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Cleft lip Part-1
Dr. Amit T. SuryawanshiOral and Maxillofacial Surgeon
Pune, India
Contact details :Email ID - [email protected]
Mobile No - 9405622455
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• Cleft lip and cleft palate comprise a form of birth defect.
• 2ND MOST COMMON BIRTH DEFECT• A cleft lip is a separation of the two sides of the
lip• The separation often includes the bones of the
upper jaw and/or upper gum• A cleft palate is an opening in the roof of the
mouth
Introduction
• It is a condition in which the two sides of the palate did not fuse, or join together, as the unborn baby was developing
• Cleft lip and cleft palate can occur on one side (unilateral cleft lip and/or palate), or on both sides (bilateral cleft lip and/or palate). Because the lip and the palate develop separately, it is possible for the child to have a cleft lip, a cleft palate, or both cleft lip and cleft palate.
Definition :
CLEFT LIP :-• It is the birth defect which results in a unilateral or
bilateral opening in the upper lip between the mouth & nose.
CLEFT PALATE :-• It is the birth defect characterized by an
opening in the roof of the mouth caused by lack of the tissue development
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• Extends back as far as 400 bc.• Hippocrates & Galen (400 BC and 150 AD
respectively) mentioned cleft lips. • In 390 BC a cleft lip was successfully joined in
China• In 1764, Le Monnier, a French dentist,
successfully repaired a cleft velum.• In 1816, Karl Ferdinand von Gräfe, a noted
surgeon who was a pioneer in early German plastic surgery, is credited with performing the first velar repair.
HISTORY
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Health Statistics in India & South Asia
The most important basic need of people – food.
India, along with Bangladesh and Nepal, have the highest percentages of undernourished children (under the age of 5) at close to 50%.2 Source: WORLD HEALTH ORGANISATION
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Mortality RateRates of maternal deaths during child birth provide insight of conditions of child birth and medical aid available. More significantly, they point to the place of women in society.
Nepal > India > Pakistan>Bhutan >Bangladesh. Sri Lanka and Nepal, have much lesser maternal deaths and are comparable to statistics from China.
Source: WORLD HEALTH ORGANISATION
Cleft Statistics In India
Cleft Deformity is still not included in Disability Act of
India.So no government grants are provided.
General public awareness about the deformity, its
occurrence and cure is extremely low.
According to the report by Tata Institute of Social
Studies – 2000 in India:- Incidence of Cleft Lip &
Cleft Palate in India is 1: 800 live births. 8
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Approximately 30,000 New Cleft Children are
born every year.
Only 25% of them get any form of treatment.
Rest 75% families remain untreated
So, Total treatment and rehabilitation is very low.
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The approximate incidence of cleft lip and palate is1.4 per 1,000 live births in IndiaSurvey by Indian health ministry in 2010
One in every 700 births results in a cleft lip and/orpalate – many within families that have no historyof cleftsINTERNATIONAL CRANIOFACIAL INSTITUTE
INCIDENCE
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CAUSES
Syndromes
AFFECTS GENOTYPE & PHENOTYPES
Genetic
Medication
1.Consanguinos marriage2.Exposure to chemicals and viruses
Environmental
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• lack of prenatal care during pregnancy,
• cigarette smoking• lack of a balanced diet and • the chronic use of non- prescribed
drugs or substance abuse
Additional risk factors
Cleft Lip: Failure of fusion of medial nasal process and
maxillary processesCleft Palate: Failure of fusion of palatine processes of maxilla
EMBRYOLOGY
www.spreadingsmile.org 14
Development of Lip – Normal & Abnormal
INTERMAXILLARY SEGMENT – formed by Median nasal process fusion at deeper level .
Composed of labial componentupper jaw componentPRIMARY PALATE portion of nasal septum
DEVELOPMENT OF PALATE – Normal & Abnormal
Palate develops from the primary palate & secondary palate
Secondary palate derived from maxillary prominences
Outgrowth of palatine shelves appear in sixth week & on each side of tongue
DEVELOPMENT OF PALATE – Normal & Abnormal
In 7th week palatine shelves attain horizontal position & fuse with each other to form secondary palate
Secondary palate fuse with nasal septum and posterior part of primary palate
Bone extend from maxilla to ossify hard palate
DEVELOPMENT OF PALATE – Normal & Abnormal
Posterior part of palatine process do not get ossified and extend posteriorly to form soft palate
The median palatine raphe indicates line of fusion of processes
DEVELOPMENT OF PALATE – Normal & Abnormal
Nasopalatine canal persists in median plane between premaxilla and secondary palate & represented in adult as incisive fossa.
DEVELOPMENT OF PALATE – Normal & Abnormal
Anatomy
Normal Musculature Incomplete Cleft
Complete Cleft
Muscles of Lip
• The main blood supply to the lip and nose area -facial artery.
• The facial artery - inferior / superior labial branches
BLOOD & NERVE SUPPLY
NERVE SUPPLY
Classification
• Davis and Ritchie classification 1922.• Each of the following subgroups is further subdivided into the
extent of the cleft (1/3, 1/2, etc).• Group I – Prealveolar clefts• unilateral,• median, or • bilateral
• Group II - Postalveolar clefts • Hard palate alone, • soft palate alone, • soft palate and hard palate, • or submucous cleft
• Group III – Alveolar clefts • unilateral,• median • or bilateral
Classification • International Confederation of Plastic and Reconstructive Surgery
classification
• This system uses an embryonic framework to divide clefts into 4 groups, with further subdivisions to denote unilateral or bilateral cases.
