Cleft Lip and PalateManagement

Ashok Ramadorai
BDS FDS RCSEd FFDRCSIre

Incidence
CLP- is a common congenital anomaly
Incidence- 1 in 600 births
C. Lip- m>f
C. Palate F>M
( since fusion of palatine shelves in F
takes one week longer than M)

Aetilogy
Multifactorial
1. Defective vascular supply in the area
involved
2. Mechanical disturbance- the size of the
tongue may prevent union of the parts
Circulating substanceDrugs(
anti- epileptic), diazepam, alcohol

3. Viral infection in utero

4. Abnormal fetal position in Utero
5. X radiation in Utero
6. Familial inheritance in CLP
Cleft lip alone shows 20% family history
and palate 40%

6. Associated anomalies
Downs syndrome, Pierre Robin
Syndrome, Trecher Collins syndrome,
Goldenhar syndrome, hemifacial
microsomia.

Classification
Kernehan and Stark 1958
1. Clefts of the primary palate only
Unilateral, Complete/ incomplete
Median , Complete/ incomplete
Bilateral , Complete/ incomplete

2. Cleft of the secondary palate only

complete/incomplete/ submucous
3. Cleft of primary and secondary palate
Unilateral, Complete/ incomplete
Median , Complete/ incomplete
Bilateral , Complete/ incomplete

KRENS Classification
LASHAL
----AL
------al
-----S
---HSH
LASH---Incomplete- lowercase; * submucous
Complete upper case

Submucous cleft- overlying mucosa is

intact, 1 in 1200 births, 90 %
asymtomatic, speech, hearing and
feeding problems may present later.
Recognized by the presence of bifid
uvla, a central greyish translucent zone
in the soft palate midline, palpable notch
in the HP.

Clinical problems
1. Feeding- Oro nasal communication,
difficulty in suckling
2. Speech/ hearing-Normal speech
requires velo- pharyngeal competence
and normal hearing. Palate function is
impaired in the presence of a cleft,
preventing an oro nasal seal.

3. Conductive deafness- abnormal

attachments of tensor veli palatini into
post part of HP instead of mid palatine
raphae, inability to close and open
eustachian tube to equalize middle ear
pressure- poor middle ear drainage and
conductive deafness

4. Dental anomalies
Missing lateral and canine, SNT,
hypo plastic teeth, delayed/ abnormal
eruption, teeth of abnormal morphology
5. Malocclusion

6. Facial appearance and growthClass III jaw relation, adverse effects of

the palatal scarring on facial growth, in
particular down and forward growth of
maxilla.
7. Self image- esteem

Aims of treatment
1. Improved aesthetics- lip, nose
dentition, jaw relation
2. Good function- speech, hearing
occlusion, respiration
3. Permanence of result- preventive
dentistry, life long dental care, stability
of occlusion
4. Improved self image

CLEFT TEAM
OMS SURGEON
Plastic surgeon
ENT Surgeon
GDP/ GP
Orthodontist
Speech therapist
Psychologist

Geneticist
Cleft support Nurse
Dental Hygienist
Dental Technician
Multi disciplinary- team approach

Management
In Utero- Fetal ultra sound- 20 week IU
TOP or intervention in utero for the cleft
Neonatal- Feeding plates, Mead Johnson
bottle, Nuyke teat,Habberman teat.
Emergency counseling done by the cleft
support nurse,

Pre surgical orthopedics- strapping,

appliance
Improves alignment of arch segments,
aids feeding, better long term result,
reduces prominence of premaxilla

0 to 3 days

3 months
6 months to 18
months

Counseling,
plate fitting,
pre surgical
orthopedics
Repair of lip
6 months- soft
palate repair
15 to 18 months HP

4to 6 years

8 to 10 years

16 and above

Secondary lip
surgery if
required
,pharyngoplasty
ABG to allow
ectopic incisor,
canine to erupt,
Lip revision
OGS, lip repair,
Rhinoplasty,

Secondary surgery
Pharyngoplasty- 7 years to adult life
OGS
ABG
Rhinoplasty
Secondary lip surgery
Closure of fistula

Lip repair
3 months to 6 months
Millard rotational / advancement flap
1960
De Laires functional repair
(Cheilorhinoplasty)

Objectives of lip repair

1. To close defect,
2. Inconspicuous scar
3. Restore cupid bow
4. Close the nasal floor
5. Recreate the missing philtral line
6. Buccal sulcus to be deepened
7. To form normal rounded ala

Palate repair
2 stages- SP- 6 months
HP 12 to 18 months
Some say both HP and SP at 18 months
Defer repair to older age decreases the
growth disturbance but poor speech,
greater psychological impact
Von Langenbeck 1977 midline repair
Furlow- Z plasty 1986

Objectives of palate
repair
1. To produce a palate of adequate
length
2. To produce a palate sufficiently
mobile to allow closure of
velopharyngeal space
3. To produce a palate whose dorsal
surface conforms to the shape of the
pharyngeal wall

Speech therapy
Pre school
2 years of age therapy starts to
identify VPI and lip function
5 years- videofluoroscopy,
nasendoscopy to objectively assess and
record palate function

Hearing problems
Pre school audiology
Recurrent middle ear infection due to
eustachian tube dysfunctionGROMMETS placed into middle ear to
drain out pus

Dental/ Orthodontic
Anterior Xbite correction
Buccal expansion prior to ABG
Fluoride and preventive dentistry
Continued dental care

Clinical standards
Advisory group -CSAG
74 surgeons in 45 centres
2/3 UK surgeons do less than 10 cases
a year
Poor results compared to EU centres
Recommended 8 to 15 centres

THANK YOU!