3. More common in south far Asians:
1 in 500
Less frequent in Africans:
1 in 2000
Prevalence in Europeans and Americans:
1 in 750
Prevalence in Pakistan1
:
1 in 523
1. Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A. Epidemiology of cleft lip and
cleft palate in Pakistan. Otolaryngol Clin North Am. 2007 Feb; 40(1):27-60.
4. Male to female ratio – 3 : 2
Cleft Lip and Palate are twice as common in
boys as in girls
Isolated Clefts of Palate are more common in
girls
75% of Clefts are Unilateral, rest are Bilateral
Left side is more frequently involved
5. The medial nasal swellings
enlarge, grow medially and
merge with each other in
the midline to form the
intermaxillary segment
Human embryo: 7 weeks
10. Kriens “LAHSHAL”
Capital letter = complete cleft
Lowercase letter = incomplete cleft
“.” or “-” = normal
Example:
LA- - - - l = complete right cleft lip and alveolus,
incomplete left cleft lip
11. Microform Cleft:
May look like
a little dent in the red part of lip
a scar from the lip up to nostril
Muscle tissue underneath cleft can be affected
and may require surgery
12. 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
13. Transabdominal
Ultrasonography :
Reliable after 4th
month
Clefts of lip
Clefts of palate:
Sagittal View
Axial View
Coronal View
Transvaginal
Ultrasonography
Three-dimensional
ultrasonography
14. Advantages of Prenatal
Diagnosis:
1. Time for parental education
2. Time for parental psychological
preparation
3. Preparation for neonatal care
and feeding
4. Opportunity to investigate other
associated anomalies
5. Gives parents the choice of
continuing the pregnancy
6. Opportunity for fetal surgery
19. Cleft lip
Makes it more difficult for an infant to suck
Cleft Palate
May cause milk to be accidently taken up into
nasal cavity
Inability to create negative pressure inside oral
cavity
Frequent regurgitations
Upper respiratory tract infections
20. In Patient with Cleft lip
Special nipples to allow baby to latch properly
Mead
Johnson/Enfamil
Cleft Feeder
Pigeon Feeder Dr. Brown’s Natural Flow
Special Needs Feeder /
Haberman Feeder
21. In patients with cleft
palate
Avoid feeding without
palatal obturator
Feeding in an upright
position
22. Local Dental Problems:
Congenitally Missing teeth (Hypodontia, Oligodontia)
Hyperdontia
Presence of natal and neonatal teeth
Abnormal tooth morphology (microdontia, macrodontia )
Fused teeth
Enamel Hypoplasia
Gemination, Dilacerations
Poor periodontal support
Orthodontics Problems:
Class III tendency
Anterior and Posterior Cross bite
Spacing and crowding
23. Facial Disfigurements
Poor nasal shape
Scar marks of surgeries
Poor lip function during
speech
Poor dental alignment and
smile
24. Middle ear disease - 22% to 88%
Conductive hearing loss and chronic
suppurative otitis media
Repeated tympanostomy tube placement
25. Abnormal curvature of eustachian tube lumen
Altered width and angulation of skull base
Abnormal insertions of the tensor and levator veli
palatini muscles into cartilages and skull base
26. 96% of children require
tympanostomy tube placement1
50% of these children required
repeat tympanostomy tube
placement 1
Frequency of otitis media
decreases as the child with CP
ages
Audiology and tympanometry as
well as exams / clinical history
1
Muntz HR, An overview of middle ear disease in cleft palate children, Facial Plast Surg. 9
(1993) 177-180.
27. Hearing loss hampers proper development of
speech
Velopharyngeal Insufficiency (VPI)
Poor pronunciation of Bilabial, Labiodental,
Linguoalveolar sounds
28. Maxillary Strapping
Nasoalveolar Moulding Appliances (NAM)
Advantages:
1. Reduces the size of cleft; aids in surgery
2. Partial obturation aids in feeding
3. Parental reassurance at a crucial time
29. Indications of NAMs:
1. Large lip defect requiring presurgical
approximatiom
2. Severe deviations in nasal cartilages columella,
nasal tip, and lateral wall
3. Post surgical nasal molding and tension
reduction across suture line
30.
