The Face

Prof. Dr.

Mohammed Ali Nasr

Congenital anomalies (Cleft lip-palate).√√√√ Trauma) Maxillo-Facial Fracture). Inflammatory ( Infection --- › Dangerous

area). Tumors (skin tumors).

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Embryonic Period From fertilization to the end of 8th week of gestation :

-by 6 days age, as implantation of a spherical mass of cells with a central cavity called Blastocyst.

-by 2 weeks: -uteroplacental circulation has begun-2 distinct layers, ectoderm and endoderm

-by 3 weeks: -mesoderm has appeared along with primitive neural

tube and blood vessels.

-4-8 weeks:-lateral folding of the neural plate followed by growth

at the cranial and caudal ends.-budding of arms and legs produces a human like

shape-precursors of skeletal muscles,, vertebrae, along with

the branchial arches that will form the mandible, maxilla, palate, external ear and other head and neck structures start to develop.

Embryo at 4 - 5 weeks (Lateral view)

Branchial Apparatus

• Six arches• Branchial clefts –

ectodermally lined.• Pharygeal pouches –

endodermally lined.• Branchial membrane

Early in the 4th week, five primordial swellings consisting primarily of neural crest-derived mesenchyme appear around the stomodeum and play an important role in the development of face

Stomodeum

1 Frontonasal prominence2 Maxillary prominences

2 Mandibular prominences

• By the end of 4th week, bilateral oval-shaped ectodermal thickenings called ‘nasal placodes’ appear on each side of the lower part of the frontonasal prominence

• Nasal placodes are primordia of the nose and nasal cavities.

Frontonasal prominence

Mouse embryo: 6 weeks

ANATOMY• Hard Palate

Maxilla( Palatine Processes) +

Palatine Bones(Horizontal Lamina)

Facial clefts Failure of the embryonic

facial prominences to fuse properly

• May be unilateral or bilateral• May involve:

Lips only: Cleft lip Palate only: Cleft palate Lip & palate: Cleft lip &

palate Region of nasolacrimal

groove: Facial clefts

Lead to difficulty in breathing feeding sucking

swallowing&

speech

Unilateral Cleft Lip

Bilateral Cleft Lip

• Median cleft lip: results from failure of the medial nasal prominences to merge and form the intermaxillary segments

• Unilateral cleft lip: result from failure of the maxillary prominence to merge with the medial nasal prominence on the affected side

• Bilateral cleft lip: results due to failure of maxillary prominences to meet and unite with the medial nasal prominences on both sides

Median Cleft lip

Unilateral cleft lip

Bilateral cleft lip

2. Oblique facial cleft: results from failure of the maxillary prominence to fuse with the lateral nasal prominence

3. Cleft palate leaves the nasal and oral cavities connected & results in nursing problem for the new born

May be: Anterior/posterior to incisive

foramen Unilateral/bilateral

Cleft lip, cleft jaw & cleft palate

Oblique facial cleft

EtiologyEtiologyGenesGenes

• 2 to 20 genes are thought to interact to result in facial clefting2 to 20 genes are thought to interact to result in facial clefting• Chromosomal abnormalitiesChromosomal abnormalities

• Trisomy 13

• Environmental agentsEnvironmental agents• MedicationsMedications :phenytoin valproate :phenytoin valproate

– With corticosteroids : With corticosteroids : Possible association could not be excludedPossible association could not be excluded..• Cigarette smokingCigarette smoking • AlcoholAlcohol • Folate deficiencyFolate deficiency

• Mechanical Mechanical √√√√• Cleft of lip increases likelihood of cleft of palate because tongue gets

trapped.

INCIDENCE Facial clefting is one of most common congenital

deformity (1:750 live births). 1:Clefts lip only (Pre-alveolar) 25%, more in male,

unilateral in75% ,bilateral in25% rarely median2:Clefts palate only (Post-alveolar) 25%, more in

females (Fusion precedes from before backward)3:Cleft lip and palate (Alveolar) 50% uni/bi

Problems are cosmetic, dental, speech, swallowing, hearing, facial growth, emotional

                  

Unilateral incomplete

                  

Unilateral complete

                  

Bilateral complete

                  

Incomplete cleft palate

                  

Unilateral complete lip and palate

                  

Bilateral complete

Prenatal DiagnosisPrenatal Diagnosis

Obstetrical Obstetrical ManagementManagement

• As of January 2002, "in utero" correction As of January 2002, "in utero" correction had been attempted only once in Mexico had been attempted only once in Mexico – The child delivered prematurely and died at two The child delivered prematurely and died at two

months of life months of life

MANAGEMENT

• Team Approach• Surgical Repair• Speech Disorders• Orthodontics

ManagementManagement• The Care will entail attention, not only to The Care will entail attention, not only to

surgical repair, but also more immediate surgical repair, but also more immediate needs such as feeding. needs such as feeding.

• Primary lip repairs can often be undertaken Primary lip repairs can often be undertaken at three months of age with palatal repairs at three months of age with palatal repairs around six months till 1.5year.around six months till 1.5year.

• Additional surgeries as well as speech and Additional surgeries as well as speech and orthodontic therapies are often needed. orthodontic therapies are often needed.

Surgical Techniques

• Unilateral Cleft Lip Repair

• rotation-advancement flap developed by Millard

• complications– dehiscence

• infection– thin white roll

• excess tension

Surgical Techniques

–Bilateral Cleft Lip Repair

– V-Y repair ,may be 2-stages

Surgical Repair- Cleft Palate

• Scarring of palate may cause impaired mid-facial growth (alveolar arch collapse, midface retraction, malocclusion)

• Facial growth may be less affected if surgery is delayed until 18-24 months, but feeding, speech, socialization may suffer.

Waldill (push-back)

2 staged repair of

cleft palate

• THANK YOU