CLEFT LIP AND PALATE craniofacial anomalies

cleft and craniofacial deformities , anomalies, implications and surgical considerations

1. CLEFT LIP AND PALATE- PART 2 Dr. SAHANA M.S

2. Introduction History Embryology Theories Etiology Epidemiology Anatomy Classification Schedule of treatment CONTENTS PART 1 PART 2 Pre surgical orthopedics Surgical techniques for cleft lip and palate Alveolar bone grafting Cleft orthognathic surgery Conclusion

3. PRE SURGICAL ASSESSMENT At birth- Thorough examination Parental counseling Pediatric evaluation Feeding instructions Pre surgical orthopedics

4. NAM is nonsurgical, passive method of bringing gum & lip together by redirecting forces of natural growth. Principle: negative sculpturing & passive molding. PRE SURGICAL ORTHOPEDICS

5. Active Appliance Semi Active Appliance Passive Appliance Latham Appliance

6. LIP TAPING

7. Rule of Ten Primary repair- repaired at approximately 10 weeks The surgeon usually uses the “Rule of Ten” The child weighs 10 pounds The child has a hemoglobin of at least 10 gm% The child has a white count of no higher than 10,000 The child is at least 10 weeks of age

8. SURGICAL CORRECTION OF CLEFT LIP AND PALATE

9. Surgical Techniques

10. The Rose-Thompson repair involves curved or angled paring of the cleft margins to lengthen the lip as a straight-line closure. Advantages- easiest to understand and perform Disadvantages- creation of a short upper lip with a notch at the vermillion- cutaneous junction. -Nasal symmetry is often hard to achieve

11. Tennison -Randall repair- The medial lip element is lengthened by introducing a triangular flap from the inferior portion of the lateral lip element. Advantages - adds length to the medial lip element - rebuilds a good floor of the nostril, - preserves Cupid’s bow Disadvantages- Z in the lip crosses the philtral line - Vermilion contour is deficient in the midline - There is a tendency to get an increase in lip height

12. MILLARDS ROTATION ADVANCEMENT FLAP This advances a mucocutaneous flap from lateral lip element into gap of upper portion of lip resulting from inferior downward rotation of medial lip element.   The repair attempts to place the lip scars along anatomic lines of the philtral column and nasal sill.

13. Incision design from the markings R A C

14. Cleft Palate Repair V-Y Pushback Von Langenbeck Palatal Repair Bardach’s Procedure Furlow Palatoplasty

15. Cleft Palate Repair V-Y Pushback (WARDILL OPERATION)

16. Von Langenbeck Operation (1861):

17. Cleft Palate Repair Furlow Palatoplasty

18. BARDACH’S TECHNIQUE

19. Orthodontic Treatment of Transitional Dentition Purpose  the dentition adjacent to cleft has to be orthodontically repositioned to prepare the cleft side for the secondary alveolar bone graft Preparing the maxillary arch for a bone graft (6-12 months) : Bonded edgewise appliance Supported with a maxillary expander quad helix expander

20. Alveolar Bone Grafting Rational

21. BONE GRAFTING PRIMARY BONE GRAFTING SECONDARY BONE GRAFTING EARLY INTERMEDIATE LATE

22. Primary Bone Grafting Popular in the 1950’s -60’s Usually done in conjunction with maxillary orthopedics Rib grafts placed either simultaneously with lip repair or shortly after Largely abandoned due to questions about maxillary growth and development

23. Primary Bone Grafting Disadvantages Data suggest that primary bone grafting has a negative effect on maxillary growth and nasolabial appearance May necessitate further bone grafting in childhood due to insufficient alveolar bulk Comparison of facial form in primary alveolar bone-grafted and nongrafted unilateral cleft lip and palate patients. Trotman CA, etal , Cleft Palate Craniofac J 33:91, 1996

24. Early Secondary Bone Grafting Done before eruption of the permanent lateral incisor Usually when the lateral is 1/3 to 2/3 formed Ages 5-6 Lateral incisor is frequently hypoplastic

25. Late Secondary Bone Grafting Done after eruption of the permanent canine Usually during adolescence or adulthood Sometimes done concomitantly with orthognathic surgery

26. Types of bone grafts Autogenous Cancellous - iliac crest Cortical- calvarium , mandible Cortico-cancellous - iliac, rib, tibia , mandible

27. Quadhelix to expand prior to ABG

28. Alveolar Bone Graft- Technique Incision and flap design for unilateral cleft defect repair Elevation of labial and buccal mucoperiosteal flaps

29. Alveolar Bone Graft-Technique Creation of labial and palatal flaps after excision of intradefect fistula Placement of particulate cancellous bone into defect

30. ORTHOGNATHIC SURGERY FOR THE CLEFT PATIENT Introduction Most patients with cleft express some amount of mid face deficiency. More so in the patient treated early for the correction of cleft.

31. CLEFT DEFECT

32. Special problems of cleft patient Alveolar clefting Oro nasal fistula Malposed teeth Mobile individual maxillae Scarring of the labial vestibule Shallow vestibule

33. Timing of surgery After the age of 18 Similar to the non cleft pts for orthognathic surgery. Orthodontic considerations Dental de compensation Transverse stability – challenging

34. Maxillary advancement in pt with unilateral cleft palate who have not undergone bone grafting Incision Similar to the non cleft pts Technique Osteotomy includes vertical step at the buttress At piriform rims cut tapers inferiorly Other steps similar to the conventional procedure.

35. Technique for the pts with unilateral cleft palate who have undergone bone grafting Similar to conventional Le Fort I Simpler, less time consuming and less morbidity. Bone grafting at the piriform region to improve the symmetry of nasal base.

36. Maxillary advancement in pts with b/l cleft lip and palate Twice as difficult as in in u/l cases Perfusion differences should be understood, specially for the pre maxilla. In cases where bone grafting is not done before down fracturing the maxilla is too risky. Anterior pedicle integrity is very important.

37. Incisions Vestibular incision till the anterior extent of lateral segment. If fistulae are present, incision should circumscribe them. Fixed gingival tissues preserved along cleft margins. A vertical incision high in the midline. Procedure Lateral cuts dependent on patient’s aesthetic needs. Septum released through midline vertical incision. Other cuts similar to conventional procedure.

38. SYNDROMIC CLEFT Common Syndromes Pierre Robin sequence Van der Woude’s syndrome Apert Syndrome Crouzan Syndrome Treacher Collins syndrome Stickler syndrome

39. CONCLUSION Cleft lip & palate are one of the most common presenting congenital conditions. Current understanding of etiology, presentation of deformity & management of child at optimal time is important. Early assessment in first days of life and multiple surgeries and counselling is necessary. Correction of defect with best possible functional & cosmetic outcome, optimal speech correction, satisfactory feeding and hearing, & dental and orthodontic health.

40. REFERENCES Millard, D. R., Jr. Cleft craft: the evolution of its surgery—vol. I: the unilateral deformity Mc Arthy - text book of plastic and reconstructive surgery Fonseca oral and maxilofacial surgery vol 6 Millard, D. R. Complete unilateral clefts of the lip. Plast.Reconstr . Surg. 25: 595, 1960. Pfeifer TM, Grayson BH, Cutting CB. Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: an outcome analysis of costs in the treatment of unilateral cleft alveolus. Cleft Palate Craniofac J 2002;

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