• Group I - Defects of the lip or alveolus • Group II - Clefts of the secondary palate (hard palate, soft palate, or
both) • Group III - Any combination of clefts involving the primary and
secondary palates
Classification
Iowa system classification: • Group –I These are defined as clefts of the lip only.
• Group-II These are defined as clefts of the palate only i.e. secondary
palatal clefts.
• Group-III These are defined as clefts of the lip , alveolus and palate i.e.
complete
cleft lip and palate.
• Group-IV These are defined as clefts of the lip and alveolus i.e. primary cleft
palate and lip
• Group –V This classification is defined as miscellaneous and includes clefts
which
do not fit into any of the above categories.
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• Veau classification • Classification system proposed in 1938.• Group I (A)• Defects of the soft palate alone• Group II (B)• Defects involving the hard and soft palates
(not extending anterior to the incisive foramen)
• Group III (C)• Defects involving the palate through to the
alveolus• Group IV (D)• Complete bilateral clefts.
Classification of cleft lip and palate
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• Kernahan and Stark classification [2]• Embryology-based classification system
proposed in 1958 that designates the incisive foramen as the dividing line between the primary and secondary palates.
• The incisive foramen is a funnel-shaped opening through which neurovascular bundles pass. It is located in the hard palate behind the middle upper teeth (incisors). This structure is an important embryological landmark, which is used to define the boundary between the primary and secondary palate.
• Primary palate includes those structures anterior to the incisive foramen (lip, pre-maxilla, anterior septum).
• Secondary palate includes those structures posterior to the incisive foramen (lateral palatine shelves, soft palate, and uvula).
Classification of cleft lip and palate
Striped Y1 & 5 - Floor of nose on right & left sides
2 & 6 - Lip
3 & 7 - Alveolar ridges
4 & 8 - Premaxilla to incisive foramen
9 & 10 - Each half of the hard palate
11 - Soft palate
12 - Congenital velopharyngeal incompetence without obvious clefts
13 - Protrusion of premaxilla
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Classification
INDIAN CLASSIFICATION Proposed by Dr. C. Balakrishnan in1975
• Group 1 Cleft lip only • Group 1a Cleft lip and alveolus • Group 2 Cleft palate only • Group 3 Cleft lip and palate
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Tessier classification Tessier classification. Left: boney clefts, Right: Soft tissue clefts.In 1976 Paul Tessier published a classification on facial clefts based on the anatomical position of the clefts. The different types of Tessier clefts are numbered 0 to 14. These 15 different types of clefts can be put into 4 groups, based on their position[7]: midline clefts, paramedian clefts, orbital clefts and lateral clefts. The Tessier classification describes the clefts at soft tissue level as well as at bone level, because it appears that the soft tissue clefts can have a slightly different location on the face than the bony clefts.
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Classification of cleft lip and palateBasic classification
www.medlife.co.in
Classification
• Lahshal classification:• Presented by Okriens in 1987
• LAHSHAL is a paraphrase of the anatomic affected by the cleft.
L lip A alveolus H hard palate S soft palate H hard palate A alveolus
L lip
Clinical features: Cleft lip- unilateralNON CLEFT SIDE CLEFT SIDE
1.DEVIATION OF BASE OF NASAL SEPTUM,
COLUMELLA
2.OBICULARIS ORIS TERMINATE AT
THE BASE OF THE COLUMELLA
1. DEVIATION OF TIP OF NOSE.
2. ALAR CARTILAGE IS• PTOTIC• STRETCHED• ROTATED
3. LOWERING OF UPPERLATERAL CARTILAGE. 4. EXCESSIVE MUSCLE EXISTS BENEATH THE
ALA NASI
SKIN OF NOSTRIL FLOOR• FINE GRAINED • FLAT• LIGHTLY HAIRED
SKIN OF LIP• FINE LINED• BULGING
THE WHITE ROLL : MUCOCUTANEOUS RIM , WHICH CONSIST OF THE CUTANEOUS INSERTION OF FIBERS OF THE EXTERNAL ORBICULARIS BAND
• SEEN EXTENDING JUST BEYOND THE MIDLINE ON MEDIAL SIDE• TENDS TO DISAPPEAR WITHINN 2-3 MM LATERAL TO CUPID BOWS PEAK ON
LATERAL SIDESTERILE MUCOSA : MUCOSA LINING THE BORDER OF CLEFT , IT SHOULD BE REMOVED A LINE DRAWN PERPENDICULAR FROM PEAK OF CUPID’S BOW ON MEDIAL & LATERAL SEGMENTS
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• Nasal distortion• Recurring ear infections • Failure to gain weight• Nasal regurgitation when bottle feeding• Poor speech • Misaligned teeth • Growth retardation (picture)• Ear infections• Hearing loss• Dental cavities• Displaced teeth• Social problems
Problems associated with cleft patients
Management
• Team Approach• Cleft surgeon has a pivotal role• Initial Head and Neck Examination• Speech Disorders• Ear Disease• Airway Problems• Surgical Repair
Head and Neck Exam
• Head- facial symmetry• Otologic- auricle and canal development and
location, pneumatic otoscopy, forks• Rhinoscopy- identifies clefting, septal
anomalies, masses, choanal atresia• Oral Exam- cleft, dental, tongue• Upper airway- phonation, cough, swallow
Thank You