9/12/2019

Price: 20

‫خطيب نجيب‬

Dina Shaban
Dr. fadi jarrab

Orofacial cleft

‫يُطلب من جمعية التصوير الطبية‬

 Management of Patients with Orofacial Clefts

Orofacial Clefts are not just confined for cleft lip & palate; it includes other
clefts in the face, in this lecture however, we will focus on the cleft lip & palate.

Definition: Congenital abnormal space or gap in the upper lip, alveolus or palate.
 The general dentist will become involved in managing these patients,
because they might have; hypodontia, supernumerary and malocclusion.

Teams involved in the management:

1 .General or pediatric dentist 6. Otolaryngologist

2. Orthodontist 7. Pediatrician
3. OMF surgeon 8. Audiologist
4. Plastic surgeon 9. Speech therapist
5. ENT 10. Psychologist, Psychiatrist.

Epidemiology: Important

 1:700 births.
 More common in Asians and Less frequent in blacks.
 In general, it is more in males.
 Cleft lip: M>F
 Cleft lip & palate: M>F (3:2) or M=F
 Cleft palate: F>M
 Isolated Cleft palate usually associated with syndromes (part of syndrome)
 75%of cases are unilateral, left side is more commonly affected than right side.
 Clefts of the lip and palate show a wide variation.


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Developmentally:
 Primary palate: consist of (lip, base of the nose, the alveolus of the 4 upper
incisors and part of the palate anterior to incisive foramen).
 Secondary palate: consist of (part of the palate posterior to incisive foramen).

Classification
(we have More than one classification)
 Cleft lip alone.  Complete cleft lip when the cleft involves
 Cleft of the primary palate. the nostril.
 Cleft of the secondary palate.  Incomplete cleft lip when the nostril is not
 Cleft of both (primary and secondary
involved.
palate)  Complete cleft palate is involving the
primary palate and the secondary palate.
 Incomplete cleft palate is either primary
palate or secondary palate.
In the figure:

A. Normal
B. cleft lip alone involving the nostril
(Complete cleft lip).
C. Unilateral cleft lip and the alveolus
(Complete cleft lip and primary palate).
D. Bilateral cleft lip and the alveolus
(Primary palate).
E. Isolated cleft palate (secondary palate).
F. Unilateral complete cleft lip and palate
(Involving primary and secondary palate).
G. Bilateral complete cleft lip & palate
(Involving primary and secondary).

Submucosal clefts: we have defect in the muscle under the mucosa, so it is

difficult to be diagnosed early because the mucosa and bone are intact.
 Maybe seen in the soft palate.
 Muscles are important for palate constriction and function.
 These patients are diagnosed at age of 1-2 years old when they start
speaking they will have (Hyper-nasal speech), the function is defected.
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 Embryology:
The entire process of the face formation takes place between the 5th and 10th
weeks of fetal life.
From (5-7 i.u weeks) start formation of Primary palate (Intermaxillary segment):

Philtrum of the upper lip, Upper jaw component which carry the 4 incisors & Triangular primary palate

 If the defect happen in this period, it will affect the primary palate.

From (6-10 i.u weeks) Palatine shelves form the secondary palate.

 If the defect happen in this period, it will affect the secondary palate.

o Medial nasal processes fuse with

maxillary processes to form the upper
lip.

o Clefts of the primary palate result

from a failure of the mesoderm to
penetrate into the grooves between
the medial nasal and maxillary
processes in 5-7 i.u weeks.

o Palatine shelves will move medially to

fuse forming the palate, they are
located below the tongue they
elevate gradually to form the palate,
 One of the theories of cleft of
secondary palate is enlarged
tongue.

o Clefts of the secondary palate are

caused by a failure of the palatine
shelves to fuse with one another in
6-10 i.u weeks.

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 Aetiology
 The exact cause is unknown in most cases.
 Syndromes account for 15% of CLP and 50% of isolated cleft palate cases.
 In isolated cleft palate, 50% of cases are a part of syndrome and we have to
do full examination of the body and refer the patient to internist to rule out
other component of the syndrome.
 Therefore, cleft lip and palate is less probable to be part of a syndrome
comparing to isolated cleft palate.
 Genetics is implicated in 20-30% of non-syndromic cleft lip or palate cases, but
the mode of inheritance is not completely understood.
 The most common factor is the Interaction between genetic predisposition
and certain environmental factors.
Environmental factors:
Smoking, Nutritional deficiencies, viruses, radiation, hypoxia, drugs (diazepam)
and vitamin excess and deficiency (Vitamin E)

Problems of cleft- afflicted individuals

1. Dental problem
o It affects primary and permanent teeth.
 Most commonly, they may have congenitally absence of teeth
hypodontia) and/or supernumerary teeth.
 Morphologically deformed and hypo-mineralized teeth.

