Evaluation and Treatment Planning For Pts With Cleft Lip and Cleft Palate and Alveolar Bone Grafting

Evaluation and treatment planning
for patients with cleft lip and cleft

palate
&
Alveolar Bone Grafting
MDS, MFDRCSI(Ire), MOMSRCSEd(Edin), MFDSRCPS(Glasg), MFDSRCSEd(Edin), FIBCSOMS, FAOCMF, F.P.F.A (USA)
HS Adenwalla Institute of Cleft Lip & Palate

The Charles Pinto Centre
JUBILEE MISSION MEDICAL COLLEGE & RESEARCH INSTITUTE
Thrissur, Kerala, India.
Dr.Varun Menon P (PROMPT2023)

PAPER III – . Plastic and
TRAUMATOLOGY Reconstructive
AND MAXILLOFACIAL Surgery – Congenital
SURGERY & Acquired Defects

• “If you would not be forgotten as soon
as you are dead, either write things
worth reading or do things worth
writing.” —Benjamin Franklin
Past Questions (RGHUS,KUHS,TN,NTR & Other univ)
• Various stages of treatment in Cleft lip and Palate patients and • Biologic Basis for surgical management of CLP
explain the rationale for timing of each stage of treatment. • Cleft alveolar bone grafting
• Protocol of management of cleft lip and palate children • Cleft rhinoplasty.

•
• Current concepts in management of CLP Cleft palate
• Celft lip and palate.
• Classify cleft lip deformities ,basic treatment plan and
management of isolated cleft lip. • Craniofacial anomalies pathogenesis classification ,concomitant findings and surgical
management.
• Classification of clefts • Pharyngoplasty with note on its technique
• Aetiology and embryological aspects in formation of CLP • Secondary alveolar bone grafting.
• Write in detail Sequential management of CLP patient. • Velopharyngeal incompetence

• Management of secondary deformities
• Nasoalveolar moulding
• Delaire Principles of cleft lip surgery
• Topography of facial muscles in cleft lip

Evaluation and
treatment planning
ABG
for patients with cleft
lip and cleft palate

Evaluation &
Treatment
planning for
patients with cleft
lip and cleft palate

Dr.Varun Menon P
Introduction
Incidence
Etiology
Embryological aspects Classification

Overview
Associated deformities and
problems
Aims and objectives of

management of cleft lip and palate
General management protocol for

the cleft patient

Increased survival rate.
The goals Improved overall masticatory and other associated functions.

and
Improved/normalized facial esthetics.
objectives of
the entire Better social acceptance and social integration.
treatment Normal psychosocial development.
plan Improve airway patency and achieve integrity of the primary and
secondary palate.
Improve speech and hearing.

Embryology

basic morphology of the face is established
between the fourth and 10th weeks of human
development
FRONTONASAL
MAXILLARY MANDIBULAR
PROCESS :-
PROCESS:- PROCESSES :-
NOSE
LOWER JAW
PROLABIUM LATERAL UPPER CHIN AND
AND LIP AND CHEEK LOWER LIP
PREMAXILLA

Facial development At end of 3rd week:
• Migration of neural crest cells- to form

mesenchyme
• -Buccopharyngeal membrane
At end of 4th week:-
• Buccopharyngeal membrane disintegrates

• A series of swellings around stomatodeum
• Frontonasal process
• Bilateral maxillary process
• Bilateral mandibular process
5th week
• nasal placodes
• the lateral and medial nasal process
• nasal pit
7th week
• max process advanced medially fused with the

medial nasal swellings which themselves have
fused with each other

Dr.Varun Menon P. Cleft & Craniofacial Reconstructive Surgeon
EMBRYOLOGICAL THEORIES
1:-FUSION OF PROCESSES:-DURSY-HIS
SEPARATE PROCESSES FUSE TO FORM THE CENTRAL FACE BY
MECKEL IN 1808

• FUSION OF PROCESSES
EMBRYOLOGICAL • SEPARATE PROCESSES FUSE TO FORM THE CENTRAL
THEORIES FACE BY MECKEL IN 1808
• FAILURE IN THE FUSION OF DURSY-HIS

