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Distribution of cleft types?
- • cleft lip alone: 15 per cent;
- • cleft lip and palate: 45 per cent;
- • isolated cleft palate: 40 per cent.
Short note on Cleft lip [2071,67,72]
Development of face?
- Face develops from median nasal process (globular process), lateral nasal process, maxillary process, mandibular arch, olfactory pit and eye.
- The central part of the upper lip (philtrum and the Cupid’s bow) develops from the fusion of two globular processes. The lateral parts of the upper lip develop from maxillary process which fuses with the medial nasal process. The lower lip develops by merging of the mandibular processes of two sides.
- Clefting of the lip and/or palate is felt to occur around the eighth week of embryogenesis, either by failure of fusion of the medial nasal process and the maxillary prominence or by failure of mesodermal migration and penetration between the epithelial bilayer of the face.
Anatomy of cleft lip?
The abnormalities in cleft lip are the direct consequence of disruption of the muscles of the upper lip and nasolabial region.
- The facial muscles can be divided into three muscular rings of Delaire:
- - Nasolabial muscle ring surrounds the nasal aperture;
- - Bilabial muscle ring surrounds the oral aperture
- - Labiomental muscle ring envelops the lower lip and chin regions.
- Unilateral cleft lip - the nasolabial and bilabial muscle rings are disrupted on one side resulting in an asymmetrical deformity involving the external nasal cartilages, nasal septum and anterior maxilla (premaxilla).
- Bilateral cleft lip - Nasolabial and bilabial muscle rings are disrupted on both sides producing a flaring of the nose (caused by lack of nasolabial muscle continuity), a protrusive premaxilla and an area of skin in front of the premaxilla devoid of muscle, known as the prolabium
Short note on Cleft palate [TU 2065,2063]
Embroyology of cleft palate?
consists of all anatomical structures anterior to the incisive foramen, namely the anterior triangular part of the hard palate, alveolus and upper lip.
- is remainder of the palate behind the incisive foramen, divided into the hard palate and, more posteriorly, the soft palate.
- Cleft palate results in failure of fusion of the two palatine shelves. This failure may be confined to the soft palate alone or involve both hard and soft palate.
- When the cleft of the hard palate remains attached to the nasal septum and vomer, the cleft is termed incomplete.
- When the nasal septum and vomer are completely separated from the palatine processes, the cleft palate is termed complete.
Classification of cleft lip and palate?
Short note on classification of cleft palate and their management. [TU 2064]
- I. Cleft lip alone: Unilateral, Bilateral or Median.
- a. Complete - extending upto nostril
- b. Incomplete - the nasal slit is intact
- II. Cleft palate -
- a. Complete - nasal septum and vomer are completely separated from the palatine processes
- b. Incomplete - There is cleft of the hard palate but it remains attached to the nasal septum and the vomer.
III. Cleft of both primary and secondary palates.
IV. Cleft lip and cleft palate together.
Etiology of cleft lip/palate?
- Genetic predisposition
- Environmental component - maternal use of drugs like steroids, diazepam and phenytoin, maternal folic acid prevents cleft lip/palate.
- Rubella infection
- Associated with other syndromes - Pierre Robin sequence, Down’s, Treacher Collins’ syndromes
Problems in cleft disorders?
- • Difficulty in sucking and swallowing. This is commonly observed in cleft palate than in cleft lip.
- • Speech is defective especially in cleft palate, mainly to phonate B, D, K, P, T and G.
- • Altered dentition or supernumerary teeth.
- • Recurrent upper respiratory tract infection.
- • Respiratory obstruction ( in Pierre Robin syndrome)
- • Chronic otitis media, middle ear problems.
- • Cosmetic problems.
- • Hypoplasia of the maxilla.
- • Problems due to other associated disorders.
What are the causes of ear problems in patients with cleft palate?
The levator veli palatini and the tensor veli palatini muscles are inserted into the eustachian tube and are probably responsible for the competence of the tube in preventing reflux of fluid from the nasopharynx into the middle ear through the eustachian tube. In patients with cleft palate, there is reflux of fluid into the middle ear through the eustachian tube resulting in otitis media.
Deformity in cleft lip?
- A cleft lip is characterized by a partial or complete lack of circumferential continuity of the lip.
- The deformity involves the mucosa, orbicularis oris muscle, and skin.
- The nasal deformity is characterized by a slumped and widened ala (nostril) that is posteriorly misplaced at its base.
