cleft and palate.ppt
TRANSCRIPT
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Cleft Lip and Cleft Palate
Yağmur AYDIN MD, Professor
University of Istanbul, Cerrahpaşa Medical FacultyPlastic,Reconstructive and Aesthetic Surgery Department
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Parents are worried about Is it possible to be normal with
treatment?Why did happened, Who has fault?How should I feed my baby?What about my future childern?
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Cleft lip and palate is result from failure of embryonic processes
Frontonasal process Nose Prolabium
Maxillary processes on each side Remainder of upper lip on each side
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HistoryIt is known from old times
extends back as far as 3000 BC Egyptian mummies Grek comedian statue (BC 7-4. century) First succesful cleft lip repair in China (AD 390) First detailed description by Yperman (1295-1351) Cotton, silver and lead use to close the palate byFranco
(1561) First modern surgery by Mirault in1844 “cross flap” Various flaps using triangle, qudrangle and curves Surgery based on embryologic development Veau (1936) Tension, Millard repairs (mid 20 th century)
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Problems in Cleft Lip
CosmeticDentalSpeechSwallowingHearingFacial growthEmotional
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Epidemiology The second most common congenital anomaly Affects 1in 750 births The incidence of cleft lip/palate varies among
different populations The most common in asians (1:500) In whites (1:750) The lowest in blacks (1:1000 or less)
Cleft lip more often in boys (left side) Isolated cleft palate more often in girls Young mothers are less risky
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Epidemiology-II Unilateral or bilateral Complet or incomplet Only cleft lip, cleft lip and palate or isolated
cleft palate Distribution (Fogh-Anderson, 1942)
Cleft Lip % 25 Cleft and palate %50 Cleft palate % 25
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ETIOLOGY (Multifactorial)
Genetic factors (% 25-40)Otozomal ressesive
Environmental factors (% 60-75)
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Genetic Factors (Otozomal Ressesive)
First child has anomaly Probability of second child % 4 Probability of third child % 10
Two childern have anomaly Probability of third child % 20
Mother or Father has anomaly Probability of first child % 5
Both mother and father have anomaly Probability of first child % 25
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Environmental factors(% 60-75)
Mothers sickness during first trimester (viral infections) Cronic diseases ( Diabetes Mellitus etc.) Drugs (tranquilizer, hipnotics, sedatives, cortizon, etc) Smoking Aspirin X Rays
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Classification Based on alveolar arcus
(Davies- Ritchie 1922) Prealveolar (cleft lip) Postalveolar (cleft palate) Transalveolar (cleft lip and palate)
Based on embryologic development(Kernehan-Stark 1958)
Primary cleft palate (anterior to incisive foramen) Secondary cleft palate (posterior to incisive foramen)
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EmbryologyPrimary Palate Forms during 4th to 7th week of Gestation
Defect anterior to incisive foramen prepalatal alveol, maksilla, lip, nose and palatine bone
Unilateral or bilateral
Cleft severity varies Complet ( all skin, muscle, mucosa, maksillary and nasal bones, nasal
cartilages)
Incomplet (intact nasal sill, minimally seperated, only small scar)
Secondary Palate Forms in 6th to 9th weeks of gestation Palatal shelves change from vertical to horizontal position and fuse Tongue must migrate antero-inferiorly
Face is formed at intrauterin at 10th week
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Face Devolopment
Frontonasal processmedial nasal
median palatal process
lateral nasal Maksillary processes
lateral palatal process Mandibulary process
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Face Devolopment
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Palate DevolopmentPrimary palate
median palatin processespremaksilla
Secondary palatelateral palatin processes
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Palate Devolepment(6-12. Weeks)
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Palate Devolopment (6-12. Weeks)
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NORMAL LIP MUSCULAR ANATOMY
CLEFT LIP ANATOMY
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Problems in Cleft Lip and Cleft Palate
• Feeding• Frequent upper respiratuary tract infection• Frequent gas regurtation• Otitis media• Nasal regurtation of food• Aspiration pneumenia• Growing retardation• Other anomalies• Psycological problems (family)
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Cleft lip and palate treatment team
Surgeon experienced in cleft management Pediatrist Orthodontist Pediatric Otorhinolaryngologist Pediatric dentist Geneticist Spech Terapist Social Worker Nurse experienced in cleft problems
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Feeding Rules
Swallowing is not impaired, oral feeding is possible
Bottle feed with additional cross cut in the end Elastic plastic bottle Bulb syringe with a nipple Feeding with a spoon The child should be held in a head-up position at
about 45 º during and after feeding Lateral position during sleeping
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When to Operate
Generally (Rules of 10’s)
Weight > 10 pound (4500 gr) Hb > 10 gr Age > 10 weeks
Cleft lips between 3-6 months Cleft palate between 12-18 months (preferred before
speech devolops)
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Cleft Lip Treatment Cleft lip
Mikroform cleft lip Unilateral cleft lip Bilateral cleft lip
Associated nasal deformity is classified as mild, moderate or severe
Alveolar arc position evaluated. If necessary “presurgical maksiller orthodontics” applied
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Presurgical Orthodontics
Start first or second weeks after delivery
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Operation technique in Microform cleft (Straight line closure)
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Surgical technique for unilateral cleft lip(Millard Rotation-Advancement)
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Surgical technique for unilateral cleft lip(Tennison Triangular Flap)
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Surgical technique for unilateral cleft lip and palate
Millard techniques provides primary lip and nasal repair . It is possible “gingivoperiostoplasy” after “Presurgical maksiller ortopedics”
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Pre -Orthodontic treatment After 3 months of Grayson molding plate application
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A.M.Kul, right unilateral primary and secondary cleft palate
Pre -Orthodontic therapy After 3 months of Grayson molding plate application
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Postoperative 6 months
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Postoperative 1,5 years
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Bilateral Cleft Lip
More complex and difficult to treat Projectil premaksilla Broad and flared nasal tip Prolabium Short columella or absent columella
Incomplet or complet It is important to retropositon the premaksilla
with presurgical orthopedic treatment Surgical techniques used for unilateral cleft
lip repair are used for bilateral cleft lip repair in one or two stage operation (Millard, Tennison...)