• FAILURE OF THE MESODERMAL MIGRATION OF FLEISCHMANN-VEAU-
STARK

• FAILURE OF THE MERGING OF PATTEN

OTHER THEORIES
STEININGER 1939:-THE RUPTURE OF
PREVIOUSLY FORMED CYSTS IN THE SOFT
TISSUE BRIDGES
FAILURE OF THE EPITHELIAL WALL TO DEVELOP

:-TONDURY IN 1950
1966 PFEIFER :-NOT BY FAILURE OF FUSION BUT

BY THE BREAKDOWN OF LIP ONCE INTACT

Migration of Neural crest cells
Facial mesenchyme( Bone ,cartilage,Fibrous

CT){Exception Vascular endothelium and muscle}
3rd week
4th Week
5th week
7th week

Palatogenesis
• 6th week {Media Edge Epithelium (MEE)}
• 7th week
• 10th week

Dr.Varun Menon P
Dr.Varun Menon P
Dr.Varun Menon P
Incidence, Genetics, and Cause

• Overall incidence of cleft lip and palate is approximately 1 in 600 to 800 live
births (1.42 in 1000) (about 220,000 new cases per year)
• Asians (0.82 – 4.04 per live births) high
• Caucasian (0.9 – 2.69 per 1000 live birth)
• low in Africans (0.18 – 1.67 per 1000 live births).
• isolated cleft palate occurs approximately in 1 in 2000 live births
• Cleft lip alone – 15%
• Cleft lip and palate – 45%
• Isolated cleft palate – 40%.

• CL/P occurs more frequent and more severe in boys than in girls.
• Unilateral clefts are more common than bilateral clefts with a ratio of 4:1
• 70% occur on the left side of the face.
• Cleft palate is seen more frequently in females
• one parent affected with a cleft has a 3.2% chance of having a child with cleft
lip and palate and a 6.8% chance of having a child with isolated cleft palate
(Grosen et al., 2010).
• Presence of a cleft in one parent and in one sibling is associated with a 15.8%
chance that the next child will have a cleft lip or palate, and a 14.9% chance
that the next child will have a cleft palate (Christensen et al., 1996).

• incidence
• 1 in 1,000 for Caucasians, 1 in 500
for Asians, and 1 in 2,500 for
Africans.

Causes
HYPOPLASIA
ABNORMAL DIRECTIONAL GROWTH OF

MESENCHYMAL PROCESS
FAILURE OF FUSION OR BREAK DOWN

OF FUSION OF MESENCHYMAL PROCESS
RISK FACTORS FOR
OROFACIAL CLEFTS
Etiology
• Non-genetic:-various environmental (teratogenic) risk factors which
may cause CL/P.
• Genetic:
Syndromic: cleft is associated with other malformation.
Non-syndromic: Here the cleft is mostly an isolated feature

Non-genetic • Maternal smoking
• Maternal first-trimester heavy alcohol consumption
factors: • intake of multivitamins or folic acid
Environmental • Drugs Prepregnancy diabetes mellitus, but not gestational diabetes.
• Maternal obesity
Factors • chlorinated disinfection byproducts in drinking water.
• environmental contaminants, such as pesticides, air pollution, and
environmental estrogens; occupational exposures, such as organic solvents

Genetic Factors
• OFCs
• syndromic clefts
• nonsyndromic clefts.
• OFC syndromes of known cause
• 3 categories:
• (1) chromosome abnormalities and genomic
rearrangements
• (2) Mendelian or single gene disorders
• (3)complex interactions of genetic,
environmental, and stochastic factors, referred to
as multifactorial Dr.Varun Menon P (PROMPT2023)
SYNDROMIC OROFACIAL CLEFTS
• Selected CL/P Syndromes with known genetic cause
Syndrome Cleft Type Observed Gene Reference

Ankyloblepharon-ectodermal dysplasia- CL/P TP63 [McGrath et al., 2001]
clefzting
Apert CP FGFR2 [Wilkie et al., 1995]
Bamforth-Lazarus CP FOXE1 [Bamforth et al., 1989]
Bartsocas-Papas CL/P RIPK4 [Kalay et al., 2012; Mitchell et al., 2012]
Branchio-oculo-facial CL/P TFAP2A [Milunsky et al., 2008]
Campomelic dysplasia CP SOX9 [Foster et al., 1994; Wagner et al., 1994]
CHARGE CP CHD7 [Vissers et al., 2004]
CLP ectodermal dysplasia CL/P PVRL1 [Suzuki et al., 2000]
Cornelia de Lange CP NIPBL [Krantz et al., 2004; Tonkin et al., 2004]
Crouzon CP FGFR2 [Reardon et al., 1994]
DiGeorge CP TBX1 [Packham and Brook 2003]

