Cleft lip and palate

Definition A cleft lip or palate is an abnormal separation in the oral-facial region that happens because tissue of the mouth or lip does not form correctly in fetal development.

B- Normal Palate - Primary palate - Secondary palate Soft palate Hard palate Clinical Aspects of Cleft Lip/Palate Reconstruction

Cleft Variants Great anatomic variation in types of clefts! Anatomic Classification based on: 1) Location 2) Completeness (Incomplete/Complete) 3) Extent Clinical Aspects of Cleft Lip/Palate Reconstruction

Classification Standardized methods Key anatomic structure Incisive foramen Primary palate Lip Premaxilla Alveolus Secondary palate Soft palate Hard palate

Cleft of primary palate (cleft lip) Unilateral Incomplete Lip only Complete Primary palate Lip, nasal floor, alveolus Result from deficiency of mesenchyme in the maxillary prominences and intermaxillary segment

Cleft of primary palate (cleft lip) Bilateral Incomplete Lip only Complete Primary palate Lip, nasal floor, alveolus

Cleft of secondary palate - Soft palat only (incomplete cleft palat) Soft and hard palat (complete cleft palat) Submucus cleft Caused by defective development of the secondary palate and result from the growth distortions of the lateral palatine processes (shelves) which prevent their medial migration and fusion

A cleft of the secondary palate can be incomplete, such as a bifid uvula or cleft of the velum only.

A complete cleft of the secondary palate includes the entire velum and hard palate to the incisive foramen.

A submucous cleft palate is a congenital defect that affects the underlying structures of the palate, while the structures on the oral surface are intact. This defect can involve the muscles of the velum and can also involve the bony structure of the hard palate.

Clefts of both the primary and secondary palate are common. When there is a combination, each section (primary palate and secondary palate) can be unilateral, bilateral, complete, or incomplete.

Etiology of cleft lip and palate

Treatment

Successful treatment requires a multidisciplinary approach Requires team approach throughout life neonatal period toddler grade school adolescence young adulthood

1 Haberman Feeder The Neonatal Period Directs care is necessary To establishes feeding complete clefts preclude feeding 1- Breast feeding not possible 2- A soft, large bottle with large hole is required 3- A palatal prosthesis may be required Haberman Feeder

1 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)

Feeding plates to assist in early feeding Obturator plate 12th July 2008

Pre surgical plates, moulding plates, feeding plates……. 12th July 2008

1 Surgical Repair The Neonatal Period Cleft Lip Cleft Palate In US - “the rule of tens” - 10 wks, 10 lbs, Hgb 10 Lip adhesion vs baby plates Cleft Palate Varies from 6-18 months - most around 10 mo Early repair may lead to midface retrusion Early repair improves speech

2 The Toddler Years Priority: Speech Growth hormone deficiency “Cleft errors of speech” in 30% Velopharyngeal insufficiency Growth hormone deficiency 40 times more common in CLAP

3 The Grade School Years Three primary issues Orthodontics poor occlusion congenitally absent teeth alveolar bone grafting fills alveolar defect - around age 12 psychological growth

4 The Teenage Years Midface retrusion Psychological development Rhinoplasty usually last procedure performed, around age 20

Repaired cleft palate in 8 year old 12th July 2008

Quadhelix to expand prior to ABG 12th July 2008

12th July 2008

Advantages of alveolar bone grafting (ABG) Provides continuity of alveolar ridge… Provides bone for canine to erupt Osseous support for adjacent teeth Majority of canines erupt spontaneously…others require surgical exposure often in combination with orthodontics. The erupting teeth often appear to then stimulate the formation of new alveolar bone 12th July 2008 Dr. Christine Underhill

erupted canine 12th July 2008

Adolescent treatment 12th July 2008

12th July 2008

Adult treatment- Orthognathic surgery 12th July 2008

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