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CLEFT LIP
&
PALATE
DR Prajesh Dubey
Department of Oral and maxillofacial Surgery
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Incidence & Prevalence
1:700 in live births
Males are affected more than females for CL+/- P, CL is more common in males while CP is more common in females
Prevalence of CL+/-P is 0.77 per 1000 live births (CL is 0.29 and CL+P is 0.48 per 1000 live births)
Unilateral > Bilateral
Left>Right
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Aetiology (Multifactorial)
Genetic: MSX, LHX, goosecoid,DLX,IRF6 genes.
Environmental: viral, radiation, drugs e.g. antibiotics, steroids, insulin, anti-epileptics, Vitamin B6 and folic acid deficiency, anaemia, anorexia, stress, alcohol, smoking
Heredity
Maternal age
Consanguineous marriages
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Embryology
Face develops between 4th and 8th weeks of I.U.L
Processes involved:
Frontonasal-LNP,MNP-Upper lip, Primary palate
Mandibular arch-maxillary-Secondary palate
CL develops when LNP fails to fuse with MNP
Primary palate cleft occurs when MXP-MNP fusion breaks down
Secondary palate cleft develops when palatal shelves fail to fuse
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Anatomy of Cleft Lip
Cleft Lip Types
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Hard Palate Anatomy
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Soft Palate Anatomy
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Anatomy of cleft palate
In cleft palate, the
aponeurosis of the tensor
veli palatini, instead of
attaching along the
posterior border of the hard
palate, is attached along
the bony cleft edges. All
the muscles that attach to
the palate insert onto the
aponeurosis of this muscle.
Thus, the overall length of
the palate is shortened
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Disruption of levator sling
Dr. Prajesh Dubey, Subharti Dental College, SVSU
The Deformity
Clefts of the Palate
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Some syndromes associated with
clefts
More than 200 syndromes include clefts
Cleft Palate :
Apert’s, Stickler’s
Treacher-Collins
Pierre-Robin
Cleft Lip +/- Palate:
Van der Woude’s
Waardenberg’s
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification 1
Davis & Ritchie Classification(1922)
Group I: Pre-alveolar clefts (unilateral,bilateral
and median)
Group II:Postalveolar clefts
Group III: Complete alveolar
clefts(unilateral,bilateral and median)
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification 2
Veau Classification (1931)
Group I: Cleft of soft palate only
Group II: Cleft of hard and soft palate
Group III: Complete unilateral cleft
Group IV: Complete bilateral cleft
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification 3
International Classification(1967)
A. Group I: Cleft of anterior (primary) palate
a. Lip: Unilateral Rt/Lt-total or partial Bilateral
b. Alveolus: Unilateral Rt/Lt-total or partial Bilateral
B. Group II: Cleft of anterior and posterior(primary+ secondary) palate
a. Lip: Unilateral Rt/Lt-total or partial Bilateral
b. Alveolus: Unilateral Rt/Lt-total or partial Bilateral
c. Hard palate: Rt/Lt-total or partial
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Classification contd.
C. Group III: Clefts of posterior (secondary) palate
a. Hard palate: Rt/Lt
b. Soft palate
D. Group IV: Rare facial clefts
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Clinical Features of Cleft Lip
Loss of continuity of orbicularis oris
Alveolus defect- deviation,hypoplasia
Nostril defect-asymmetry,columella deviation etc.
Maxilla-vertical and horizontal hypoplasia
Dental abnormalities
In bilateral cases-projection of prolabium and premaxilla
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Clinical features of Cleft palate Intact palate is necessary
for normal function of
speech and swallowing.
Soft palate function is
important for valve action
on Eustachian tube.