2. Malocclusion
o Cleft palate cases show skeletal discrepancies between the size, shape, and
position of jaws.
 Because the maxilla is underdeveloped -small and narrow- in the
Anteroposterior, vertical and horizontal dimension.
o Class III malocclusion is seen in most cases.
 Retardation of maxillary growth is the main factor responsible for
malocclusion, the mandible usually is normal.
o Operative (surgical) trauma will cause excessive fibrosis; this will result in
excessive effect on the growth of the maxilla.
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  We always try to delay the surgery in order not to affect the
development but at the same time it should be done when the patient
should function normally, for example:- if the patient is 1-2 yr old we
should do surgery for him because he should speak at this age but it
should not be done before in order not to affect the development.
3. Nasal Deformity
 Alar cartilage is flared.
 Columella is pulled toward non-affected side.
 Surgical correction is deferred.

4. Feeding(Feeding requires more time and care)

* The sucking and swallowing reflexes are normal, but swallowing is not
effective because there is incomplete closure in the area, once we close it the
swallowing will be effective.
 Specially designed nipples, elongated and extend further into the baby’s
mouth will help.
 Feeding requires more time and care.

5. Ear Problems
* Cleft palate patients are predisposed to recurrent otitis media (infection of middle ear)
 Levator and tensor veli palatini insertion are affected. Their insertion are
in the auditory tube, therefore they will affect opening and closure of this
tube and the movement of the ostium opening, thus, recurrent infections
will happen.
 This may lead to conductive hearing loss.

6. Speech Difficulties
a) Retardation of consonant sounds.
b) Hypernasality(cleft soft palate).
c) Articulation problems.
d) Hearing problems.

7. Associated Anomalies
 20 times more likely to have another congenital anomaly.
 Most common: atrial septal defect.
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 Treatments

First surgery: Cheilorraphy: (cheil = lip, rraphy = repair)

It is the Surgical correction of the cleft lip.
 When cheilorraphy should be done?
 Rule of 10 (the baby’s weight should be 10 lbs, should be 10 weeks old
and the Hemoglobin level should be 10 g/dl )
 We delay the surgery 10 weeks for safety of general anesthesia.
 What is the aim of this treatment? To restore:
 The functional arrangement of the muscle, because it reflects the
function (The most important muscle is the orbicularis oris).
 The Lip that displays normal anatomic features.
 Serve to restore symmetry of the nasal tip.

Second surgery: Palatorraphy

It is a surgical repair of the secondary palate (only soft tissue closure of the secondary palate)
 When palatorraphy should be done?
 Between the age of 12-18 months.
Speech development (start at 1-2 years old) so, we have to repair the
secondary palate before Speech development, because the intact
secondary palate is important in speech development (primary palate
does not affect the speech, we repair it later).
 It is done by open flap posterior to incisive foramen  suture they
muscles to gather  suture the mucosa to close the secondary palate

Advantages of early closure: Disadvantages:

1. Better palatal muscle development.  Surgery is more difficult.
2. Ease of feeding.  Maxillary growth
3. Better development of phonation. restriction.
4. Improved psychological state.
5. Better auditory tube function
 (bcz we correct the insertion of levator
veli palatine and tensor veli palatine)

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Third surgery: Alveolar Cleft Grafts
It is a surgical repair of the Primary palate (there will be defect in the bone (alveolus) and soft tissues)
 When Alveolar Cleft Grafts should be done?
 Between the ages of 9 & 10 years, according to the dental development
it is done when two thirds of root of the unerupted canine has formed,
to facilitate the eruption of the canines.
 Orthodontic expansion of the maxilla is done before or after bony graft.

The patient will have a Residual oro-nasal fistula

it causes:
We put bone in this fistula to get
a. Oral fluids escape
these advantages:
b. Nasal secretions escape 1. Restoring alveolar integrity
c. Teeth erupt into the cleft (malposition) 2. Preventing arch collapse
d. Collapse of the alveolar segments 3. Support for the teeth
e. Speech impairment if the cleft is large 4. Closure of the fistula
5. Lip and nose (alar) support
Source of bone is usually from cancellous 6. facilitate teeth eruption
bone from the iliac crest. 7. facilitate implant placement
Recently, they use Synthetic bone.

Preoperative Cleft Defect

1. Incision& flap and elevate the soft tissues.
2. Put a plastic sheet in the nose to show the nasal floor.
3. Close the nasal floor &mucosa to become like a container
for the bone graft.
4. Bone graft.
Postoperative bone graft
5. Suturing.

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The last surgery: Orthognathic Surgery
 When is the time to do it?
 After growth (16 years old in female & 18 in male).
* Patients have skeletal Class III, Maxilla is retruded and constricted in
transverse plane.
* We do advancement and expansion of the maxilla, and because the
Relapse is very high, we stabilize & support the maxilla by bony grafts
(blocks).
* If the distance is very long we do distraction osteogenesis.

The challenges here is that:

 There is a lot of scarring in the palate so the incision, elevation of the flap &
movement is extremely difficult.
 Maxilla takes its blood supply from the palate, the blood supply her is also
compromised so, it is risky and it takes time.
 Beside that the bone is fragile and not of good quality and the amount of
bone is not as the normal patient.

The first & second surgeries in most countries done by plastic surgeon, the third
one (closure of alveolar cleft) is always done by oral and maxillofacial surgeon.