- The nasal floor is nonexistent in complete clefts and the nasal septum is deviated.
LAHSAL classification of cleft lip and palate?
- LAHSHAL system for classification of cleft lip andpalate patients which was modified on the recommendation of Royal College of Surgeons Britain by omitting one “H” from the acronym “LAHSHAL”.
- LAHSAL system is a diagrammatic classification of cleft lip and palate.
- • The first character is for patient’s right lip and last character for patient’s left lip
- • ‘L’ for lip, ‘A’ for alveolus, ‘H’ for hard palate, ‘S’
- for soft palate
- • Capital ‘LAHS’ - complete’ type
- • Small letters ‘lahs’ - incomplete type
- • ‘LAHSHAL’ - Complete bilateral cleft of lip, alveolus, hard and soft palate.
A baby is born in the ward having unilateral cleft lip with cleft palate in the ward. Explain your approach regarding the further management of such baby. [TU 2063]
Management of cleft lip and palate?
- Antenatal diagnosis - All but isolated cleft palate can be diagnosed by ultrasound scan after 18 weeks’ gestation.
- Parents will need counselling and support.
- Feeding - Some babies are able to feed normally but some will need assistance.
- Airway - Major respiratory obstruction is uncommon and occurs exclusively in babies with Pierre Robin sequence. Hypoxic episodes during sleep and feeding can be life-threatening. Intermittent airway obstruction is more frequent and is managed by nursing the baby prone.
Surgery - Milard Criteria
Secondary management - Following primary surgery, regular review by a multidisciplinary team is essential. Many aspects of cleft care require long-term review regarding hearing, speech, dental development and facial growth.
- Millard criteria (Rule of ‘10’) is used to undertake surgery for cleft lip.
- • 10 pound in weight
- • 10 weeks old
- • 10 gm % haemoglobin.
- Criteria for surgery for Cleft Palate
- • 10 kg weight
- • 10 months of age (10—18 months)
- • 10 gm % haemoglobin.
What are the principles of operation in cleft lip?
- The normal shape and symmetry of the lips have to be restored
- The vertical length from the floor of the nose to the vermillion border of lip should be maintained
- Accurate apposition of margins are essential for proper healing
- Vermillion border of the lip should be constructed well
- Cupid's bow should be intact
- Integrity of orbicularis oris should be maintained by proper suturing of muscle layer to have a good oral sphincter
- Associated deformity of the nose should be corrected.
Repair of cleft lip?
- Millard’s rotation-advancement flap involves downward rotation of the medial portion of the lip and advancement of the lateral portion into the defect created by the rotation.
- The repair is based on the principle that existing elements need to be returned to their normal position to restore the normal anatomy while remaining cognizant of future growth and the effects of surgery on growth.
- Muscular continuity is achieved by subperiosteal undermining over the anterior maxilla.
- Nasolabial muscles are anchored to the premaxilla with non-absorbable sutures.
- Oblique muscles of orbicularis oris are sutured to the base of the anterior nasal spine and cartilaginous nasal septum.
- Closure of the cleft lip is completed by suturing the horizontal fibres of orbicularis oris to achieve a functioning oral sphincter
Full muscular exposure and reconstruction is imperative in many incomplete clefts if facial symmetry is to be acheived.
Repair complete cleft lip along with cleft of the palate?
1. Orthodontic treatment - The objective of presurgical orthodontic treatment is to lengthen the columella, reposition the nasal cartilages towards the tip and align the alveolar segments
2. Gingivoperiosteoplasty - Small incisions are then made on the gingivoperiosteum on either side of the cleft. The gingivoperiosteum is then mobilized on either side. The nasal floor of the gingivoperiosteum is sutured. The labial and the palatal gingivoperiosteum are then sutured. After gingivoperiosteoplasty, if there is a wide gap then this area needs to be grafted with a bone as a secondary procedure
Short note on Cleft palate repair [TU 2068]
Principle of repair of cleft palate?
- • Cleft palate is usually repaired in 12—18 months. Early repair causes retarded maxillary growth (probably due to trauma to growth center and periosteum of the maxilla during surgery if done early). Late repair causes speech defect.
- • Both soft and hard palates are repaired.
- • Whenever complicated problems are present, staged surgical procedure is done.
- • Wardill- Kilner push back operation—by raising mucoperiosteum flaps based on greater palatine vessels. This is a form of V-Y advancement of mucoperiosteum of the hard palate and achieves anteroposterior lengthening