1.

2 etiology orofacial

- birth defects: can be present from birth (does not mean evident/with evident)
before birth (spina bifida) after birth (vsd, defness, cerebral palsy, cryptochidism).
Can be surctural: CLp, spina bifida, club foot, hypospadia, achondroplasia.
- orofacial clefts: distruption during 1st trimester (apoptosis embryonal fusion of lip,
palate, nose). Failure of normal craniofacial development like proliferation,
migration, apoptosis
- can syndromic and non-syndromic, unilateral/bilateral/isolated,
- cause: gene, evironmental fetal, not fully understood , drugs, interaction gene-
environment
- fetal environmental: maternal history, lifestyle (alcohol, smoking 1st, low
sosioeconomic and education, exposure to chlorinated solvents), nutrition
(increased needs and maternal-parental occupation, maternal disease and drugs
(viruses acute viral infections and cold, influenza, epilepsy, bronchial asma,
anticonvulsant like diphenylhydantoin dan phenobarbital, multidrug therapy, folic
acid antagonist  clp, NSAID.
- tidak terpengaruh oleh moving population
- prevention: healthiest pregnancy (medical condition like STD, diabetes, thyroid,
seizure, high blood pressure should be controlled)
- folic acid 400micrograms/day at least 1 month before and during pragnancy or 3
month prior

5.1 challenges of Cleft surgeries in low and middle income countries duringthe covid 19
pandemic

- Cleft care is not just repair, multidisciplinary aproach to restrore cosmetics and
funcion equality outcome. Many children lack accsess to surgical services especially
in low and middle icome countries and more than 6 million child death annually. In
pandemics, different surgical disciplie rolling out SOP and cancellation of routine
clinic consultation, lack of manpower, many young nigerian doctors were emigratin
to UK.
- low and middle income countries high demad of surgeries equipment, reduction in
pay or No. pay at all, No. insurace, hunger, increase violation, and increase of
mortality in children.
- many political leaders in africa still belife that covid 19 is hoax, so it is leading to
death of CLP patients from malnutrition and infections.
- the impact of covid to CLP patient is enormous, they can be assesed after the
pandemics. Effort must be stepped up to communicate with maternity home
operators on neonatal care especially in area of feeding

5.2 impact of covid 19 on cleft surgery in 2020

- ASPS recomendation on march 2020 all the elective surgeries was postponed.

5.3. cleft orthodontics

- orthodontist is a dental specialist who deals with growth and development of the
jaws and their relationship to each other as the malalignment of the teeth within the
dental arches. Mostly as a reflection of the initial intrinsic deformities of the cleft
itself as well as post-surgical changes.
- malocclusion is often as growth-related problem. The orthodontist should see the
infant soon after birth and continue to review facial growth and occlusal
development throughtout the period of growth. The goals of the orthodontic
treatment are to improve of aesthetics, improve oral health and function,
eliminating of need for surgical or major prosthetic measures, and improve self
esteem.
- time and squencing: neonatal and infancy/prsurgical infant orthopaedics (birth to 2
years), primary dentition (2-6 years), mixed dentition (7-12 years), and permanent
dentition stage.

5.4 cleft midface and orthognatic surgery

- midface hypoplasia is an inevitable result of cleft repair. Maxillary retrusion starts

very early and progresses to adulthood. To operating on the child before the
child increased growth its better to do distraction osteogenesis. To operating
adult do the sae thing and fix it with plates and screws. So you have to make
decision to choose wheater distracting osteogenesis or orthognatic surgery
accorfing to the requirements. Distraction osteogenesis you have to considerate
lefort ½ segment or anterior maxillary distraction (crowded teeth and No. to
increase size of maxillary).
- steps: identify the problems (the conditions of jaws, alveolus, and teeth),
orthodontics and surgical plan,

6.1 nutrition therapy (maternal nutrition and the prevention of clefts)

- prevelence of orofacial anomaly mostly in asian and native america. Genetic with
environmental and nutritional factor can cause cleft lip and palate. Also maternal
smoke exposure from houshold biomass fuels.
- periconceptional folic acid use ide effective in preventing neural tube defects. All
women 15-45 years 400 mcg of folic acid daily. Accordin g to U.S public health
reseach Total folic acid intake daily 1000mg or less. Women with NTD pregnency
sould take 4000mcg daily.
- hypothesis says that deficiency of folic acid can affect of failure the neural tube to
close and can affect on delayed migrating cells. Study says tat mothers of child with
 orofacial cleft have a recurrence risk that is 35-45 times greater than the general
population.