Ectrodactyly-ectodermal dysplasia- CL/P TP63 [Celli et al., 1999]
clefting
Familial gastric cancer and CLP CL/P CDH1 [Frebourg et al., 2006]
Gorlin CL/P PTCH1 [Hahn et al., 1996; Johnson et al., 1996]
Holoprosencephaly CL/P GLI2 [Roessler et al., 2003]

Holoprosencephaly CL/P SHH [Roessler et al., 1996]
Holoprosencephaly CL/P SIX3 [Wallis et al., 1999]
Holoprosencephaly CL/P TGIF [Gripp et al., 2000]
Isolated cleft palate CP SATB2 [FitzPatrick et al., 2003]
Kabuki CL/P MLL2 KDM6A [Lederer et al., 2012; Ng et al., 2010a]
Kallmann CL/P FGFR1 [Dode et al., 2003]
Lethal and Escobar multiple pterygium CP CHRNG [Morgan et al., 2006]
Loeys-Dietz CP TGFBR1, TGFBR2 [Loeys et al., 2005]
Miller CP DHODH [Ng et al., 2010b]
Oculofaciocardiodental CP BCOR [Ng et al., 2004]
Opitz G/BBB CL/P MID1 [Quaderi et al., 1997]

Kallmann CL/P FGFR1 [Dode et al., 2003]
Lethal and Escobar multiple pterygium CP CHRNG [Morgan et al., 2006]
Loeys-Dietz CP TGFBR1, TGFBR2 [Loeys et al., 2005]
Miller CP DHODH [Ng et al., 2010b]
Oculofaciocardiodental CP BCOR [Ng et al., 2004]
Opitz G/BBB CL/P MID1 [Quaderi et al., 1997]
Oro-facial-digital CL/P GLI3 [Johnston et al., 2010]
Oro-facial-digital type 1 CL/P OFD1 [Ferrante et al., 2001]
Otopalatodigital types 1 and 2 CP FLNA [Robertson et al., 2003]
Pierre Robin CP SOX9 [Benko et al., 2009]
Popliteal pterygium CL/P IRF6 [Kondo et al., 2002]
Saethre-Chotzen CP TWIST1 [el Ghouzzi et al., 1997; Howard et al., 1997]
Stickler type 1 CP COL2A1 [Snead and Yates 1999]
Stickler type 2 CP COL11A1, COL11A2 [Snead and Yates 1999]
Tetra-amelia with CLP CL/P WNT3 [Niemann et al., 2004]
Tooth agenesis with or without cleft CL/P MSX1 [van den Boogaard et al., 2000]
Treacher Collins CP TCOF1 [Group 1996]
Van der Woude CL/P IRF6 [Kondo et al., 2002]
X-linked cleft palate and ankyloglossia CP TBX22 [Braybrook et al., 2001]
Siderius X-linked mental retardation CL/P PHF8 [Laumonnier et al., 2005]

A.M. Sadove et al / Clin Plastic Surg 31 (2004) 231–241

Classification

ANATOMIC AND MORPHOLOGIC PERSPECTIVES
• Davis and Ritchie (1922)
• Group I: Prealveolar process cleft (clefts affecting the lip)
• 1. Unilateral (right/left: complete/incomplete)
• 2. Bilateral (right: complete/incomplete; left:
complete/incomplete)
• 3. Median (complete/incomplete)
• Group II: Postalveolar process cleft (clefts affecting the palate)
• 1. Soft palate
• 2. Hard palate
• Group III: Alveolar process cleft (any cleft involving the alveolar
process)
• 1. Unilateral (right/left: complete/incomplete)
• 2. Bilateral (right: complete/incomplete; left:
complete/incomplete)
• 3. Median (complete/incomplete)

• Brophy (1921 to 1923)

