problem is easily overcome through the use of specially designed bottles that are elongated and extend further into the baby’s mouth. 5. Ear Problems - Children with a cleft of the soft palate are predisposed to middle ear infections. - The levator veli palatini and the tensor veli palatini, which are normally inserted into the same muscles on the opposite side, are left unattached when the soft palate is cleft. - These muscles have their origins directly on or near the eustachian auditory tube. These muscles allow opening of the ostium of this tube into the nasopharynx. This action is demonstrated when middle ear pressures are equalized by swallowing during changes in atmospheric pressure. When this function is disrupted, the middle ear is essentially a closed space, without a drainage mechanism. Serous fluid may then accumulate and result in serous otitis media. - Children with cleft palate frequently need to have their middle ear “vented.” (myringotomy) - In individuals whose soft palate is cleft, the velopharyngeal mechanism cannot function because of the discontinuity of the musculature from one side to the other. Thus the soft palate cannot elevate to make contact with the pharyngeal wall. The result of this constant escape of air into the nasal cavity is hypernasal speech. 3|Page  Nermeen Mostafa 6. Speech Difficulties Speech problems are usually created by cleft lip and palate deformity. Retardation of consonant sounds (i.e., “p,” “b,” “t,” “d,” “k,” and “g”) is the most common finding. Hypernasality is usual in patients with a cleft of the soft palate and may remain after surgical correction. 7. Recurrent chest infections: While swallowing of milk by the child, it enters the nose and the chest due to improper seal leading to recurrent chest infections. 8. Breathing problem Timing of Surgical Repair Lip repair → 3-6 months (repair of orbicularis oris sphincter) Palatal repair → 9-18 months. Most surgeons adhere to the proven “rule of 10” as determining when an otherwise healthy baby is fit for surgery Weight = 10 pounds Hb = 10 gm/dl Leukocytes = 10,000 10 weeks of age. Lip closure: Lip closure is usually made at 3 months of age Lip closure is made at 6 months when naso-alveolar molding device is used Naso-alveolar molding device - It’s used to reduce the size of the cleft or palate deformity of the lip, gum and nose before surgical repair. - It’s always indicated in repair of bilateral cleft - It’s used in the unilateral cleft when the deformity is very big only - It aids feeding process of the child as it seals the gap in the palate 4|Page  Nermeen Mostafa Naso-alveolar molding, pre-operative lip taping and lip adhesion Techniques of lip repair. 1. Unilateral cleft lip repair. Rotation-Advancement (RA) (large lip repair) Disadvantage: Resulting notch in the vermillion border Triangular flap technique Straight line repair 5|Page  Nermeen Mostafa Rectangular Flap Z-Plasty 2. Bilateral cleft lip: Millard’s concept of BCL repair The points: 1. Philtrum +2mm=4mm 2. End of white roll +1mm x2 3. Collumella +alar base. 4. Philtrum length points. 6|Page  Nermeen Mostafa Surgical Management Hints 7|Page  Nermeen Mostafa Cleft palate repair: Thie following technique repairs only the hard palate (double layer closure) von Langenbeck operation The following technique repairs the soft palate as well as gaining length for the palate Furlow’s Z-plasty: (the best technique to solve the speech problem) Another technique for repairing cleft palate is using a part of the cheek mucosa to close the gap and narrow it (Buccal Musculo-mucosal flap) Dingman Retractor Provides excellent exposure during cleft palate repair by retracting the cheeks, tongue, and other tissues. 8|Page  Nermeen Mostafa Grafting the Alveolar Cleft WHY: The Rationale for ACG 1. Oro-nasal fistulae elimination. 2. Maxillary arch stabilization. 3. Bony support. 4. support to the nasal alar base. 5. Dental implants. 6. Periodontal support of neighboring teeth. When: Timing for ACG 1. Primary bone grafting before deciduous dentition. 2. Secondary bone grafting during the mixed stage of dentition (6-12 yrs). 3. Tertiary bone grafting after completion of permanent dentition. HOW? The standard of care. Donor sites: particulate bone (Extra or Intra-oral sources). Age: 6 - 12 years. Merits (advantages) Demerits (disadvantages) Maintains maxillary arch dimension. Affected quality of the soft tissue Supports eruption of permanent teeth. Needs coordinated orthodontic and surgical care. No reported negative impact on facial ------ growth. Graft Materials 1. Autogenous grafts a) Extra oral donor sites: Anterior illiac crest. b) Intraoral donor sites: Symphyseal grafts. 2. Allogeneic grafts. 9|Page  Nermeen Mostafa Referral Centers. The ideal criteria of a Cleft Center: 1. Multidisciplinary Co-operation. 2. Trained specialties in management of children with a Cleft. 3. Good Patient treatment. 4. Dedication to self-improvement. Notes: As the patients with a cleft palate grow, the maxilla collapses due to: - Scar tissue contraction - No bone in the cleft site Maxillary expansion should be done before the age of 6-12 years to be ready to receive a bone graft Sign of success of bone grafting → interdental bone formation confirmed by periapical radiograph, also there’s berglund classification which determines the stage of success A patient with cleft palate may suffer from Class III (mandibular prognathism). Although the transverse width is restored by the bone grafting & maxillary expansion, the antero- posterior growth is restricted due to scar tissue contraction. Patient > 18 years of age, any intervention will be orthognathic surgeries E.g.: An old patient presented with Class III & a repaired cleft palate 1st corrective procedure → advancement of maxilla 2nd corrective procedure → palatal lengthening as by z-plasty technique. Sometimes distraction osteogenesis can be used with the maxilla to induce bone formation. 10 | P a g e Nermeen Mostafa 11 | P a g e