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AND PALATE
INCIDENCE
Common in south asians 1 in 500
Less frequent in africans 1 in 200
Prevalance in pakistan 1 in 523
Boys are more affected than girls 3:2
75% are unilateral
Left side is more affected than right
side
EMBRYOLOGY
DEVELOPMENT
OF PALATE
CLASSIFICATION
Generally classified as
Isolated cleft of lip/palate
Combined CL+CP
Unilateral or bilateral
complete (if it crosses nasal philtrum) or
incomplete (if it does not cross philtrum)
Veau classification
Kernehans stripped Y
Millard modification of kernehan stripped Y
Kriens LAHSHAL
VEAU CLASSIFICATION
GROUP 1
Cleft of the soft palate
GROUP 2
Cleft of hard and soft palate up to
incisive foramen
GROUP 3
Complete unilateral cleft lip and palate
GROUP 4
Complete bilateral cleft lip and palate
LAHSHAL
CLASSIFICATION
L=lip (right)
A=alveolus (right)
Capital letter = complete
H=hard palate (right)cleft
Lower case letter =
S=soft palate
incomplete cleft
(median)
. or , = normal
ETIOLOGY
Genetics, inherited from one or both
parents
Environmental factors
Drugs, phenytoin, retinoids
Infection, rubella
Smoking
Alcohol
Hypoxia
Vitamin A defeciency
Folic acid defeciency
DIGANOSIS
Cleft can be diagnosed prenatally
Can be diagnosed by using 3-D imaging in
ADVANTAGE
Prenatal education
Psychological preperation of parents
Helps to asses and investigate other
associated anomalies
SEQUENCE
Cleft palate
Micrognathia
Glossoptosis (retrarction of
tongue)
SYNDROMIC CLEFT
STICKLERS SYNDROME
Flttened face
PRS
Ear infections
Occular HTN
Retinal detachment
VELOCARDIOFACIAL
SYNDROME
Cardiac abnormality
Abnormal facies
Thymic aplasia
Cleft palate
Hypocalcemia/hypoparathyroidism
VAN-DER-WOUDES
SYNDROME
Genetic disorder
Combination of lower lip pits+CL
PROBLEMS
Feeding
Breathing
Speech problems
Hearing
Esthetic problems
Nasal deformity
Dental problems
FEEDING
Infant cannot suck
May cause milk to be
Mead-Johnson
cleft palate nurser
Haberman feeder
Pigeon nipple
after birth
High frequency of otitis media
Myringotomy is performed to relese otitis
media fffusion
DENTAL PROBLEMS
Missing teeth
Hypodontia
Hyperdontia
Natal teeth
Microdontia/macrodontia
Enamel hypoplasia
Poor PDL support
Early loss of teeth
Class III tendency
Spacing
Crowding
Xbite
NASAL DEFORMITY
Poor nasal shape
Scar mark due to surgery
ESTHETIC PROBLEMS
Poor dental alignment
Poor smile
Poor lip function during speech
EAR PROBLEM
Middle ear infection
Hearing loss
SPEECH PROBLEMS
Velopharyngeal insufficiency (VPI)
Poor pronounciation of bilabial,
MANAGEMENT
TEAM APPROACH
Genetic scientist
Peditrician
ENT surgeon
Paedodontist
Oral surgeon
Prosthodontist
Plastic surgeon
Speech therapist
Pshyciatrist
Social worker
PRENATAL
Diagnosis and parental counseling
0-6 MONTHS
General assessment for associated anomalies
ENT evaluation- breathing, feeding, swallowing and
hearing
Pre surgical orthopedics (0-3 months)
Primary lip repair (3-4 months)
6 MONTHS-2 YEARS
Speech and oral sensory motor assessment
Grommets/ear tubes (as needed)
Primary palate repair (9-12 months)
PRESCHOOL: 3-5 YEARS
Dental care
Speech assessment and therapy
years (male)
Revision chielo-rhinoplasty
Replacement of missing teeth (as needed)
PRESURGICAL
ORTHOPEDICS
Gentle application of pre surgical orthopedic force
ACTIVE APPLIANCE
Active
appliances
They are fixed
intra orally
apply traction
through
mechanical means
such as elastic
chains, screws,
and plates.
Passive
appliances
OTHER METHODS
External force can be
applied by
external taping of the lip
a head cap with elastic
straps
or a surgical lip adhesion.
normal appearnce
Timining is between 3-6 months
A RULE OF TEN is followed to ensure the
infant is fit for surgery.
Infant should be at least 10 weeks of age
Weigh 10lbs
Haemoglobin level 10g/100ml
TECHNIQUE
Blair, Le Mesurier, Tennison and Randall contributed
PRINCIPLES
1. ROTATION OR LENGTHENING OF SHORTENED
2.
3.
4.
5.
6.
ANATOMY
Difficult to repair
Absence of muscle in
prolabial segment
Lack of philtrum dimple
Lack of Philtral columns
Absent Roll margins
Premaxillary segment
protrudes making tension
free margins of muscle
repair difficult.
