CLEFT LIP & PALATE

CLEFT LIP
● A unilateral or bilateral congenital fissure of the upper lip, usually lateral to the midline; can extend
into the one or both nostrils and may involve the alveolar process
● This is caused by defects in the fusion of the maxillary and the globular processes.
BEFORE AND AFTER REPAIR OF CLEFT LIP

CLEFT PALATE
A congenital fissure of the palate caused by failure of the palatal shelves to fuse; may extend to connect
with unilateral or bilateral cleft lip
CLEFT OF THE SOFT AND HARD PALATE

EMBRYOLOGY FORMATION
● Cleft lip and palate present due to a failure of normal fusion of embryonic processes during
development in the first trimester of pregnancy
● With normal fusion- no cleft will result
● Fusion starts in the pre-maxillary region and continues backward to the uvula

DEVELOPMENT OF THE LIP

● Formation of the lip:
- Between week 4 and 7 ​in utero
- A cleft lip becomes apparent by the end of the second month in ​utero

DEVELOPMENT OF THE PALATE

● Takes place during week 8-12
● Cleft palate is evident by the end of the third month

3D SONAR IMAGE OF FOETUS

 TYPES OF CLEFT LIP
● Incomplete unilateral
● Complete unilateral
● Complete bilateral

UNILATERAL CLEFT BILATERAL CLEFT

CLASSIFICATION OF CLEFTS

Class 1 = Cleft on the tip of the uvula

Class 2= Cleft of the uvula
Class 3= Cleft of the soft palate
Class 4= Cleft of the soft and hard palate
Class 5= Cleft of the soft and hard palate that continue through the alveolar ridge on the one side of
the of the premaxilla
Class 6 = Cleft of the soft and hard palate that continue through the alveolar ridge on both sides,
leaving a free premaxilla
Class 7 = Submucous cleft, palate is short, uvula could be bifid, groove is situated at the midline of
the soft tissue and closure of the pharynx is incompetent

PREVALENCE
- 50% cleft lip + palate
- 25% cleft lip only
- 25% cleft palate only

MALE VS FEMALE
- More males affected 2:1
 ETIOLOGY
Genetic Factors:
- dominant : one of parent affected; 50% chance with every pregnancy. 1:2 eg Van der Woude
Syndrome
- Mocked syndrome: autosomal recessive condition
- Both parents may appear normal but both are carriers
- 25% chance out of every pregnancy 1:4

CHROMOSOMAL
- Trisomy 13 or Patau syndrome
30%-80% have cleft lip
- Trisomy 18 or Edward’s syndrome
10-20% have a cleft

ENVIRONMENTAL
● Teratogens:​ Environmental agents and substances interfering with the development of the unborn
baby.
● Drugs:​ (cross the placenta and enter the unborn baby’s bloodstream)
● Epanutin: ​(Epilepsy)
● Emphetamines & Lithium (Psychiatric disorders)
● Bacterium: ​(anti-biotic)
● Possibly cortisone, barbiturates, valium and caffeine, vitamin A, Inadequate diet
● Tobacco and alcohol consumption

PRENATAL DIAGNOSIS
- High resolution ultrasound
- 3D and $D sonars

CAN A CLEFT BE REPAIRED?

- Yes
- Golden rule of 10
10 weeks, 10 pounds, hemoglobin 10 mg/ml
- Li: 3-4 months
- Palate: 8-9 months
- Health of infant and type pf cleft will determine repair.

PURPOSE FOR EARLY TREATMENT

● I aid in feeding
● Encourage development of the pre-maxilla
● Assist in partial closure of the hard palate cleft
● Assist families to adjust to the birth of the child with a cleft (lip or palate

PROCEDURE IN GENERAL
● GA
● Hospital 2-3 days
● Mother rooms with baby
● Lip scars prominent directly after surgery

LONG TERM PLASTIC SURGERY MANAGEMENT

Cleft lip: early intervention
5 years scar reduction
Notch in lip filled 10 years
Nasal Deformity:
- Degree of deformity depends on severity of cleft lip
- First attempt to correct Cleft lip and to correct nose
- Always residual deformity
- Minor adjustments 4- years
- BUT nose develops during adolescence
Final nasal surgery 14-16 years

CLEFT PALATE REPAIR

Primary closure- 18 months or earlier

GOALS FOR TREATMENT

- Produce anatomic closure

- Promotes and maximize military growth and development
- Schieve normal function- chewing, speech
- Relive airway and breathing problems
- Establish good dental aesthetics and functional occlusion

BONE GRAFTING
1. Alveolar repair ridge
- Placed before eruption of the maxillary teeth in cleft site
- Created “normal’ arc
- Provide support to the adjacent teeth next to the cleft area (thin bone)

2. Hard Palate
- Provides closure of fistulae
- Helps to repair or relieve a compromised airway

- Bone Resources:
Rib
Iliac crest
Skull
Mandible

PROSTHODONTICS
Types of appliances:
- Obturator: A removable prosthesis to provide closure of a palatal opening.
- Speech aid prosthesis: a removable appliance to complete the palatopharyngeal valving required for
speech.

