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    Cleft Lip & Palate

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    Rah Ma Ghassan
    This document discusses cleft lip and palate, including risk factors, management, and the importance of a multidisciplinary team approach. Key points include: cleft lip and palate is the second most common birth defect; risk factors include genetics and environmental exposures; treatment begins at birth and continues into adulthood, requiring specialists from various disciplines like plastic surgery, dentistry, speech therapy, and nutrition. Managing cleft lip and palate effectively requires a coordinated team approach to address issues ranging from feeding difficulties to dental, speech, and facial development challenges over the lifespan.

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    Cleft Lip & Palate

    Uploaded by

    Rah Ma Ghassan
    10 views77 pages
    This document discusses cleft lip and palate, including risk factors, management, and the importance of a multidisciplinary team approach. Key points include: cleft lip and palate is the second most common birth defect; risk factors include genetics and environmental exposures; treatment begins at birth and continues into adulthood, requiring specialists from various disciplines like plastic surgery, dentistry, speech therapy, and nutrition. Managing cleft lip and palate effectively requires a coordinated team approach to address issues ranging from feeding difficulties to dental, speech, and facial development challenges over the lifespan.

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    This document discusses cleft lip and palate, including risk factors, management, and the importance of a multidisciplinary team approach. Key points include: cleft lip and palate is the second most common birth defect; risk factors include genetics and environmental exposures; treatment begins at birth and continues into adulthood, requiring specialists from various disciplines like plastic surgery, dentistry, speech therapy, and nutrition. Managing cleft lip and palate effectively requires a coordinated team approach to address issues ranging from feeding difficulties to dental, speech, and facial development challenges over the lifespan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    10 views77 pages

    Cleft Lip & Palate

    Uploaded by

    Rah Ma Ghassan
    This document discusses cleft lip and palate, including risk factors, management, and the importance of a multidisciplinary team approach. Key points include: cleft lip and palate is the second most common birth defect; risk factors include genetics and environmental exposures; treatment begins at birth and continues into adulthood, requiring specialists from various disciplines like plastic surgery, dentistry, speech therapy, and nutrition. Managing cleft lip and palate effectively requires a coordinated team approach to address issues ranging from feeding difficulties to dental, speech, and facial development challenges over the lifespan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 77

    Cleft Lip & Palate

    Risk factors, management and team disciplinary work

    Dr. Mohammad Thabet


    Tutankhamun
    On March, 2005, Egyptian
    archaeologist Zahi Hawass
    revealed that ,
    the results of a CT scan performed
    on the pharaoh's mummy.
    The pharaoh had :
    •cleft palate
    •An impacted wisdom tooth

    King’s Mask
    • Cleft lip and palate is the second most common congenital
    anamoly after clubfoot

    A considerable knowledge about the etiology and embryology is


    required for proper diagnosis and treatment planning of such
    patients

    Treatment begins soon after birth and continues till adulthood


    requiring a team approach.
    Definition in simple
    Cleft lip: congenital deformity of the upper lip that varies from a notching to a
    complete division of lip,any degree of clefting can occur.
    Cleft palate: a congentital split of palate that may extend to uvula,soft palate
    and into hard palate,the lip may or maynot involve in the cleft of the palate
     Joaquin Phoenix – Actor
    Incidence
    •A-Genetic risks
    • One affected parent, risk of the first child 2%
    • One affected child, risk of next child with is (4%).
    • One affected parent and one affected child risk of next child with is 10%
    • Two affected parents, risk of first child 60%
    Prevalence around 1:2000 live births.

    55% Associated with syndromes such as Down, Treacher-Collin, Pierre-Robin sequence.

    CP the incidence is higher in females overall (3:2).


    Gender distribution:
    CLP has greater incidence in males 3:1

    CP the incidence is higher in females overall (3:2).

    There is a male predominance of submucus clefts.

    There is equal gender incidence of isolated soft palate clefts and cleft lip alone
    Syndromic and non-Syndromic clefting

    •15% of cleft children have additional malformations especially BCLP and CP to have additional malformations (400 syndrome) ,
    example:

    • 1- Van der Woude


    • 2- Pierre Robin sequence. Triad of: cleft palate, micrognathia, macroglossia
    • 3- Treacher Collins
    4. Van der Woude syndrome
    2. Pierre robin syndrome
    3. Apert’s syndrome
    1. Treacher collins syndrome
    Etiological Factors:
    • Multifactorial etiology

    1) Chances increases if more than one family member if affected

    2)  More the severity, greater the chances of recurrence in sibling

    3) Higher risk if affected individual is of less affected sex


    4) Risk decreases in remotely related individuals
    5) Consanguinity increases the rate because of sharing of genes
    Etiological Factors:

    I- Genetic problems: Chromosomal OR Mutant genes


    II. Environmental risk factors:
    1-Maternal exposure to:
    Tobacco smoke (hypoxia)

    Alcohol (alteration cell fluidity)

    2- poor nutrition: Folic acid


    (vitamin B2 & B6)

    Vitamin A

    low zinc concentrations (Bufalino et al , 2010)


    3- viral infection e.g.: Rubella virus

    4-Medications: Anticonvulsant drugs (Dilantin- diazepam)

    5-Stress

    7-Obesity

    8-Fever during pregnancy (Mossey et al ,2009)


    PREDISPOSING FACTORS
    ➢High maternal age
    ➢ Diabetes

    ➢ Toxemia

    ➢ Reduced blood supply


    ➢ Folic acid deficiency

    ➢ Racial – mongoloids

    ➢ Radiations
    Current concepts on the effect of Meta-Analysis
    environmental factors on cleft lip and
    palate

    1. Smoke .
    2. Alcohol .
    3. Folic acid deficiency

    Solana et al, 2013


    4.Stress ,Obesity or Fever,
    required more research in the
    future
    Advantages of prenatal cleft diagnosis
    -  Psychological preparation for parents to have realistic

    expectations
    Parent education for cleft management
    - 

    -  Preparation for neonatal care and feeding


    Opportunity to investigate other abnormalities
    - 

    Possibility of fetal surgery


    - 
    Disadvantages of prenatal cleft diagnosis
    -  Emotional disturbance

    -  High maternal anxiety and dysfunction

    -  Termination of pregnancy
    The goals of treatment for the child with a cleft lip/ palate:

    • Repair the birth defect (lip, palate, nose)


    • Achieve normal speech, language and hearing
    • Achieve functional dental occlusion and good dental health

    The Center for Children with Special Needs


    Seattle Children’s Hospital, Seattle, WA
    Plastic
    Pediatric surgeon
    Pediatrician
    dentist

    Orthodontis ENT surgeon


    A team
    coordinator

    Maxillofacial
    Nutritionist
    surgeon
    Speech
    Social workers
    pathologist
    Team-Oriented Care for
    Orofacial Clefts
    A Review of the Literature

    McGrattan & Ellis 2013

    Team-oriented care results


    in better outcomes in individuals
    with orofacial clefts
    DENTAL
    ➢ Tooth agenesis, hypodontia (most common)

    ➢ Supernumerary teeth (2nd most common)


    ➢ Enamel hypoplasia (CI)
    ➢ Crossbites
    ➢ Ectopic eruption, transposition
    ➢ Taurodontism, dilacerations
    Clinical features

    • Common finding-natal neonatal teeth (cleft palate)

    • absent lateral incisor

    • missing premolar

    • supernumerary teeth ectopic lateral incisor

    • Palatal eruption of permanent Canine

    • Anomalies like enamel hypoplasia, microdontia,macrodontia,fused teeth

    • over bite

    • Lateral facial profile


    Clinical features

    • protruberance and mobile premaxilla in infants


    • Bilateral cleft
    • Posterior cross bite
    • Rotated permanet incisor
    • Premature loss (deficiency) of alveolar bone
    Speech difficulties :

    Retardation of consonant sounds (p, b , t, d, k, g)

    Hindrance to early vocabulary development.

    Hyper nasality – cleft of soft Palate

    Hearing problems contribute


    Hearing loss

    Hearing loss and middle ear disease

    Otitis media- early , in 1st month of life

    Prolonged middle ear effusion →permanent damage to the middle ear


    Nasal deformities :

    Cleft extending to floor of nose- alar cartilage flared,

    Columella pulled to non cleft side

    Lack of underlying bone support - ↑ problem

    Surgical corrections- deferred until all other procedures are completed -as correction of alveolar
    clefts, maxillary skeletal retrusion - alter osseous foundation of nose.
    SKELETAL

    ➢Maxillary deficiency
    ➢ Mandibular prognathism

    ➢ ➢ Class III malocclusion

    ➢ Concave profile
    “Feed the child and treat the mother”
    Feeding :

    • Normally the infant creates a negative oral pressure while


    sucking the milk.

    • use special bottles and nipples.

    • With breast feeding use Breast pumper


    The Haberman Feeder

    The Mead Johnson Cleft


    Palate Nurser
    The Pigeon nipple
    • Nasal regurgitation:

    food comes back out of baby’s


    nose during a feeding.
    Baby tired easily during feeding

    Feeding sessions 20-30 min.


