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1、Cleft Lip and Cleft Palate,Normal Lip With Anatomical Terms,Vermilion :The lower margin of the upper lip is called the vermilion and is characterized by its rosy color. Cupids bow : The term Cupids bow is used to describe the concave or dipped portion of the vermilion border in the center of the upp
2、er lip Tubercle: Peak of the Cupids bow:,Philtrum/philtral dimple: The portion of the upper lip between the two philtral columns is known as the philtrum philtral columns or lines: Above the center of the upper lip is a dimple called the philtral dimple, and the raised ridges on either side of this
3、dimple are the philtral columns or lines,Normal Lip With Anatomical Terms,Types of facial clefts,Cleft lip,Median cleft,Lateral Facial Cleft,Oblique Facial Cleft,Median Facial Cleft,Lateral Facial Cleft(Hemifacial Macrosomia),Bilateral Oblique Facial Cleft,Cleft Lip,1.Definition of cleft palate,Clef
4、t lip, sometimes called harelip, is a congenital malformation of embryonic origin that affects the lip . It occurs by itself or together with an alveolar or palatal cleft.,2. Incidence,The incidence of oral clefts varies from 1 to 2.21/1000 . The incidence of cleft lip varies across races(approximat
5、ely 1 to 1000 for whites and 0.41 for blacks in United States). Male preponderance is marked in the more severe or complete cleft lip , the male : female ratio being approximately 3:2. In most series cleft lip with cleft palate is reported as 1.5 to 3 times as frequently as isolated cleft lip.,2. In
6、cidence,In China, the incidence is about 1.8/1000 ,and the condition occurs more frequently in males than females.,3. Etiology,The cause of clefts is not understood very well. Whilst we know what happens, we do not know why. Parental age Drug use Infections during pregnancy Smoking or/and drinking d
7、uring pregnancy Heredity , Family History X-ray,microwave deficiency of vitamin C,D,B Environmental Factors,5.Types of cleft lip,Although many classifications have been proposed, we prefer to use definitive and descriptive terms in order to avoid confusion: 1.According to the position: A cleft lip m
8、ay be unilateral or bilateral .upper lip cleft and Left-sided occurrence are more frequent than the lower and the right side. A median cleft and clefts of the lower lip are extremely rare.,5.Types of cleft lip,2. According to the extent: The cleft may vary in extent, being either incomplete or compl
9、ete. 1) A complete cleft lip : is one in which the cleft extends through the floor of the nostril. This type is almost invariably accompanied by an alveolar or palatal cleft . 2) An incomplete lip cleft :often varies merely a nothing of the vermilion border, to one that extends partway up toward the
10、 threshold of the nostril. Occasionally shows a scarcely perceptible notching of the vermilion border and a slight grooving of the skin surface ,indicating an imperfect muscular union beneath. .,Unilateral cleft lip,Unilateral complete cleft lip,Unilateral incomplete cleft lip,Unilateral incompletec
11、left lip,Unilateral incompletecleft lip,Unilateral Complete Cleft Lip,lb,Bilateral cleft lip,bilateral incomplete cleft lip,bilateral complete cleft lip,bilateral mixed cleft lip,Bilateral Complete Cleft Lip,17-year-old girl with bilateral cleft lip and cleft palate,Bilateral cleft lip/palate,Bilate
12、ral cleft lip/palate,bilateral mixed cleft lip,5. Presenting Features,Deformity and dysfunction arising from primary abnormality will lead to : Separation of the lip abnormal facial development speech anomalies: usually not serous airway abnormalities Feeding problems psycho-social difficulties: ass
13、ociated with aesthetic and functional deficiencies,In almost every lip cleft there is an associated nasal disfigurement. This usually, but not always, varies in severity in direct proportion to the width of the cleft. Thus an incomplete cleft may exhibit only a slight spreading and flatness of the a
14、ffected nostril, while in a wide bilateral cleft the nostrils are extremely flattened and distorted the nasal tip retracted, and the nasal columella shortened,The muscles of the mouth in cleft lip fail to meet in the midline and thus seek other attachments. These substitute attachments prevent the m
15、uscles from becoming fully functional, and their development is incomplete.,6.Treament,1.Team approach,The management of clefts requires the participation of the following experienced specialists: a surgeon : such as a plastic surgeon, an oral/maxillofacial surgeon, a craniofacial surgeon, or a neur
16、osurgeon an audiologist : who assesses hearing a pediatric dentist or other dental specialist: such as a prosthodontist, who makes prosthetic devices for the mouth);,an orthodontist : who straightens the teeth and aligns the teeth and jaws. a geneticist : who screens patients for craniofacial syndro
17、mes and helps parents and adult patients understand the chances of having more children with these conditions,Team approach,a nurse : who helps with feeding problems and provides ongoing supervision of the childs health an otolaryngologist : an ear nose and throat doctor, or ENT a pediatrician : to
