Cleft Lip and Cleft Palate

1. Cleft Lip and Cleft Palate Yağmur AYDIN MD, Professor University of Istanbul, Cerrahpaşa Medical Faculty Plastic,Reconstructive and Aesthetic Surgery Department

5. Parents are worried about • Is it possible to be normal with treatment? • Why did happened, Who has fault? • How should I feed my baby? • What about my future childern?

6. Cleft lip and palate is result from failure of embryonic processes • Frontonasal process • Nose • Prolabium • Maxillary processes on each side • Remainder of upper lip on each side

7. History It is known from old times • extends back as far as 3000 BC • Egyptian mummies • Grek comedian statue (BC 7-4. century) • First succesful cleft lip repair in China (AD 390) • First detailed description by Yperman (1295-1351) • Cotton, silver and lead use to close the palate byFranco (1561) • First modern surgery by Mirault in1844 “cross flap” • Various flaps using triangle, qudrangle and curves • Surgery based on embryologic development Veau (1936) • Tension, Millard repairs (mid 20 th century)

8. Problems in Cleft Lip • Cosmetic • Dental • Speech • Swallowing • Hearing • Facial growth • Emotional

9. Epidemiology • The second most common congenital anomaly • Affects 1in 750 births • The incidence of cleft lip/palate varies among different populations • The most common in asians (1:500) • In whites (1:750) • The lowest in blacks (1:1000 or less) • Cleft lip more often in boys (left side) • Isolated cleft palate more often in girls • Young mothers are less risky

10. Epidemiology-II • Unilateral or bilateral • Complet or incomplet • Only cleft lip, cleft lip and palate or isolated cleft palate • Distribution (Fogh-Anderson, 1942) • Cleft Lip % 25 • Cleft and palate %50 • Cleft palate % 25

11. ETIOLOGY (Multifactorial) • Genetic factors (% 25-40) Otozomal ressesive • Environmental factors (% 60-75)

12. Genetic Factors (Otozomal Ressesive) • First child has anomaly • Probability of second child % 4 • Probability of third child % 10 • Two childern have anomaly • Probability of third child % 20 • Mother or Father has anomaly • Probability of first child % 5 • Both mother and father have anomaly • Probability of first child % 25

14. Environmental factors(% 60-75) • Mothers sickness during first trimester (viral infections) • Cronic diseases ( Diabetes Mellitus etc.) • Drugs (tranquilizer, hipnotics, sedatives, cortizon, etc) • Smoking • Aspirin • X Rays

15. Classification • Based on alveolar arcus (Davies- Ritchie 1922) • Prealveolar (cleft lip) • Postalveolar (cleft palate) • Transalveolar (cleft lip and palate) • Based on embryologic development (Kernehan-Stark 1958) • Primary cleft palate (anterior to incisive foramen) • Secondary cleft palate (posterior to incisive foramen)

16. Embryology Primary PalateForms during 4th to 7th week of Gestation Defect anterior to incisive foramen • prepalatal alveol, maksilla, lip, nose and palatine bone • Unilateral or bilateral • Cleft severity varies • Complet ( all skin, muscle, mucosa, maksillary and nasal bones, nasal cartilages) • Incomplet (intact nasal sill, minimally seperated, only small scar) • Secondary PalateForms in 6th to 9th weeks of gestation • Palatal shelves change from vertical to horizontal position and fuse • Tongue must migrate antero-inferiorly • Face is formed at intrauterin at 10th week

18. Face Devolopment • Frontonasal process medial nasal median palatal process • lateral nasal • Maksillary processes lateral palatal process • Mandibulary process

19. Face Devolopment

21. Palate Devolopment • Primary palate median palatin processes premaksilla • Secondary palate lateral palatin processes

22. Palate Devolepment(6-12. Weeks)

23. Palate Devolopment (6-12. Weeks)

24. NORMAL LIP MUSCULAR ANATOMY CLEFT LIP ANATOMY

25. Problems in Cleft Lip and Cleft Palate • Feeding • Frequent upper respiratuary tract infection • Frequent gas regurtation • Otitis media • Nasal regurtation of food • Aspiration pneumenia • Growing retardation • Other anomalies • Psycological problems (family)

26. Cleft lip and palate treatment team • Surgeon experienced in cleft management • Pediatrist • Orthodontist • Pediatric Otorhinolaryngologist • Pediatric dentist • Geneticist • Spech Terapist • Social Worker • Nurse experienced in cleft problems

27. Feeding Rules • Swallowing is not impaired, oral feeding is possible • Bottle feed with additional cross cut in the end • Elastic plastic bottle • Bulb syringe with a nipple • Feeding with a spoon • The child should be held in a head-up position at about 45 º during and after feeding • Lateral position during sleeping

28. When to Operate Generally (Rules of 10’s) • Weight > 10 pound (4500 gr) • Hb > 10 gr • Age > 10 weeks Cleft lips between 3-6 months Cleft palate between 12-18 months (preferred before speech devolops)

29. Cleft Lip Treatment • Cleft lip • Mikroform cleft lip • Unilateral cleft lip • Bilateral cleft lip • Associated nasal deformity is classified as mild, moderate or severe • Alveolar arc position evaluated. If necessary “presurgical maksiller orthodontics” applied

30. Presurgical Orthodontics Start first or second weeks after delivery

32. Operation technique in Microform cleft (Straight line closure)

33. Surgical technique for unilateral cleft lip (Millard Rotation-Advancement)

34. Surgical technique for unilateral cleft lip (Tennison Triangular Flap)

35. Surgical technique for unilateral cleft lip and palate Millard techniques provides primary lip and nasal repair . It is possible “gingivoperiostoplasy” after “Presurgical maksiller ortopedics”

36. Pre -Orthodontic treatment After 3 months of Grayson molding plate application

37. A.M.Kul, right unilateral primary and secondary cleft palate Pre -Orthodontic therapy After 3 months of Grayson molding plate application

38. Postoperative 6 months

39. Postoperative 1,5 years

48. Bilateral Cleft Lip • More complex and difficult to treat • Projectil premaksilla • Broad and flared nasal tip • Prolabium • Short columella or absent columella • Incomplet or complet • It is important to retropositon the premaksilla with presurgical orthopedic treatment • Surgical techniques used for unilateral cleft lip repair are used for bilateral cleft lip repair in one or two stage operation (Millard, Tennison...)

49. Treatment of Premaksilla • Lip repair or “Lip-adeshion” • Elastic traction ( with a Head Bonnett) • Premaksillary retantion (Latham) • Nazoalveoler molding (Grayson) • Surgical premaksilla excision or set-back (severe maxillary retrusion)