    • Swallow air during feeding

    Burp the baby every 15 minutes


    during and after feedings
    Feeding interventions for growth and development in
    infants with cleft lip, cleft palate or cleft lip and palate
    (Intervention Review)

    Squeezable bottles easier to use


    but there is no evidence of a difference
    in growth outcomes .
    Glenny et al , 2008
    speech
    • Air escapes through the gap in the
    roof of the mouth and out the nose.

    • Hypernasality

    speech and language pathologist


    Speech
    Hearing and ear infections

    Eustachian tube malfunction

    frequent Ear Infections

    Hearing loss

    ENT
    Orofacial problems

    • Altered facial appearance

    • Early or late and ectopic eruption of teeth

    • Missing, supernumerary, neonatal and hypoplasied teeth

    • Poor occlusion (cross bite, overbite)


    Orofacial Management of CLP
    At BIRTH - 18 months

    • Initial contact and interview with parents

    • Registration with Cleft Palate Scheme

    • Arrange contact with parental Support groups


    Pre-surgical appliance

    • An impression of the maxillary arch is taken


    as early as 24 hours after birth.
    24 hours after birth

    Obturator
    Feeding Plate
    Premaxillary retraction using soft elastic tape
    (Microfoam Tape, 3M).
    Nasoalveolar molding of the bilateral cleft deformity
    Bonnet appliance
    Premaxillary Retraction.

    In cases of bilateral cleft lip and palate, premaxillary


    segment may be positioned severely anterior to the
    maxillary arch if lip surgery is undertaken with the
    premaxilla in such an abnormal position, the chances
    of lip dehiscence by increased pressure at the suture
    lines are increased.
    Segments may be deviated laterally to one side of the cleft
    defect. In such cases a straight extra oral force would
    not
    place the pre maxilla in the facial midline, it must be
    positioned before pre maxillary retraction. By the
    application of sequential differential force to the
    premaxilla with elastic straps attached to the bulb
    prosthesis.
    An impression is made of the infant's premaxilla for
    construction of an external acrylic "bulb" prosthesis.
    This appliance is fitted over the protruding and laterally displaced premaxilla and anchored to
    the infant's head with a bonnet appliance.
    Advantages
    1. Provides a false palate which help in feeding .
    2. Provides maxillary cross-arch stability and prevents arch
    collapse .
    3. Provides maxillary orthopedic moving of the cleft segments
    to the correct place before surgery .
    Effectiveness of pre-surgical infant
    orthopedic treatment for cleft lip
    and palate patients: a systematic
    review and meta-analysis

    Papadopoulos et al, 2012


    cheiloplasty (surgical closure of the lip).

    • Initial lip closure at


    approximately 3 months of age.

    Peter Hodgkinson et al, 2005


    Bone Grafting of Alveolar Cleft Defects
    • Primary bone grafting refers to bone-grafting procedures in children younger than 2

    years of age.

    • Primary alveolar cleft bone grafting is controversial.

    • A recent survey from American Cleft Palate–Craniofacial Association reported that

    only 3% 1ry graft provides excellent results.


    Palatoplasty

    • Closure of the palate between (12m-2Y)

    The purpose of palate closure


    • Normal speech

    • hearing

    • swallowing
    But!!

    • The extent and timing of palatal surgery is one of the major and continuing

    controversies in cleft management.

    • It is likely to interfere with growth of the midface.


    Hard Palate Repair Timing and
    Facial Growth in Cleft Lip and
    Palate:
    A Systematic Review

    The review showed inconclusive evidence about the


    effect of timing of hard palate repair on facial growth
    in patients with cleft lip and palate.
    Liao et al, 2006
    (PRIMARY DENTITION STAGE)
    • Maintaining oral health of child

    • Keep teeth free from caries

    • Periodic recall examinations, possibly to 3- to 4-month intervals.

    • Topical fluoride applications and fissure sealing

    • Possible revision of lip repair


    Interciptive orthodontics
    MIXED DENTITION STAGE

    • Ectopic eruption of permanent central and lateral incisors >>>>>

    teeth alignment .

    • Cross bites of >>>>>> Palatal expansion


    • Secondary bone grafting

    • Providing bony support to teeth


    adjacent to the cleft site .

    • Time :12 months before surgery


    (9-12y)
    Adolescence and early adulthood
    • Final tooth alignment

    • Fixed appliance orthodontic treatment.

    • Pre-surgical and postsurgical orthodontics

    • Orthognathic surgery

    • Cosmetic surgery
    Pediatric dentist Role
    • Maintaining the highest standard of oral health

    The presence of dental disease can severely


    compromise both surgical and orthodontic success.
    Pediatric dentist Role

    • The parent interview

    • Initial Examination of baby

    • Medical history

    • Dental records

    • preventive care

    • Dental care
    Thank You

    H.A

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