Speech, deglutition and
hearing is affected
Maxillary development is
retarded
Malocclusion Dr. Prajesh Dubey, Subharti Dental College, SVSU
Treatment
AIMS & OBJECTIVES
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
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Treatment
Multi-disciplinary Approach Plastic surgeon
Maxillofacial surgeon
ENT surgeon
Speech therapist
Child psychologist
Trained nursing staff
Orthodontist
Prosthodontist
Pediatrician
Geneticist
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Treatment
General Management Protocol
Immediately after birth- paediatric consultation, counselling,
feeding instructions, evaluation by geneticist, diagnosis of
life expectancy and tests
Within 1st few weeks of life- team evaluation including
hearing test
At 10-12 weeks- surgical repair of lip (3-6 mths in India)
Before 1 year to 18 mths: team evaluation and surgical
repair of cleft palate and placement of Grommets (pressure
equalization tubes)
3 mths. after palate repair: team evaluation and speech and
language assessment
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Treatment
3-6 years: team evaluation, behavioural intervention, speech therapy, treatment of middle ear infection, fistula repair, soft palate lengthening, psychological evaluation
5-6 years: lip, nose revision if necessary, pharyngeal surgery
7 years: Orthodontic consultation
9-11 years: Alveolar bone grafting
12 years: Orthodontic treatment
15-18 years: Prosthetic rehabilitation for missing teeth
18-21 years: Orthognathic surgery, Rhinoplasty, final lip revision
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Lip repair
Millard’s rule of 10:
10 weeks of age
10 gm % Hb
10 lb weight
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Millard’s Rotation-Advancement
OTHERS: RANDALL-TENNISON Z-PLASTY, DELAIRE’S FUNCTIONAL
CHIELOPLASTY, NOORDORF’S MODIFICATION OF MILLARD’S TECHNIQUE
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Bilateral Lip Repair
Straight Line Closure
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Techniques of Palatal Repair
Langenbeck (1860)
Veau (1920)
Kriens (1969
Furlow’s double opposing Z-plasty
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Langenbeck’s Technique
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Veau-Wardill-Kilner “Push-back”
Technique
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Krien’s Intravelar Veloplasty
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Furlow’s Double-opposing Z-
plasty
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Complete Palatal Repair
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Soft Palate Repair
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Alveolar Bone Grafting
1. Grafting achieves stability of the arch and prevents collapse of the alveolar segments.
2. Grafting provides room for the canine and lateral incisors to erupt into the arch.
3. Grafting restores continuity not only of the alveolus, but also of the maxilla at the piriform rim. This supports the ala and provides improved stability and support for the nose.
4. Grafting of the alveolar defect provides an opportunity for the surgeon to address any residual oronasal fistula
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Alveolar Bone Grafting
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Velopharyngoplasty
“Velopharyngeal insufficiency” (VPI) is defined as inadequate closure of the nasopharyngeal airway port during speech production.
The audible nasal air escape with resultant hypernasal speech that is associated with VPI is perhaps the most debilitating consequence of the cleft palate malformation.
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Superiorly based pharyngeal flap
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Orthognathic Surgery
Maxillary retrusion
requires advancement
of the maxillary base
anteriorly which is
usually done via a Le
Fort I osteotomy.
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Orthognathic Surgery
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Orthognathic Surgery
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Other Concomitant Treatments
Hearing assessment
Speech assessment and therapy
Orthodontics
Prosthetic replacement of missing teeth
General dental care
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Orthodontic Intervention
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Prosthodontic Intervention
1. FOR REPLACEMENT OF
MISSING TEETH
2. FOR CLOSURE OF PALATAL
FISTULA
3. FOR CORRECTION OF
SPEECH
Dr. Prajesh Dubey, Subharti Dental College, SVSU
General Dental Care
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Fluoride Application
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Routine Dental Treatment
Oral Prophylaxis
Treatment of Carious teeth
RCT
Extraction of malformed teeth
Crown and Bridge
Implants
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Prevention
Parental Counselling
Genetic testing
High dose folic acid supplements
Dr. Prajesh Dubey, Subharti Dental College, SVSU
Conclusion
CLP is a distressing condition for the patient and
his family.
The condition requires multiple surgical
procedures from birth to maturity and frequent
outpatient visits.
The treatment presents serious challenges to
healthcare delivery systems and dedicated cleft
centres with a multi-specialty teams only can
provide complete and successful outcome.
Dr. Prajesh Dubey, Subharti Dental College, SVSU
THANK YOU
Dr. Prajesh Dubey, Subharti Dental College, SVSU