1. CLEFT LIP AND PALATE

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

3. Incidence More common in south far Asians: Less frequent in Africans:
Prevalence in Europeans and Americans:
1 in 750

4. 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

5. Embryological Background
Head and Neck of 4-Week Old Embryo
Glossopharyngeal
nerve
Vagus nerve
Trigeminal nerve
Facial nerve

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

7. 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

8. 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

9. Classification A‐incomplete cleft of the secondary palate
B‐Complete cleft of the
C‐Incomplete cleft of the
primary and secondary palate
D‐Unilateral complete cleft of
the 1 and 2 palates
E‐bilateral complete cleft of the
1 and 2 palates

10. Other Types of Clefts Microform Cleft: Submucous Cleft Palate:
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

11. Prenatal Diagnosis
Cleft lip can be easily diagnosed by performing ultrasonography in the second trimester
Diagnosing a cleft palate with ultrasonography is very difficult
Three-dimensional imaging has been introduced to prenatal ultrasonography diagnostics of cleft anomalies

12. 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

13. Etiology “Actually no one knows exactly what causes clefts”
Multiple factors may be involved, like:
Genetics (inherited characteristic) from one or both parents
Environmental factors
Drugs: 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

14. 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)

15. Problems Associated With Cleft Lip and Palate
Feeding
Dental problems
Nasal Deformity and Esthetic Problems
Ear Problems
Speech Difficulties
Associated Anomalies

16. 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

17. Dental Problems Local Dental Problems: Orthodontics 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

18. Nasal Deformity and Esthetic Problems
Facial Disfigurements
Poor nasal shape
Scar marks of surgeries
Poor lip function during speech
Poor dental alignment and smile

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

20. Speech Problems: Hearing loss hampers proper development of speech
Velopharyngeal Insufficiency (VPI)
Abnormal air

21. MANAGEMENT OF CLEFT LIP AND PALATE

22. Schedule of Treatment 8-9 Year: 3 Month: 10 Year: 9-18 month:
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

23. Multidisciplinary Cleft Lip And Palate Team
Genetic Scientist
Pediatrician
Pedodontist
Orthodontist
Oral and Maxillofacial Surgeon
Prosthodontist
Plastic Surgeon
Psychiatrist
Speech Therapist

24. Feeding
Cleft lip= makes it more difficult for an infant to suck on a nipple
use 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

25. Pigeon Feeder Dr. Brown’s Natural Flow to relieve gas
Mead Johnson/Enfamil Cleft Feeder Special Needs Feeder / Haberman Feeder
Pigeon Feeder Dr. Brown’s Natural Flow to relieve gas

26. 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)

27. THANK YOU FOR YOUR ATTENTION