Seminar on

CLEFT LIP AND PALATE

CLEFT LIP:

Cleft lip is a birth defect that results in a unilateral or bilateral opening in the upper lip between the mouth and nose.

CLEFT PALATE:

Cleft palate is a birth defect characterized by an opening in the roof of the mouth caused by a lack of tissue development.

DEVELOPMENT OF CLEFT

(a) Cleft Lip : Various theories have been given for its development.

- Failure of fusion between median nasal process and maxillary process.

- Failure of mesodermal migration between the two layered epithelial membrane. This leads to a breakdown and cleft formation.

- Rupture of cyst formed at the site of fusion.

(b) Cleft Palate : Various theories have

been given for its development.

- Alteration in intrinsic palatal shelf force

- Failure of tongue to drop down

- Non fusion of shelves

- Failure of mesodermal migration

- Rupture of cyst formed at the site

Of fusion.

ETIOLOGY 1. Genetic factors

2. Nutritional disturbances during development

3. Physiologic, Emotional or traumatic stresses during development

4. Defective vascular supply to the area involved

5. A mechanical disturbance where the size of the tongue may prevent the union of parts

6. Various environmental factors like infections (e.g. Rubella), exposure to radiation, drugs like thalidomide, antiepileptic durgs, hormonal pills, quinine etc.

7. Maternal consumption of alcohol and smoking

CLASSIFICATION

1.Morphological Classification

(a) By Davies and Ritchie (1922)

(b) By Veau (1931)

2.Embryological Classification

(a) By Kernahan & Stark (1958)

(b) By Spina (1974)

1.a Classification by Veau

Group-I Cleft of the soft palate only

Group-II Cleft of the hard and soft

palate till the incisive foramen.

Group-III Complete unilateral cleft of the soft palate,hard palate,the alveolar ridge and the lip on one

side

Group-IV Complete cleft of the soft palate, hard palate, the alveolar ridge and lip on the both side.

2.a Classification by Kernahan and Stark

Group-I Cleft of the primary palate only

(i) Unilateral (ii) Bilateral (iii) Total (iv) Sub-total

Group-II Cleft of the secondary palate only (i) Total (ii) Sub-total

(iii) Submucous

Group-III Cleft of the primary & secondary palate

(i) Unilateral -Total, Sub-total (ii) Median - Total, Sub-total (iii) Bilateral -Total, Sub-total

2.b Classification by Spina

Group-I Pre-incisive foramen clefts (i) Unilateral (ii) Bilateral (iii) Median

Group-II Tran-incisive foramen clefts

(i) Unilateral (ii) Bilateral

Group-III Post-incisive foramen clefts (i) Total (ii) Partial

Group-IV Rare facial clefts

SYMBOLIC AND COMPUTERGRAPHIC

PRESENTATIONBy Kernahan (1971)

Modified by Ehlsaky & Millard

(Rt)

1,5 : Nasal floor

(Lt)

2,6 : Lip

3,7 : Alveolus 4,8 : Hard palate anterior to incisive foramen. 9,10: Hard palate posterior to incisive foramen 11 : Soft palate

NORMAL ANATOMY

(ACCORDING TO KERNAHAN AND STARK CLASSIFICATION)

GROUP 1 UNILATERAL GROUP 1a UNILATERAL GROUP 1a BILATERAL

(CONTD.)

GROUP II COMPLETE GROUP III UNILATERAL GROUP III BILATERAL

CLEFTS OF LIP

BILATERAL COMPLETE CLEFT PALATE

INCOMPLETE CLEFT PALATE

BILATERAL CLEFT LIP AND PALATE

UNILATERAL CLEFT LIP AND PALATE

INCIDENCE (a)Among different races

Whites - One out of 800 Blacks - One out of 2000 Japanese or Indians - One out of 500

(b) Of different clefts Cleft lip alone - 25% Cleft palate alone - 25% Cleft lip and palate both - 50%

(c)Males > Females (for combined cleft lip & palate) Females > Males (for cleft palate only)

(d) Unilateral defects > Bilateral defects

(e) Left sided defects > Right sided defects

(f) Increase in parental age increase risk of producing affected child.

CLINICAL FEATURES(1) FACIAL DEFORMITY – NOSE TIP DEVIATED TO NORMAL

SIDE, ALA ON CLEFT SIDE FLARED, NOSTRIL HORIZONTALLY ORIENTED, LIP DEFORMITY, HYPOPLASTIC AND A COLLAPSED MAXILLA ON SIDE OF THE CLEFT AND THE CLEFT PALATE .

- FOR BILATERAL CLEFTS ADDITIONAL FEATURES LIKE PROTRUDED PRE-MAXILLA, SMALL PRO-LABIUM, ABSENT COLUMELLA AND SHALLOW GINGIVOLABIAL SULCUS.

(2) INABILITY TO SUCK MOTHER’S MILK(3) NASAL INTONATION FOR CLEFT PALATE(4) NASAL REGURGITATION

(CONTD.)

(5) TOOTH DEFECTS – WHICH MAY BE• SUPER NUMERARY TEETH• CONGENITALLY MISSING TEETH• T- CINGULUM• PEG LATERALS• THICK CURVED HYPOPLASTIC INCISORS• NATAL TEETH• GERMINATION • DELAYED ERUPTION OF PERMANENT TEETH• HYPOPLASTIC INCISORS NEXT TO ALVEOLAR DEFECTS

(6) ASSOCIATED SYNDROMES – CLEFT LIP MAY BE ASSOCIATED WITH FOLLOWING SYNDROMES

• DOWN’S SYNDROME• WARDEN BURG’S SYNDROME• VANDERWOUDE’S SYNDROME• ORO-FACIAL DIGITAL SYNDROME• TREACHER COLLIN’S SYNDROME• PIERRE ROBIN’S SYNDROME• KLIPPEL FEIL’S SYNDROME

REFERENCES:

1. TEXTBOOK OF PEDODONTICS: SHOBHA TANDON2. DENTISTRY FOR CHILDHOOD AND ADOLESCENT: McDONALD, AVERY