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Treatment of Premaksilla
Lip repair or “Lip-adeshion”
Elastic traction ( with a Head Bonnett)
Premaksillary retantion (Latham)
Nazoalveoler molding (Grayson)
Surgical premaksilla excision or set-back (severe maxillary retrusion)
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Bilateral Incomplet Cleft lip Operation Technique
Millard (Two stage)
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Bilateral Incomplet Cleft lip Operation Technique
Straight Line Closure (One stage)
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Cleft Palate
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Cleft PalatePalate and palatal muscles close the
velopharengeal valveVelofarengial closure can not be done in
cleft palate patient.Patient can not create intraoral pressure Feeding and speach are effected
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AnatomySoft palate muscles insert on posterior
margin of remaining hard palate rather than midline raphe
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Affects 1/2500 living births More often in girls Heredity is less affects Complete up to incisive foramen
İncomplete Only soft palete cleft
Cleft Palate
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Problems with cleft palate
FeedingSpeechHearing and middle ear problemsAdditional anomalies (% 30)Psychological problems
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Goal of Palatal Repair
Understanble speechNo maxillary retrusionNo hearing problemGood occlusion
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Submucous Cleft Palate Anatomic problem
Muscles are not fused middle of palate (muscular diastasis) notch at the back of the hard palate Bifid uvula persistentear disease swallowing difficulties
Mostly asymptomatic % 15 velopharengeal insufficiency
Short soft palate Limited motion Easy to get tired while speaking
When light goes through nose, light can be seen from oral side It is not necessary surgical treatment until child growth enough
to cooperate
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•Treatment of Submucous Cleft Palate
Submucous cleft palate only requires surgery if it is causing problems for the individual
The most common reason for treating a person with a submucous cleft palate is because of abnormal, nasal-sounding speech
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Palatoplasty Technique
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“Double opposing Z Plasty”
Von Langenback Method
Surgical treatment of isolated cleft palate
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Pierre Robin Sequence Micrognathy
Glossoptosis
Airway obstruction
Cleft palate( % 50 )
Breathing and feeding problem
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Complications Acute Period
bleeding, Airway obstruction Infection Wound seperatiom
Late maksillary hipoplasia, dental oklusion problems) Hearing problems velopharyngeal insufficency Fistula formation
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Cleft lip and palate treatment time table
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Velopharyngeal Insufficency
The inability of the velopharyngeal sphincter to sufficiently separate the nasal cavity from the oral cavity during speech
Speech problem (hypernasality, nasal emission, consanant production difficulty, decrese
in voice strength and short phrases)
swallowing problems
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Treatment of Velopharyngeal Insufficency
Patient should evaluate by speech terapist before any treatment
Nasendoscopic evaluation and Multiview videofluoroscopy is importany diagnostic tests
Goal is to provide normal velopharyngeal anatomy
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Pharyngeal wall motion. A: Frontal view of the oropharynx showing gradations ofmedial motion of the lateral pharyngeal walls. 0 = no motion, 5 = maximal motion to the midline.
Pharyngeal wall motion. B: Markings for a proposed tailor-made pharyngeal flap. The 2.5 cm width is one half the width of the posterior pharynx5 and would be appropriate for a patient whose pharyngeal wall motion ranges from 3–3.5.
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Surgical Treatment of Velopharyngeal Insufficency
Pharyngeal Flaps (Superior, inferior pedicled)
Pharyngoplasty (Hynes, Orticochea)
Soft palate lengtening and levator muscle repair
Posterior wall augmentation (teflon, proplast)
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Other Operations Fistula Repair Velopharyngeal Insufficency correction (5 yeras)
Secondary Onarımlar (preschool age)
Alveolar bone grafting (before canine theth eruption)
Orthodontic Surgery (12-14 years) (Le-Fort I Maksillary osteotomy, Mandibular split ramus osteotomy)
Rhinoplasty (16-18 years)
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Thank you for your Attention