Purpose of Prosthesis :
- Closure of the palate
- Replacing missing teeth
- Scaffolding to fill out upper lip
- Aid in chewing/eating
- Restore vertical dimension
 PROSTHETIC DEVICES

Feeding Obturator

Feeding Obturator in
Position

Speech Aid
Examples

Obturator to seal fistula

in palate

FEEDING
● Cleft lip no severe feeding problems
● Palatal cleft:
- No breast feeding
- Bottle feeding (breast milk in bottle) Haberman feeder
- Bottle teats longer
- Enlarged openings (not to large)
- Cut cross over teat.
- Steady flow of milk
HABERMAN FEEDER
FEEDING CONTINUE

● Plastic bottle Gently squeeze milk out

● Soft pliable teat
● Feeding takes longer
● Hold baby upright
● Burp often
● Frequent intervals

FEEDING UPRIGHT

● NUK dummy is recommended

● Sick or premature baby – naso-gastric tube

ORAL HYGIENE OF BABY

● Keep cleft clean

● After milk bottle give water in bottle
● Flush away excess milk and food
● Moisten gauze or cotton bud
● Clean cleft
● Cleft not a wound
● Milk not cleaned can crust around cleft
● Peeled of can traumatize mucous membranes around cleft

MILK DEPOSIT AFTER FEEDING

SOLIDS/ FOOD

● Start as with any other baby

● Strain food, feed with spoon
● Mash solids later as baby becomes older
● Avoid spicy and acid food
● Also avoid:
● Nuts
● Peanut butter
● Melted cheese and cream
● Leafy veg.
● Fruit with pips and peels

EAR PROBLEMS
● Higher incidence for infections Otitis media
● Slight hearing loss
● Test hearing
● ENT
● Grommets placed /tympanostomy tube
● To aerate the middle ear

DENTAL PROBLEMS
● Orthodontic problems: due to malocclusion and clefts orthodontic treatment may start as young as
three years of age
● Orthodontic devices- difficult to maintain oral hygiene
● Congenital missing teeth- often lateral incisor on the side of the cleft
● High caries risk: due to malocclusion, bundling of teeth
● Surgical repair of lip: scar tissue is often tight
● Scar tissue in surgical repair areas are often sensitive
● Central incisor may be hypoplastic
● Bone thin both sides of the cleft area- be careful during instrumentation and making use of fulcrum
● What is there is still a fistula after palatoplasti?
- Regarding fluoride and fissure sealant applications?
Careful with etch or fluoride to enter into the cleft or fistula - cover with gauze or…
Position patient upright

ORAL HYGIENE CHALLENGES

ORAL HYGIENE MANAGEMENT
● Prevention essential for habilitation of cleft lip and palate patient.
● Every attempt should be made to prevent further loss of teeth via extractions due to caries
● Three to four monthly visits to the oral hygienists

ORTHODONTIC TREATMENT

OBJECTIVES FOR APPOINTMENT PLANNING

● Re-call patient every 3-4 months

● Objectives:
- Review biofilm control
- Early caries detection
- Dietary advice
- Assess cleanliness of removable prosthesis
- Remove calculus
- Caries prevention program- fluoride and fissure sealants
- Prosthesis and speech aid may contribute to halitosis

APPOINTMENT CONSIDERATIONS
● Due to multiple medical appointments pt may become “clinic tired”
● Lowered self-esteem and difficulties with social interaction
● Communication could be difficult as speech may almost be indiscernible
● Hearing- depends on the amount of hearing loss

PATIENT INSTRUCTIONS
● Personal daily care: select toothbrush
Brushing methods
Auxiliary aids
● Fluoride: daily fluoride, dietary supplements and professional application- precautions?
● Rinsing instructions: M/R only for children who are able to rinse

ORAL HYGIENE CARE INSTRUCTIONS

● The young child/toddler
● Parents should be shown how to lift the repaired lip, stretching the lip carefully by sliding an index
finger along the labial gingiva.
● An interdental brush is especially helpful for teeth in the cleft region of the hard palate.
Parents should be given the opportunity to practice the tooth brushing technique in the dental
office
DENTAL CARE: 4-7 YEARS
● Orthodontic dental records.
● X-rays, especially maxillary occlusal radiographs.
● Clinical photos.
● Phase I orthodontics around age 7-9 removable or fixed appliances (research article on biofilm)
● Provide appropriate preventive and restorative care.

DENTAL CARE: 7-9 YEARS.

Preparation for the Alveolar Bone Graft

● Removal of primary teeth in surgical field to permit healing and primary closure of graft site
● Arch Expansion with appliance
● Gingival health – reduce inflammation in surgical site

Bone Grafting: Age 7-9 Years

● Alveolar bone grafting may be performed between 7 and 9 years of age.

● Grafting only restores the alveolar process, however; no graft is placed in the palate and bone does
not form there.
● A lateral incisor as well as a cuspid may erupt through the area of new bone formation.
 DENTAL CARE: AGE 7-9 YEARS. ORAL HYGIENE INSTRUCTIONS

● Cleaning of any anterior teeth positioned high in the labial sulcus should be given special attention.
● The child is shown how to lift the upper lip out of the way to facilitate brushing.
● Fissure sealants should be provided as soon as the teeth have erupted sufficiently.
● Dental records to monitor jaw growth, dental development and bone graft.
● Braces for dental alignment as needed.
● Prosthetic replacement of missing teeth as needed.
● Monitor dental hygiene; provide appropriate preventive and restorative care.