6.2 cleft nutrition

- feeding and nutritional challenges are commonly the first problems encountered by
childern with congenital cleft lip and palate. Early nutrition is important to optimal
growth and development. Infant with cleft palate are unable to suck exract milk to
meet their daily nutritional requirements. Nutrition is a key factor for maternal,
newborn, and child health.
- Cleft palate: incuficient of sucking and escape food in to nose. It is important to
ensure CLP infant to able to maintain weight and normal growth.
- Baby with cl and csp can berastfeeding. Feed often every 2-3 hours sit upright
position

6.3 social care for person with orofacial cleft

7.1 assesment of VPD

 VPD: can also called as velopharyngeal insufficiency (caused by anatomical

abnormality such as cleft palate and sapce occupying lesions), velopharyngeal
incompetence (cause by abnormal function of elements of velopharyngeal sphingter
such as repaired cleft palate and neurological disorders), and velopharyngeal
mislearning (caused by abnormal functioning like abnormal speech training,
inappropriate use of VPS, incorrect learning and the result is failure of VPS closure).
 Effect VPD on spech: hypernasality, nasal emission, week or omitted consonants,
subtitution, abnormal resonance, compensatory articulation.
 Etioogy: strustural, neurogenic, mechanical iterfrence, phoneme specific
 Clinacal presentation: speech develops to 3-3 ½, assesment should be planned at
and after 4 year, instrumentation should be planned at above 5 years.
 Assesment VPD:
1. Clinical evaluation by surgeon: history patient, history of surgery, history nasal
regurgitation, history of speech therapy.
2. Clinical examination
 Preliminary assesment: patient name, parent, class,

7.2 the impact of cleft oalate on speech

 Infant have elevated larynx , epuglottis closer to soft palate, oral cavity initially filled
by tongue, and vocalisation lact oral resonance.
 Anatomical constraints-lip (bilabial sounds like b, p, non speech movement,
communication when feeding)
7.3 cleft speech therapy in context of the speech laguage therapy practice

 Major speech challenges of cleft patients are absence of quality voicing improper
articulation. The goals for CST include ensuring of quality speech through the
creation of new motor speech patterns that replace speech sound errors and
initiating correct articulation.
 CST requires a multidisciplinary professionals service: speech language therapis,
surgery, dentistry, psycologist, nursing, prosthesis, and orthodontist. The more
comprehensive service delivery team is the better the service outcomes.
 Flawless speech has become a must have skill for every modern day person to
succeed in life.

7.4 management of newborn with cleft during covid 19

 Children immune system are still developing and may respond to pathogens
differently than adult immune system.
 Newborns with cleft lip and palate must continue to be seen in consultation with
respect of all security measures, in order to give psychological support to the parents
and advice for nutrition before surgery.

7.5 multidisciplinary team approach to cleft care

 The complexity of CLP need more than one expert for holistic management of the
patient. Typical team or ideal approach of CLP are medical, surgical, speech,
psychosocial, and dental professional.

8.1 outcome measures of assesment for oral health and dentalfacial aesthetics in patients
with orofacial clefts

 Continued audit of performence and in particular clinical outcomes is essensial in

order to maintain and continually improve patient care. These outcomes also help to
compare different types of treatment modalities across centers.
 Challenges: large number of outcomes, each speciality with multiple methods of
assessing care, different type of cleft cannot always be assessed using same
methods.
 Study models: goslon yardstick, 5 year old indeks, and modified huddart bodenham
indeks

8.2 standards for reporting outcomes of cleft care

 Oucome measures are designd to assess the quality of cleft care. the standards for
outcomes need for meaningful reporting of cleft care outcomes, compareing, and to
guide best practices.
 Outcomes of cleft care: normalized nasolabial and aesthetic appearence, intact
primasry and secondary palate, normlized speech, language, and hearing, nasal
 airway patency, calss 1 occlusion and normal mastication function, good dental and
periodentalhealth, and normal psychosocial development.
 The oucome methodes has to be easy to use, reliable, and applicable.

8.3 epidemiology of CLP

8.4 telemedicine in clp