cleft lip and palate6)sem... · 2020-03-24 · techniques of cleft lip closure • a variety of...
TRANSCRIPT
CLEFT LIP
AND PALATE
Ass.Prof. Abdullah Atef Hammuda Oral Maxillofacial Surgery
Faculty of Dentistry
Minia University
DEFINITION
A cleft is a congenital abnormal space or gap between two structures that normally fuse or merge
Can involve many structures of the orofacial region
Major congenital clefts affect the lip ,alveolar ridge, hard & soft palate
Submucosal clefts:
when mucous membranes are complete but underlying tissue is incomplete
FREQUENCY
• White population = 1 in 1000 live births. T
• Asian population = 2 in 1000 live births,
• Black population = < 0.5 in 1000 live births
• Male children > female children.
• Unilateral : bilateral = 9 : 1
• Left : right ration is 2: 1
• Combined cleft lip and palate = 50 % > isolated cleft palate (30%), > isolated cleft lip or cleft lip and alveolus (20%).
• the risk to subsequent siblings increases with the severity of the cleft.
ETIOLOGY
Familial tendencies
Tratogenic drugs
Deficiency/excess of V. A & deficiency of riboflavin
Traumatic stress
Infection, Radiation
Alcohol, drugs steroid , toxins, smoking ,
Mechanical obstruction by enlarged tongue
Relative ischemia to the area due to defective vascular supply
Syndromes: e.g. Van der Woude syndrome
EMBRYOLOGY
At 4 week IU of facial development Initially there are Five primary tissue masses:
Frontonasal process which give medial & lateral nasal processes
Two maxillary processes
Two Mandibular Processes
During 5th week of IU two
maxillary processes grow inwardly
from the sides
The medial nasal grow in
downward direction from above to
fuse with maxillary process and
form the upper lip
Upper lip formation
Failure of fusion of the medial nasal process and the maxillary process Cleft lip
The maxillary processes continue to grow in a medial direction & compress the medial nasal toward the midline
7 week embryo
Primary palate formation
6week embryo
7week embryo
The medial nasal process merge at the surface & deeper and form the primary palate
at the end of 6th week Two maxillary
processes grow inward to give lateral palatal
shelves
the lateral palatine processes (shelves)
grow medially then downward on either
side of the tongue
Tongue moved downward allow for
elevation of the palatine shelves to fuse
with each other
Secondary palate formation
7,5week embryo Ten week embryo
Two lateral palatal shelves grow toward each other and fuse
anteriorly with primary palate &at this point incisive foramen is
formed & continuo growing posteriorly to complete formation
of secondary palate
8,5 week
Failure of fusion of the palate shelves with the primary palate or with each other result in Cleft palate
CLASSIFICATION
(VEAU SYSTEM)
CLEFT LIP:
CLI vermilion border
CLII vermilion border &lip
CLIII vermilion border &lip &floor of the nose
CLIV Any bilateral cleft of the lip incomplete/ complete notching
CLASSIFICATION (VEAU SYSTEM)
• Veau I Cleft of the soft palate
• Veau II Cleft of the soft and hard palate
• Veau III Unilateral complete cleft
• Veau IV Bilateral complete cleft
Dental problems:
Abnormalities of teeth
In number (supernumerary , absence)
In size (microdontia or macrodontia)
morphology, eruption, classification
Enamel hypoplasia
Malocclusion class II retrusion of maxilla
Narrow dental arch lateral cross bite
operative trauma Limited growth of the maxilla
Problems associated with cleft lip & palate
Feeding : nasal reflux or regurgitation, Ineffective sucking
Ear problems: recurrent otitis media &hearing loss
Speech difficulties cleft of soft palate (hypernasality)
Nasal deformity lack of underlying bony support to the base of the nose
DIAGNOSIS
Physical examination
hard palate by palpation: absence of posterior nasal spine
Can be confirmed by occlusal radiograph
Soft palate: bifid uvula
Bluish line (translucent membrane)
Patient says (ah): soft palate furrow in the midline
Ulltlrasonography
MANAGEMENT
GOALS OF SURGICAL CARE FOR CLEFT
LIP PATIENTS
• Normalized esthetic appearance of the lip and nose
• Intact primary and secondary palate
• Normal speech, language, and hearing
• Nasal airway patency
• Class I occlusion with normal masticatory function
• Good dental and periodontal health
• Normal psychosocial development
IMPORTANCE OF TEAM WORK
• Successful management of CLP patients requires
coordinated care provided by a number of different
specialties including:
• oral/maxillofacial surgery,
• otolaryngology,
• genetics/dysmorphology,
• speech/language pathology,
• Orthodontics, prosthodontics, and others.
X-RAY CLEFT LIP AND PALATE
TREATMENT
Treatment of (CLP) include cleft & associated problem which implies : Feeding (obturators)
Hearing ,speech early audiologic & speech evaluation is recommended
Psychological support for the family & patient during protracted management
Treatment is done at different age-dependent phases
CL as early as possible (3 m) ,
rule of ten 10weeks 10pounds,10 mg per dl hg
CSP 1year of age to enhance normal speech
CHP 4-5 years of age allow more maxillary growth
Orthodontic :
Before primary dentition retract anterior displaced premaxilla segment
9 years of age expansion of the maxilla to correct relationship between the teeth
10 -11 years bone grafting one half to two third unerupted canine root has formed supporting base of the teeth
13 years full orthodontic alignment can start
Plastic surgery of (lip & nose and soft palate),
orthognathic surgery is often required later in life
TECHNIQUES OF CLEFT LIP CLOSURE
• A variety of techniques have been used to repair the cleft lip such as:
• Le Mesurier’s quadrilateral flap or rectangular flap (Saunders et al 1986),
• Millard’s rotation advancement flap (Tardy et al 1995),
• Z-plasty and modified-Z-plasty repair (Fernandes and Hudson 1993),
• Modified rotation advancement repair (lower one third triangular flap) (Lee, 1999),
• Utero-neonatal cleft lip repair (Steleniki et al 1999).
CLEFT LIP REPAIR “MILLAR”
PRE-POST OP. CLEFT LIP
PRE-POST OP. CLEFT LIP
Hard and Soft Palate Repair
Expansion vs. contraction
Surgery of Cleft Palate
Maxillary Alveolar Cleft
Bone Graft and PRP
Surgical Flap And Bone Grafting
RESEDUAL ALVEOLAR CLEFT REPAIR
INTRODUCTION
A residual alveolar cleft is an obstacle when
considering rehabilitation of the dental arch.
Their sequela include:
Teeth Malposition
Insufficient periodontal bone support and
periodontal inflammation.
• Wide exposure with proper flap design.
• Nasal floor reconstruction.
• Packing the defect with bone graft (autogenic,
Allogenic or Mixed),
• Closure of pre-existing oronasal fistula.
Surgical technique
Mixture of HA particles and symphyseal bone
Symphyseal bone graft.
Iliac crest bone graft
Iliac crest bone graft
Mixed
Preop. Postop.
1 year
Preop.
Postop.
CONCLUSION
Chin bone and iliac crest have comparable results
both clinically and radiographically.
Chin bone is superior regarding maintenance of
post-grafting alveolar crest height. However, it is
less in amount in comparison to the iliac crest.