While on call…
25yo G1 P1 delivers a full-term infant after 12hrs of uneventful labor.  The infant was found to have a cleft lip and palate.  How should the care for this infant, and his mother, be?

Outline

Cleft Lip
 Unilateral, Bilateral
 Etiology, Epidemiology, pathophysiology,

treatment

Cleft Palate
 Etiology, Epidemiology, pathophysiology,

treatment  Operation technique

15% CL. females CL   2nd baby 1/30 (genetic counseling) . 40% CP  Males CL/P.Incidence of Cleft Lip and Palate  1/750-1000 live births (2nd to club foot) 45% CL/P.

anticonvulsants –5%  Syndromes .Aetiology Genetic – all forms of inheritance have been described .50% CP and 15 % CL/P have associated anomalies  .occurs as part of >100 syndromes .trisomy 13 and 18) in 12%  Environmental – viral? – steroids. with chromosomal abnormalities (esp.

and mandibular processes form the face  Left CL due to failure of fusion of median nasal and maxillary processes  .maxillar y.Embryology of Cleft Lip Weeks 4-7  frontonasal.

Prenatal Diagnosis by U/S at 12 weeks – a good thing ? .

Unilateral incomplete Unilateral complete Bilateral complete Incomplete cleft palate Unilateral complete lip and palate Bilateral complete .

Unilateral Cleft Lip  Complete  Incomplete .

Bilateral Cleft Lip  Incomplete  Complete .

?orthodontist  3 months – hearing test  3-6 months – lip repair +/ 10-18 months – palate repair +/ 2-3 years -dental and speech evaluations  .Sequence of Interventions Prenatal-1st few weeks – plastic surgeon and nurse/coordinator.

?lip and nose revision . speech and pharyngoplasty  9-14 years – orthodontia +/.bone graft  Adolescence . team conference if necessary  . orthodontia and bone graft.Sequence of Interventions (cont.) 5 years – initial team conference  7-9 years – team reassessment re lip and nose revision.

large bottle with large hole is required  a palatal prosthesis may be required .The Neonatal Period  Pediatrician:  directs care  establishes feeding ○ complete clefts preclude feeding  breast feeding not possible  a soft.

Presurgical Intervention .

The Neonatal Period  Presurgical Orthodontics (Baby Plates)  Molds palate into more anatomically correct position  decreases tension  may improve facial growth  Grayson. presurgical nasal alveolar molding (PSNAM) .

when?  . weight  Fetal or newborn – risks  Muscle and vertical height  Nasal tip .Cleft Lip Repair Old rule of 10’s – Hb. age.

Techniques Cleft Lip Repair .

Surgical Techniques  Cleft Lip Repair  unilateral ○ rotation-advancement flap developed by Millard ○ complications  dehiscence .infection  thin white roll .excess tension .

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Nasal Tip Revisions .Unilateral .

Nasal Tip Revisions Bilateral .

syndromic  34% Stickler (eyes. floor of mouth release. 11% VCF  Positioning > tongue-lip adhesion. joints).Pierre Robin Sequence Micrognathia  Glossoptosis  ?horseshoe cleft palate  17% non. tracheostomy or mandibular distraction  .

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Objectives of Palate Repair Normal speech  Preservation of facial growth  Preservation of hearing  Separation of oral/nasal cavities  Normal dental occlusion  Normal swallowing  .

Embryology of Cleft Palate weeks 8-11  Premaxilla from median nasal processes  Palatal processes from maxillary processes fuse with premaxilla and nasal septum from anterior to posterior  .

Types of Palatal Clefts Submucous  Soft  Unilateral  bilateral  .

Eustachian Tube Dysfunction .

?nurse Plastic surgeon Otolaryngologist and Audiologist Speech Pathologist Dentist and Orthodontist Maxillofacial Surgeon .Cleft Palate Team       Coordinator .

Cleft Palate Repair V-Y Pushback  Two Flap Palatoplasty  Furlow Palatoplasty  .

Cleft Palate Repair V-Y Pushback      Two uni-pedicled flaps (greater palatine artery) and one or two anteriorly based pedicled flaps Posterior flaps rotated in a V-Y advancement technique increasing the length of the palate Nasal mucosa not closed Improved speech results compared with bipedicled techniques Indicated for incomplete clefts .

Cleft Palate Repair Schweckendick’s Primary Veloplasty Incisions made in soft palate  Muscle bundles released from the posterior hard palate and rotated  Reconstruction of levator sling  Closure of mucosal layers separately  .

.Cleft Palate Repair Furlow Palatoplasty     Lengthens the soft palate Reconstructs the muscle sling. Also commonly used to correct velopharyngeal insufficiency in patients with submucous cleft palate Speech outcomes are improved compared with other palatoplasty techniques.

 Velopharyngeal insufficiency .7% to 23%  Sites of fistulization are typically the anterior hard palate and the junction of the hard and soft palate.Cleft Palate Repair Complications  Oronasal fistula .8.

Pharyngoplasty Timing – motivation.obstruction  . sleep apnea  Risks – bleeding. dehiscence.caries. infection. orthognathic surgery  Unpredictable – insufficient improvement.

Orthodontia and Alveolar Bone Grafting .

Terimakasih .