CLEFT LIP AND PALATE

Introduction

• A cleft is a congenital abnormal space or gap in the uppper lip, alveolus, or lip

• HARE LIP

Importance in dentistry

• Most common congenital anomalies to affect the orofacial region. These are deformities that involve the dental specialities throughout their protracted course of treatment.

• Special dental needs( anodontia or supernumery teeth)

• Malocclusion

Problems encountered in rehabilitation

• Parent counseling – explaination and reassurence • Prepare for protracted course of treatment - team approach

• Treatment must address Appearance Speech Hearing Mastication Deglutition

• Occurrence – 600 to 1000 live births • Boys: girl babies- 3:2• Commonly affect lip, alveolar ridge, hard and

soft palate• 3/4th unilateral • Left > right

Classification

Primary palate -anterior to incisive foremen • Lip-unilateral / bilateral• Alveolus-unilateral / bilateralSecondary Palate - posterior to incisive foremen Hard palate- Rt/Lt Soft palate

Classification

Davis and ritchie (1922)Group I; Pre alveolar clefts (uni, bi, median)Group II; Post alveolar cleftsGroup III; Complete alveolar clefts(uni, bi, median)

Primary palate

ETIOLOGY• HEREDITARY • ENVIRONMENTAL FACTORS

• Lack of complete knowledge of causes

• HEREDITARY– Genetic – 40%-CLEFT LIP– 18-20%-CLEFT PALATE

• ENVIRONMENTAL– Viral Infections

– Exposure to Radiation

– DRUGS-antibiotics, steroids, antiepileptic drugs

– Nutritional Deficiency of vit A, vit B, iron

– Excessive consumption of alcohol/smoking

– Consanguineous marriage-occurrance of congenital abnormalities

– Maternal age

Syndrome associated clefts

Dominant syndromes1. Vander woude’s syndrome2. Oral-facial-digital syndrome3. Velocardiofacial syndrome

Embryology

Embryology Facial primordia-4th week- primordial stomodeum-5 facial primordiaSingle FNP(FRONTONASAL PROMINENCE)

Paired MXP(Maxillary prominence)

Paired MDP(mandibular prominence)

Median nasal process MNPLateral nasal process LNP

• FNP- FOREHEAD,DORSUM,APEX OF NOSE

• MXP-UPPER CHEECK,UPPER LIP,

• MDP-CHIN,LOWER LIP,LOWER CHEECK

• MNP-NASAL SEPTUM;merge-philtrum of upper lip,premaxilla,primary palate

• LNP-ALAE OF THE NOSE

• Primary palate-Median Palatine Process MPP DEVELOPS FROM INTER MAXILLARY SEGMENT only pre maxillary part of maxilla

• Secondary palate-lateral palatine process-mesenchymal projections frominternal aspect of MXP

FORMATION OF CLEFT • UCL- Failure of MXP merged MNP(on affected

side)

• BCL-Failure of MXP merged MNP

• CPP-Failure LPP(rt & lt ) MPP(rt/lt)

• CSP-Failure LPPrt LPPlt

Associated problems

• Dental problems• Skeletal Malocclusion • Nasal deformity • Feeding • Ear problems • Speech difficulties • Associated anomalies

Associated problems

• Dental problems– Affects development of teeth– Congenital absence of teeth– Presence of supernumerary teeth– Crowding or displacement of teeth– Morphologically deformed or hypomineralised– Cleft seen b/w-lateral incisor & canine

Malocclusion – class III malocclusion– Hypoplastic maxilla– Narrowing of palatal vault (Early palatal closure-(scar

contracture)- limits growth of maxilla)

Malocclusion

• Space maintainance • Orthodontic treatment

-aim to move abnormally positioned maxillary arches & pre maxilla to normal relationship.(before the first surgery-through-till after the last surgery)

Orthognathic surgery

- Flat tip of the nose- Short / absence of columella- Widening of alar base- Hypoplasia of septal cartilages

CheilorhinoplastyNasal revision – last corrective procedure

Nasal deformity

Feeding

• Bottle feeding – not possible sucking negative pressure is not created due to inadequate seal

• Specially designed elongated nipples • Use of eye droppers • Large syringes with rubber extension tubes

connected to them. • This method considerable amount of air

swallowed - frequent burping necessary

Ear problems

• Serous otitis media – suppurative • Chronic inflammatory changes – conductive

deafness not sensory neural loss

Speech difficulties

• Consonant sound retadation• P, b, t, d, k and g• Hypernasality • Dental malformation, malocclusion and

abnormal tongue placement may develop before the palatal closure and produce articulation problem

• Hearing problem further complicates ..

• Velopharyngeal incompetence – escape of air between nasopharynx and oropharynx

• soft palate is a valve - pharyngeal wall

Associated anomalies

• Approax in 30% other anomalies ranging from club foot to neurological defect

Goal of surgical care • Normalized esthetic appearance of thelip 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

Timing of surgical repairParents insist on correction of all defects as early as

possible and single surgery Multi disciplinary team approach• Feeding plate ?• Paediatric consultation • Nutrition consultation• Lip surgery 3 months• Palate surgery 1 year• Speech therapy / ENT• Orthodontics• Alveolar bone graft 8 – 9 years

Feeding plate

Surgical Treatment Age Timing Considerations

1. Cleft lip repair 10 to 12 weeks

2. Cleft palate repair 9 to 18 months (Exact timing of repair is based on child’s speech/language age)

3. Pharyngoplasty for VPI 3 to 5 years

4. Alveolar Bone graft reconstruction 6 to 9 years

5.Orthognathic surgery 14 to 16 years for females,16 to 18 years for males

6.Dental implant placement 16 to 18 years

7. Lip/nasal revision After age 5 years (Varies widely depending

on clinical findings and psychosocial concerns.)

Definitive nasal surgery usually delayed until adolescence.

Lip repair

• Cheilorrhaphy • Timing • Rule of 10’s • child was at least 10 weeks old,• 10 pounds in weight, and• hemoglobin value of 10 dL/mg

• Surgical technique to elongate cleft margin to match normal length and symmetry

• Reorienting and reuniting the muscle • Three layer closure

• Lip closure in linear fashion causes scar contraction – notching at upper lip

• Rotation advancement repair – Millard technique• Cleft extending through floor of nose , the continuity

of nasal apparatus disrupted • Restore symmetry of lip and nose

Bilateral cleft

Palatal closure

Palatal closure - around 18 monthsPalatorrhaphy one stage two stage (18-24 months and 4-5 years )Techniques Von langenbeck bipedicled repairVeau-wardill-kilner unipedicled repair

Palatorrhaphy

• to create a mechanism capable of speech and degluttition with out significantly interferring with subsequent maxillary growth

• Main goal - competent velopharangeal mechanism- Partitioning nasal & oral cavity

Palatorrhaphy

Aim is to obtain a long and mobile soft palate capable of producing normal speech

Three layer closure • Nasal mucosa• Muscle• Oral mucosa

Von langenbeck operation

Wardill operation

Alveolar cleft grafts

Problems faced due to alv cleft • escape of oral fluids to nose • Drainage of nasal secretion into oral cavity• Eruption of teeth• Collapse of alveolar segments• speech

Alveolar bone grafting• Primary-time of lip/ palate closure before 2 yrs• Secondary

– Early06 to 7 yrs- performed at the time of maxillary lateral incisor eruption

– Late-9-11 yrs-just before canine eruption

• Grafting at the time of le fort I-osteotomy• Revision grafting

• Donor site– Ilium,calvaria,hydroxyapatite crystals….etc

Orthognathic surgery

• Lefort I osteotomy• DO