Columella short
Wide nasal tip
Flare alar base
PRINCIPLES
ESTABLISH SYMMETRY
DESIGNIGNING A PROLABIAL FLAP OF
APPROPRIATE WIDTH
FORMING THE CUPIDS BOW AND MEDIAN
TUBERCLE FROM LATERAL LIP ELEMENTS
ESTABLISH MUSCLE CONTINUITY
RECONSTRUCTION OF NASAL TIP AND
COLUMELLA
REPOSITIONING THE ALAR BASE
MANAGEMENT OF PREMAXILLA
muscles
Seal communication between the oral and nasal
cavities
TIMING OF REPAIR:
Historically cleft palate repair of the hard
ANATOMY:
Minor submucous cleft:
affect soft palate only
Bifid uvula
Notching of posterior nasal
spine
Translucency in mid palatine
region of soft palate due to
lack of muscle
Abnormal orientation and
attachment of the muscles,
primarily
Levator palatini
Tensor palatine
Musculus uvula
Muscle bundle insert
longitudinally into the posterior
PRINCIPLE
Main principle is to detach and retropose the
TWO-FLAP PALATOPLASTY
Commonly used
For complete unilateral and bilateral cleft
of palate
Edges of cleft are incised from alveolus to
base of uvula
Bilateral full thickness muco periosteal flap
is raised
Levator palatini muscles are released and
dissected
Reposition horizontally and sutured
Bilateral releasing incision are made to
palate cleft
Bilateral releasing
incisions are made
muco periosteum is
elevated
Complete stripping
of nasal mucosa
Then close nasal
layer, muscle and
oral mucosa in
layers
Z-plasties of oral
and nasal mucosa
to repair the cleft
ADVANTAGE:
Restore the
normal anatomic
position of levator
palatini in midline
Increases soft
palate length
KILNER (V-Y
PUSHBACK) REPAIR
was the commonest technique
V-Y procedure is performed
mucoperiosteal flap and the soft palate are retroposed
SPEECH DYSFUNCTION
Resonance
Articulation
Phonation
Language delay
CAUSE
Velo pharyngael insufficiency
Oro nasal fistula
Weak lip pressure
Abnormal tongue pressure
Malposed teeth
Abnormal jaw relationship
Neuromuscular dysfunction
Hearing loss
VELOPHARYNGEAL
INSUFFICIENCY(VPI)
It is as a failure of the separation
DIAGNOSIS OF VPI
SPEECH ANALYSIS:
The main symptom is hypernasality of the voice. The
TREATMENT (SURGICAL)
FLAP PHARYNGOPLASTY:
When the pharyngeal flap is used, a flap of
NON SURGICAL
used for nonsurgical closure.
There are two types of prostheses.
speech bulb: The speech bulb is
ALVEOLAR CLEFT
REPAIR
Goal is to maintain bony continuity of alveolar
ridge
Provide bone support for the teeth adjacent ti
cleft
Seal nasal and oral cavity
Facilitate eruption and orthodontic movement
of teeth mostly canine
Maintain healthy periodontium
Provide alar base support
Improve nasal symmetry
TIMING OF REPAIR
Secondary bone grafting at the age of 7-11
years is done
This coincides with development of one half to
two thirds of root of canine or lateral incisor if
present.
Graft material is corticocancellous bone from
iliac crest, rib, symphysis, calvarium and tibia.
Before grafting of bone maxillary expansion
should be completed to provide acess to the
defect.
PRINCIPLES
Closure of nasal floor
Removal of any supernumerary teeth in the
cleft
Fill with bone
Approximate oral mucosa
Orthodontic movement can be initiated in 3-4
months if required
Palatal retainer should be placed after surgery
to prevent loss of maxillary width
ORTHODONTIC
MANAGEMENT
2-10 weeks:
Pre surgical orthopedics
6-10 years:
Phase I orthodontics:
10-14 years:
Maintain maxillary expansion and alignment of teeth
Monitor facial growth and eruption of teeth
14-18 years:
Phase II orthodontics:
REPLACEMENT OF TEETH
Most common teeth is maxillary lateral incisor
Managed by closing the space and substitute the adjacent
CORRECTION OF
MAXILLARY
HYPOPLASIA
Maxillary hypoplasia is due to restriction of
midfacial growth
It can be attributed partly due to
congenital malformation
Scar contracture following primary palate
surgery
deformity
Lip and nose revision is done during late
adolescence after correction of maxillary
hypoplasia
Done to achieve balanced facial esthetics
SECONDARY LIP
DEFORMITY
Residual deformity in unilateral cleft
include
Mismatch of cutaneous vermillion border
realignment and small triangular flap
or Z-plasty procedure
Vertical shortening of lip full thickness
revision of skin, muscle and mucosa
Hypertrophic scar
include
Tight upper lip Abbe flap
Poor philtral column
Poor cupids bow
Poor vermillion show in midline
Scar
Shallow labial sulcus perform Z-plasty
N
A
H
T OU
Y