31. Premaxilla is extremely
protrusive
Premaxilla and prolabium
can be of variable size
Columella is deficient/almost
nonexistent
Palatal shelves are collapsed
Bilateral Cleft Lip
32. Bilateral Cleft Lip
Repositioning of protrusive
maxilla
Support from intraoral
component
Retention with
Denture adhesive
Elastic strap
33. • Time of surgery: approximately at10 weeks
“Rule of Ten”
Child weighs 10 pounds
Child has a hemoglobin of at least 10 grams/dl
Child has a WBC count < 10 thousand
Child is at least 10 weeks of age
35. Cleft Lip Repair
Bilateral
bilateral rotation advancement with attachment to
premaxilla mucosa
36. Dorf and Curtin1
10% occurrence of articulation errors when
palatoplasty was completed by 1 year
86% incidence of articulation errors when repair
was complete after 1 year
Haapanen and Rantala2
Significantly fewer children in the groups repaired
before 18 months had hypernasal speech,
articulation errors, or required secondary surgery
to correct speech
1. Dorf DS, JW Curtin: Early cleft palate repair and speech outcome: A ten year experience. J Bardach
HL Morris Multidisciplinary Management of Cleft Lip and Palate. 1990 WB Saunders Philadelphia 341-
348.
2. Haapanen ML, Rantala SL. Correlation between the age at repair and speech outcome in patients
with isolated cleft palate. Scand J Plast Reconstr Surg Hand Surg. 1992;26(1):71-8.
38. 1. Schweckendick’s Primary Veloplasty
Incisions made in soft palate
Muscle bundles released from posterior hard
palate and rotated
Reconstruction of levator sling
Closure of mucosal layers separately
42. Furlow Palatoplasty
Lengthens soft palate
Reconstructs the muscle sling
Used to correct velopharyngeal insufficiency
Can be used for treatment of submucous clefts
43.
44. Aim: Prepare the dentition adjacent to cleft
for the secondary alveolar bone graft
Avarge Duration: 6-12 months
Appliances:
1. Bonded edgewise appliance
2. Supported with a maxillary expander quad
helix expander
48. Primary Bone Grafting
1. Bone graft done at the time of primary
cheiloplasty
2. Bone graft done during the first 2 years of life
3. Bone graft done prior to the eruption of the
primary canine
49. Secondary Bone Grafting
Done before eruption of the permanent canine
In CLP dental age lags behind chronological
age
Early bone graft: 2-5 years of age
Intermediate bone graff: 6-15 years of age
Late bone graph: 16 year and older
50. Advantages:
1. Provides bone for eruption and orthodontic
repositioning of teeth
2. Closure of oro-nasal fistulas
3. Support and elevation of alar base
4. Stabilization of pre-maxilla in bilateral cases
5. Establishing continuity of alveolar ridge
51. Autogenous
Cancellous- iliac crest
Cortical- calvarium, mandible
Cortico-cancellous- iliac, rib, tibia, mandible
Allogeneic1
Graft resorbs, remodels, may contribute to
osteoinduction and osteoconduction
Alloplast2
Bone grows into, around alloplast
No active osteoinduction but some osteoconduction
Teeth do not erupt through alloplast
1. Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary alveolar clefts in
humans- A preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987.
2. Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect in a primate
model. J Oral Maxiilofac Surg 47:946-952, 1989.
59. • Correction of anterior
crossbite
• Arch expansion
• Stability of results is
questionable
• Slower results as
compared to normal
subjects
Face mask therapy:
60. Late mandibular growth may aggravate
problems
Hypernasality may increase
Definitive dental prosthesis may be planned
Treatment planning
Mild skeletal discrepancy: Dental compensations
Moderate skeletal discrepancy: Orthognathic surgery
Severe skeletal discrepancy: Distraction osteogenesis
61. Lefort I maxillary advancement
Relapse after rigid fixation1
Mean maxillary horizontal relapse of 20.5%
Mean vertical relapse of 22.2% within first year
Velopharyngeal insufficiency
1. Heliövaara A, Ranta R, Hukki J, Rintala A. Skeletal stability of Le fort I osteotomy in
patients with unilateral cleft lip and palate. Scand J Plast Reconstr Surg Hand Surg
2001;35:43-49.
68. Patients with a cleft lip and palate requirePatients with a cleft lip and palate require
highest standard ofhighest standard of multidisciplinary caremultidisciplinary care
Management starts pre-natally after initialManagement starts pre-natally after initial
diagnosis, followed by a long treatment aimingdiagnosis, followed by a long treatment aiming
at restoration of oral health and function whileat restoration of oral health and function while
achieving optimum estheticsachieving optimum esthetics
Right intervention at right timeRight intervention at right time can significantlycan significantly
improve the quality of lifeimprove the quality of life
69.
70.
71. Timing: 17-20 years of age
Standard techniques
Tip projection
Alar rotation
Columellar lengthening
72. Goals of Surgery
1. Reducing the size of opening between oral
and nasal cavities
2. Reconnecting palatal muscles to restore
function
3. Restore the anatomical length of soft palate