• Veau (1931)
• Type 1:Clefts of the soft palate posterior to
the hard palate
• Type 2: Complete clefts of the palate from
the incisive foramen posteriorly through
the soft palate
• Type 3: Complete unilateral cleft lip and
cleft palate
• Type 4: Complete bilateral cleft lip and
cleft palate

• Fogh-Andersen (1942)
1. Harelip (single or double)
2. Harelip with cleft palate
EMBRYOLOGIC 3. Isolated cleft palate
PERSPECTIVES 4. Rare atypical clefts, e.g., median
cleft lip

Kernahan and Stark (1958)
1. Clefts of structures anterior to the

incisive foramen
2. Clefts of structures posterior to the

incisive foramen
3. Clefts affecting structures anterior

and posterior to the incisive foramen
• American Cleft Palate–Craniofacial Association
Classification (Harkins et al., 1962)
• 1. Clefts of the prepalate (cleft of lip and embryologic
primary palate)
a. Cleft lip (cheiloschisis)
b. Cleft alveolus (alveoloschisis)
c. Cleft lip, alveolus, and primary palate (cheiloal- veoloschisis)
• 2. Clefts of the palate (cleft of the embryologic secondary
REFINEMENT palate)
• Cleft of the hard palate (uranoschisis)
• Cleft of the soft palate (staphyloschisis or veloschisis)
• Cleft of the hard and soft palate (uranostaphyloschisis)
• 3.Clefts of the prepalate and palate
(alveolocheilopalatoschisis)
• 4.Facial clefts other than prepalatal and palatal
• a. Cleft of the mandibular process
• b. Naso-ocular clefts
• c. Oro-ocular clefts
• d. Oroaural clefts
• Classification of the lip, alveolus, and palate (based on
embryologic principles):
• Clefts of the anterior (primary) palate
• Clefts of the anterior (primary) and posterior
(secondary) palates
• Clefts of the posterior (secondary) palate
International • Classification of rare facial clefts (based on
topographical findings):
Classification • A. Median clefts of the upper lip, with/without
(Broadbent et al., 1969) hypoplasia or aplasia of the premaxilla
• B. Oblique clefts (oro-orbital)
C. Transverse clefts (oroauricular)
D. Clefts of the lower lip, nose, and other very rare
clefts

• Spina (1973)
• group 1 pre- foraminal clefts
(clefts lying anterior to the incisive foramen) Clefts of the lip with or without an alveolar
cleft
• group 2 trans-foraminal clefts
(clefts of the lip, alveolus and palate)
• group III post-foraminal clefts.

Postincisive foramen clefts

TOWARD CONSENSUS
• Kernahan’s striped-Y
• Modifications by
• Elsahy (1973)
• Millard (1976)

• ‘‘If the future is to bring any
increase in our understanding of
the cleft lip and palate problem,
a uniform method of
classification is essential.’’
—Kernahan and Stark (1958)

The 1981 Committee determined
that the Kernahan and Stark
classification of 1955 and the ACPA
ACPA Reclassification Committee
Classification of 1962 were better
(Whitaker et al., 1981)
systems, based on their syntheses
of current knowledge and simplicity
and clarity of presentation.
The Cleft and
Craniofacial Team

Oral Maxillofacial Surg
Clin N Am - (2016)

Timeline of
Surgical
Treatment

• “rule of 10s.” Wilhelmsen and
Musgrave in 1966 following cutoffs:
• weight greater than 10 lb (4.5 kg),
• hemoglobin greater than 10 g/dl,
• leukocyte count less than 10,000
cells/μl.
• Millard later modified this proposed
cutoff in 1976
• patients weighed more than 10 lb
(4.5 kg)
• had a hemoglobin value greater
than 10 g/dl,
• were older than 10 weeks.
Millard DJ. The optimum time for cleft lip surgery. In:
Millard DJ, ed. Cleft Craft. Boston: Little, Brown;
1976:69–74.
Oral Maxillofacial Surg Clin N Am - (2020)
• Stage I is the newborn with an unrepaired cleft lip and palate.
• Stage II is the young child with successful repair of the soft tissues of the cleft lip and palate.
• Stage III is the adolescent with naso-maxillary deformity and resultant difficulties with speech
• Lip/nose repair* 10-12 weeks articulation, chewing ability, swallowing mechanism, breathing, and limited self-esteem.
Palate repair* 10-12 months
Pharyngoplasty 4 years and • Stage IV is the successfully reconstructed young adult.
older • In current practice, the major challenge in cleft care is the successful surgical transition from stage III
Bone graft/fistula (teenager with naso-maxillary deformity) through stage IV (the fully reconstructed young adult).
closure* 7-11 years
Orthognathic
surgery 15-17 years
Lip Revision 5-18 years
Rhinoplasty 13-18 years
*Procedures required
for all patients with a
complete cleft

