Cleft lip

Introduction

What is Cleft Lip and Palate? Congenital abnormal space or gap in the upper lip, alveolus and palate

Incidence

More common in south far Asians: 1 in 500 Less frequent in Africans: 1 in 2000 Prevalence in Europeans and Americans: 1 in 750

Incidence

Cleft Lip and Palate occur twice as often in boys as in girls Isolated Clefts of Palate are more often in girls 75% of Clefts are Unilateral, rest are Bilateral Left side is more involved than right side

Head and Neck of 4-Week Old Embryo

Trigeminal nerve
Facial nerve
Glossopharyngeal nerve
Vagus nerve
Embryological Background



Embryological Background
Development of the Lip: Unpaired Frontonasal Prominence Medial and Lateral Nasal prominences 2 maxillary prominences 2 mandibular prominences

Embryological Background

Fusion defects can occur anywhere between these prominences The defect in the fusion between the frontonasal and maxillary will lead to cleft lip

Embryological Background

Development of Palate: We have two parts of two different embryonic origins: 1 ) primary palate : the triangular part of hard palate anterior to incisor foramen which originate from the premaxilla ( frontonasal prominences). develop between 4th and 8th week of gestation 2 ) secondary palate : remaining part of the hard palate and all soft palate posterior to incisor foramen which comes from palatine shelves of the maxillary prominences develop between 8th and 12th week of gestation

A‐incomplete cleft of thesecondary palateB‐Complete cleft of thesecondary palateC‐Incomplete cleft of theprimary and secondary palateD‐Unilateral complete cleft ofthe 1 and 2 palatesE‐bilateral complete cleft of the1 and 2 palates Classification

Other Types of Clefts

Microform Cleft: May look like a little dent in the red part of the lip a scar from the lip up to the nostril. Muscle tissue underneath the cleft can be affected and may require surgery Submucous Cleft Palate: Midline deficiency or lack of muscular tissue Often a submucous cleft palate is associated with a bifid or cleft uvula Posterior nasal spine is almost always missing Speech Problems are common

Prenatal Diagnosis

Diagnosis
Advantages of Prenatal Diagnosis: Time for parental education Time for parental psychological preparation Opportunity to investigate other associated anomalies Gives parents the choice of continuing the pregnancy

Etiology

“Actually no one knows exactly what causes clefts”Multiple factors may be involved, like:Genetics (inherited characteristic) from one or both parents Environmental factorsDrugs: corticosteroids (anti-inflammatory), phenytoin (anticonvulsant)Infections: like rubella during pregnancy. Alcohol consumption, smoking, hypoxia during pregnancy, some of dietary and vitamins deficiencies (like folic acid and vitamin A deficiency)Maternal Age

Nonsyndromic Cleft

Pierre Robin Sequence is the most common associated nonsyndromic anomaly is a relative term describing the small size of the lower jaw ) and Glossoptosis (is a medical condition and abnormality which refers to the downward displacement or retraction of the tongue)

Problems Associated With Cleft Lip and Palate

Feeding Dental problems Nasal Deformity and Esthetic Problems Ear Problems Speech Difficulties Associated Anomalies

Feeding Difficulties

Cleft lip= makes it more difficult for an infant to suck on a nipple Cleft Palate= may cause formula or breast milk to be accidently taken up into the nasal cavity Inability to create negative pressure inside oral cavity Frequent regurgitations Upper respiratory tract infections

Dental Problems

Local Dental Problems: Congenitally Missing teeth, Hypodontia, Hyperdontia, Oligodontia Presence of natal and neonatal teeth Anamalies of tooth morphology like microdontia, macrodontia etc Fused teeth Enamel Hypoplasia Poor periodontal support, early loss of teeth Gemination, Dilacerations Orthodontics Problems: Class III tendency Anterior and Posterior Cross bite Spacing and crowding

Nasal Deformity and Esthetic Problems

Facial Disfigurements Poor nasal shape Scar marks of surgeries Poor lip function during speech Poor dental alignment and smile

Ear Problems

Middle ear disease - 22% to 88% Conductive hearing loss and chronic suppurative otitis media may result

Speech Problems:

Hearing loss hampers proper development of speech Velopharyngeal Insufficiency (VPI) Abnormal air

Schedule of Treatment

Birth: Initial Assessment Pre-surgical assessment 3 Month: Primary Lip repair 9-18 month: Palate Repair 2 Year: Speech assessment 3-5 Year: Lip Revision Surgery
8-9 Year: Initial interventional Orthodontics Preparation for alveolar bone grafting 10 Year: Alveolar Bone Grafts 12-14 Year: Definite Orthodontics 16 Year: Nasal Revision Surgery 17-20 Year: Orthognathic Surgery

Multidisciplinary Cleft Lip And Palate Team

Genetic Scientist Pediatrician Pedodontist Orthodontist Oral and Maxillofacial Surgeon Prosthodontist Plastic Surgeon Psychiatrist Speech Therapist

Feeding

Cleft lip= makes it more difficult for an infant to suck on a nippleuse special nipples to allow the baby to latch properly (either pump or use formula)Cleft Palate= may cause formula or breast milk to be accidentally taken up into the nasal cavity don’t feed baby without palatal obturator (prosthetic palate) feed in an upright position to keep milk from coming out of the nose

Mead Johnson/Enfamil Cleft Feeder Special Needs Feeder / Haberman Feeder

Pigeon Feeder Dr. Brown’s Natural Flow to relieve gas


Presurgical Orthopeadics:
1. Reduces the size of cleft; Aids in Surgery 2. Partial obturation aids in feeding 3. Parental Reassurance at a crucial time Maxillary Strapping Nasoalveolar Moulding Appliances (NAM)