18、monitor overall health and development,Team approach,Team approach,a psychologist or other mental health specialist: to support the family and assess any adjustment problems a speech-language pathologist : who assesses not only speech but also feeding problems and other necessary specialists : who t
19、reat specific aspects of complex craniofacial anomalies.,Team Members,2. surgical repair of cleft lip, Timing of Operation : selecting a suitable time to operate on the cleft lip varies from surgeon to surgeon. Some clinics prefer operating on the infants immediately following birth, preferably with
20、in 48 hours, even 24hours. Others consist that the surgery should be delayed for a minimum of 8 to 10 weeks following the birth.,rule of tens,Although there are still many different opinions, the most accepted standpoint is that lip repair should be carried out when the childs general health and wei
21、ght permit the safe induction of general anesthesia. anesthesia. The time-honored “rule of tens” is a useful guide to the timing of surgery: According to this rule, lip repair should be carried out when the child has attained a weight of 10 pounds, is 10 weeks old, and has a hemoglobin concentration
22、 higher than 10 milligram/dl .,Timing of Operation in china,1. Unilateral cleft lip : 36 months old 2. Bilateral cleft lip : 612 months old, The Purpose of Repair: a. Restoration of normal/near normal anatomy b. Restoration of normal/near normal function c. Promotion of normal/near normal developmen
23、t resulting in satisfactory,2. surgical repair of cleft lip,The purpose is, of course, to restore the anatomic parts to their proper positions to promote normal growth and development. An effective repair must realign the vermillion and Cupids bow of the lip, reconstruct the upper lip and philtrum,
24、and reapproximate the orbicularis oris muscle within the repair.,2. surgical repair of cleft lip,Criteria for lip repair Accurate skin, muscle, and mucous membrane union Symmetrical nostrils, Symmetrical nostril floors Symmetrical vermillion border Preservation of the cupids bow A minimal scar,2. su
25、rgical repair of cleft lip, Anesthesia : General anesthesia is used.,2. surgical repair of cleft lip(taking unilateral lip repair as an example), methods of unilateral lip repair: Tennision-Randall Method ( Triangular flap method ) Millard method : ( Rotation-advancement method ) It is the most popu
26、lar technique for unilateral cleft lip described by Millard.,Millard method the first step : Markings,Midline nadir 2 Peaks of Cupids bow 1,3 New Cupids bow peak on cleft side 4 The extent of rotation curve 5 Commissures 6,7 Alar base on cleft side 8 The incision is made along line 6-3,3-5 and 8-7-4
27、,Millard method the second step : Making The incision,The incision is made along line 6-3,3-5 and 8-7-4 A rotation incision on the medial side permits the entire Cupids bow component to drop down into the normal position. The flap B helps to pull the columella and membranous septum into position. Th
28、e defect between A and B is then filled by the advancement flap C from the lateral side.Advancement of the lateral flap c rotates the ala into position and corrects the deformity of the nostril.,Millard method the second step : suture,The longitudinal incision 5-3 follows and imitates the natural li
29、ne of a philtral column. The Z-plasty in the upper portion of the lip is hidden in the shallow and in the crease lines of the nostril floor. The muscle and subcutaneous sutures should be carefully applied.,Unilateral Cleft lip on the left side.,To repair a cleft lip, the surgeon will first make an i
30、ncision on each side of the cleft from the lip to the nostril.,The cleft lip is then drawn together and stitched to create a normal cupids bow shape to the upper lip.,The scar left after surgery will gradually fade with time.,The scar left after surgery,The scar left after surgery,Cleft Palate,1.Def
31、inition of cleft palate,Cleft palate is a congenital malformation of embryonic origin that affect the palate . It occurs by itself or together with an alveolar or lip cleft.,2.Incidence of cleft palate,The incidence of cleft lip and palate varies with different races. The incidence of cleft palate a
32、lone is 1 out of 2,500 people according to reports from ADA.,Breakdown of Facial Clefts,3. Etiology,As with cleft lip, the etiology of cleft palate is multifactorial. Animal models have demonstrated that vitamin A, corticosteroids, and phenytoin produce cleft palate when given in pregnancy.,4.Classi
33、fication,1.Cleft of the soft palate only 2.Incomplete cleft of palate : extending no further than the incisive foramen.,3.Complete unilateral cleft : extending from the uvula to the incisive foramen in the midline, then deviating to one side and usually extending through the alveolus at the position