Dr.Varun Menon P
Long term Multicenter studies

(PROMPT2023)
• original Eurocleft study (1992).

• Eurocleft (Shaw et al., 2005)
• follow-up project known as “standards of care for cleft lip and palate in Europe: Eurocleft”
ran between 1996 and 2000 and found that of the 201 centers that registered with the
network, 194 followed differing protocols.
• Americleft study.
• Americleft (Russell et al., 2011)
• cleft group in Switzerland
Topics to Focus
OPERATIVE EVALUATION
BONE SUBSTITUTES Timing of Surgery
TECHNIQUE METHODS:
3D analysis using
-Bergland scoring Kindelan scoring cone- beam
system system computed
tomography (CBCT)

SURGICAL TIMING
• according to chronological age:-
• primary ABG (around 2 years),
• early secondary ABG (2–5 years)
• secondary ABG (6– 12 years)
• tertiary ABG ( > 12 years) .
• By dental age ABG :-
• primary ABG (deciduous dentition)
• secondary ABG (mixed dentition)
• tertiary ABG (permanent dentition).
• Primary ABG was the main surgical procedure until Boyne and Sands reported
secondary ABG in 1972.

GRAFT MATERIALS
Calvarial Bone
Iliac bone Tibial bone
bone substitutes

Kindelan scoring system Bergland scoring system

Trap door technique.
Cortical split technique
Cortical split technique
Dr.Varun Menon P (OMFS PG TALK 2022)

Burr hole technique.
Dr.Varun Menon P (OMFS PG TALK 2022)

• “If you would not be forgotten as soon
as you are dead, either write things
worth reading or do things worth
writing.” —Benjamin Franklin
Dr.Varun Menon P (OMFS PG TALK
2022)

Evaluation and Treatment Planning For Pts With Cleft Lip and Cleft Palate and Alveolar Bone Grafting

Uploaded by

Copyright:

Available Formats

You might also like

Evaluation and Treatment Planning For Pts With Cleft Lip and Cleft Palate and Alveolar Bone Grafting

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Evaluation and Treatment Planning For Pts With Cleft Lip and Cleft Palate and Alveolar Bone Grafting

Uploaded by

Copyright:

Available Formats

Evaluation and treatment planning

for patients with cleft lip and cleft

HS Adenwalla Institute of Cleft Lip & Palate

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

• Protocol of management of cleft lip and palate children • Cleft rhinoplasty.

• Write in detail Sequential management of CLP patient. • Velopharyngeal incompetence

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Embryological aspects Classification

Aims and objectives of

General management protocol for

Dr.Varun Menon P (PROMPT2023)

The goals Improved overall masticatory and other associated functions.

treatment Normal psychosocial development.

Improve speech and hearing.

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

• Migration of neural crest cells- to form

At end of 4th week:-

• Buccopharyngeal membrane disintegrates

• max process advanced medially fused with the

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

FAILURE OF THE EPITHELIAL WALL TO DEVELOP

1966 PFEIFER :-NOT BY FAILURE OF FUSION BUT

Dr.Varun Menon P (PROMPT2023)

Facial mesenchyme( Bone ,cartilage,Fibrous

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

ABNORMAL DIRECTIONAL GROWTH OF

FAILURE OF FUSION OR BREAK DOWN

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

• Selected CL/P Syndromes with known genetic cause

Syndrome Cleft Type Observed Gene Reference

Dr.Varun Menon P (PROMPT2023)

Holoprosencephaly CL/P GLI2 [Roessler et al., 2003]

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

Dr.Varun Menon P (PROMPT2023)

1. Clefts of structures anterior to the

2. Clefts of structures posterior to the

3. Clefts affecting structures anterior