Cleft lip and palate

Introduction
 Cleft is a gap in the anatomical structure
 Facial clefting is the second most common
congenital deformity (after cleft foot).
 Affects 1 in 700 births
 Problems are cosmetic, dental, speech,
swallowing, hearing, facial growth,
emotional
 incidence
 Varies according to geographical location
 Incidence is 1:700 live births
 Cleft lip and palate is more common in
male then female i.e. 3:2
 Isolated cleft palate is more common in
female
 Embryology
 Primary Palate- Triangular area of hard
palate anterior to incisive foramen to point
just lateral to lateral incisor teeth
– Includes that portion of alveolar ridge and four
incisor teeth.
 Secondary Palate- Remaining hard palate
and all of soft palate
 Embryology
 Primary Palate
– Forms during 4th to 7th week of Gestation
– Cleft of primary palate and lip Results from
failure of mesodermal penetration of the grove
between medial nasal and maxillary process
• Secondary palate
– Forms during 6th to 9th week of gestation
– cleft of secondary palate results from failure of
palatal shelve to fuse with one an other due to
failure of tongue to descend in to oral cavity
 Causes
 Syndromes related 15%
 Isolated (nonsyndromic) 50%

 Syndromes are;
 pierre robin syndrome
 Cleidocranial dysostosis
 Treacher Collins syndrome
 Mecfee syndrome
 Causes
 Heredity 30%
 Nutritional deficiency
 Radiation
 Drugs
 Hypoxia
 Viral infections
 Vitamin deficiency and access

 Causes
 Anemia
 Tobacco smoking
 Alcohol
 Consanguineous marriage
 Maternal age
 Stress
Risk for cleft lip and palate
 Depend upon ;
 Number of family members with cleft
 Relation with cleft patient
 Race
 Sex and
 Type of cleft
 Parent having one child with cleft the risk
for having next is 2—5%
 Risk
 More then one family member having cleft
the risk increase to 10—12%
 Unaffected sibling of a child with cleft has
1% chance to have a child with cleft
 Syndrome related patient have 50% chance
of having a child with cleft
 Classifications
 International approved classification
Group I Cleft of anterior palate
a) Lip uni/bi lateral RT/LFT Total/Partial
b) Alveolus uni/bi lateral RT/LFT total/partial

Group ii Cleft of anterior and posterior palate

c) Lip uni/bi lateral Rt/lft total/partial
d) Alveolus uni/bi lateral Rt/lft total/partial

e) Hard palate RT/lft total/partial

 Classification
 Group iii Cleft of posterior palate
a) Hard palate
b) Soft palate

Group iv Rare facial cleft

Kernahans classification
 Effect of cleft
 Appearance
 Speech
 Haring
 Mastication
 Deglutition
 Psychological
 Dental
 Structure effected
 Lip; skin, muscles, mucosa
 Alveolus
 Hard palate Anterior and posterior
 Soft palate
 Nose
 Problems with cleft patient
Dental problem;
a) Congenital absence of teeth
b) Supernumerary teeth
c) Hypo plastic teeth
d) Male occlusion
Nasal deformity
a. Columella of nose is pulled to the non cleft side
b. Alar cartilage on cleft side is extended
 Feeding problem
 Can not suck breast milk because negative
pressure can not be made in the oral cavity
 Ear problems
 Proven to middle ear infections because levator
veli platini and tensor veli platini have origen
from the auditory tube. These muscle allow
opening of tube in to naso pharynx this function is
disturbed in palatal cleft so there is middle ear
infections
 Speech problem
 Retardation of consonant sound i.e.
i,e,p,b,t,d,k and g.
 Hyper nasality
 Articulation of the words
 Hearing problem contribute to speech
problem
Aim/object of management
 To correct the deformity surgically so the
patient have acceptable esthetic
 To permit intelligible speech
 To correct the dentitions for proper function
and esthetics
 Cleft team
 Pediatric dentist
 Orthodontist
 Prosthodontist
 Oral surgeon/plastic surgeon
 Speech pathologist
 Psychologist
 Social worker

 Timing of surgery
 Cleft lip as early as possible
 Rule of 10 is adopted i.e.
 10 weeks age
 10 pounds weight
 10% hemoglobin
 Soft palate 8—18 months
 Hard palate 4—5 years
 6 advantages of early
closure
 Better palatal and pharyngeal muscle
development
 Ease of feeding
 Better phonation skill
 Better auditory function
 Better oral hygiene
 Improved psychological state for parent
 2 disadvantages of early
closure
 Difficult surgery due to small structure
 Scar formation causes maxillary growth
retardation
Early closure of lip-advantages
 Molding action on distorted alveolus
 Assist in feeding
 Psychological benefit
 Minimum scaring
 Cheilorrhaphy
 Objectives
 Function and esthetic i.e.
 To restore the functional arrangement of
orbicularis ores musculature
 To restore the normal function of upper lip
 To provide a lip with normal anatomical
structures i.e. vermilion tubercle, cupid bow
and philtrum
 Surgical procedures
 Le measurer technique
 Tennyson technique

 Wynn operation

 Millard rotation advancement technique

Each technique has its own advantages and

disadvantages
In unilateral cases the un effected side is used
for guide line
 Palatorraphy

One stage surgery

Two stage surgery

1st stage soft palate closure(staphylorraphy)

2nd stage hard palate closure(uranorraphy)

Objectives
 Speech and deglutition without interfering maxillary
growth

Creating velopharyngeal mechanism

Separating nasal cavity from oral cavity
 Soft palate surgery
 Closed in three layers
 Nasal mucosa
 Muscles
 Oral mucosa
 If soft palate is short then it is closed by w-
y push back procedure(wardell) or by u-
push back procedure(dorrance-brown)
 Surgical techniques

Hard palate closed with soft tissue only

Von logenback operation; cleft margins incised
and soft tissues undermined, lateral releasing
incision given at junction of palate with alveolus,
soft tissue water tight closer over the cleft

Soft palate closure most difficult due to;

Access, light, retraction, surgeon can work only
from oral side
 Alveolar cleft grafting
 Timing of surgery; at the age of 7-10years
when maxillary growth is almost completed
 Before the eruption of permanent canine
 When 2/3 root of canine is completed
 Alveolar cleft grafting is needed due to 5
problems
 1.oral fluid escape in to nose
 2. nasal secretion drains in to oral cavity
 Alveolar grafting

3. Teeth erupt in to cleft

4. Alveolar segment collapsed

5. Speech is effected
Advantages

Prevent collapse of arch

Provide support for erupting teeth

Closure of oro-antral fistula

Creation of solid foundation for nasal base


 Conclusions
 Cleft Lip and Palate are common congenital
deformities that often affect speech,
hearing, and cosmesis; and may at times
lead to airway compromise.
 The oral surgeon is a key member of the
cleft palate team, and is in a unique position
to identify and manage many of these
problems .