34、 of the future lateral incisor tooth. 4.Complete bilateral cleft : resembling type 3 with two clefts extending forward from the incisive foramen through the alveolus.,Cleft of the soft palate only,Complete unilateral cleft,Complete bilateral cleft,Complete bilateral cleft,Unilateralcomplete cleft li
35、p and palate,Bilateral complete cleft palate and lip,Bilateral cleft lip and palate,Bilateral cleft lip and palate,Velopharyngeal closure,During speech and swallowing the palate moves both superiorly and posteriorly against the posterior pharyngeal wall to separate the oral pharynx and nasal pharynx
36、.This is called Velopharyngeal closure.,When palate is cleft ,however, not only is there inadequate Velopharyngeal closure but, in addition , the opening in the palate permits the air stream to pass partly through the nose. Thus ,the air stream ,passing through both nasal and oral cavities, can not
37、be altered properly to produce the normal sounds.,5.Symptoms,Separation of the palate Speech and/or language problem: Nasal voice Recurrent ear infections Nasal regurgitations during bottle feeding Psychological problems : of the adolescent or adult patients and patients families.,Feeding bottles an
38、d teats for babies born with cleft lip and/or palate,An infant with a cleft will have problems sucking as communication with the nasal cavity will allow air to pass into the oral cavity instead of drawing milk from a feeding bottle or the breast. Thus, squeezable bottles with a directional teat, or
39、a variable-flow teat and pump-action valve, are required The Cleft Lip and Palate Association recommends that normal feeding methods should be encouraged.,6.Treament,1.Team Approach,2.Timing of operation,In China , surgeons most commonly carry out the surgical repair of cleft palate when the patient
40、 is 3 years old ,whatever incomplete or complete, unilateral or bilateral.,3.Aim of operation,The ultimate aim of cleft palate surgery is to produce a palate that is able to fulfill the two main functions of the normal hard and soft palate. 1.the first is to maintain a mechanical partition between t
41、he oral and nasal cavities, thereby preventing the introduction of foreign bodies into the nasal cavity, with the consequent possibility of infection of nose and middle ear.,2.the second function of palate is its participation in speech production , or we can say to gain adequate velopharyngeal clos
42、ure.,3.Method of operation(taking incomplete cleft as an evample),V-Y Retroposition (“push-back”) Procedure General anesthesia is used and the palate is injected with 0.25% lidocaine with 1:200,000 epinephrine solution to reduce blood loss.,A .outline of incision.B .The flaps are raised.C .Suture of
43、 the mucous membrane.D .Position of the flaps at the completion of the operation.,The surgeon makes an incision along both sides of the cleft.,Tissue is drawn together from both sides of the cleft to rebuild the roof of the mouth.,Before and after surgery,SPEECH THERAPY,The effect of a cleft lip and
44、 palate on speech is very variable and not always related to the type or extent of the original problem. Generally however, a cleft lip without a cleft palate rarely has any effect on speech. Sometimes if the cleft lip involves both sides, or if the gum is also affected, there may be some minor spee
45、ch difficulties.,SPEECH THERAPY,Children with cleft lip and palate commonly need speech therapy. Speech production requires coordination of the tongue, hard and soft palate. This coordination is achieved by the movement of the muscles within the tongue and soft palate. Children with cleft palate hav
46、e an abnormal insertion and movement of the muscles within the soft palate. They may also have poor coordination of the tongue movements and its placement. This results in an abnormal speech requiring speech therapy.,Treatment Goal of Speech Therapy,The goal of speech therapy is to elimination of th
47、e patients particular speech disorders by the time the child enters kindergarten.,Method,Activities for therapy should be done in a natural and fun way where possible and parents should not place the child under pressure. Here are some guidelines recommended to parents: 1.Talk to your child from a v
48、ery early age. Do not just do an activity; talk your child through it, e.g. at bathtime, “heres the soap/water/towel etc.”, “Mammy is washing”, “washing hands/face/toes etc.”.,2. Name everyday items such as cup, spoon, plate, car, door, dog, bricks etc. for your child to help him/her to understand a
49、nd use vocabulary. 3. Going through simple picture books and naming the various items helps vocabulary. 4. Pretend play with teasets, dolls, shops, dressing up etc. is a great fun activity in which your child can learn lots of simple vocabulary and sentences. Again talk your child through the activi
50、ty e.g. “dolly is eating”, “eating cake”, “pouting the tea”, “heres the cup etc”.,5.Telling simple stories from picture books is very helpful and enjoyable. Adapt language suitable to the child rather than using the book rigidly. 6.Singing little songs and nursery rhymes also helps to develop langua