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1、Cleft Lip and Cleft Palate,Normal Lip With Anatomical Terms,Vermilion:The lower margin of the upper lip is called the vermilion and is characterized by its rosy color.Cupids bow:The term Cupids bow is used to describe the concave or dipped portion of the vermilion border in the center of the upper l
2、ip Tubercle:Peak of the Cupids bow:,Philtrum/philtral dimple:The portion of the upper lip between the two philtral columns is known as the philtrumphiltral columns or lines:Above the center of the upper lip is a dimple called the philtral dimple,and the raised ridges on either side of this dimple ar
3、e the philtral columns or lines,Normal Lip With Anatomical Terms,Types of facial clefts,Cleft lip,Median cleft,Lateral Facial Cleft,Oblique Facial Cleft,Median Facial Cleft,Lateral Facial Cleft(Hemifacial Macrosomia),Bilateral Oblique Facial Cleft,Cleft Lip,1.Definition of cleft palate,Cleft lip,som
4、etimes called harelip,is a congenital malformation of embryonic origin that affects the lip.It occurs by itself or together with an alveolar or palatal cleft.,2.Incidence,The incidence of oral clefts varies from 1 to 2.21/1000.The incidence of cleft lip varies across races(approximately 1 to 1000 fo
5、r whites and 0.41 for blacks in United States).Male preponderance is marked in the more severe or complete cleft lip,the male:female ratio being approximately 3:2.In most series cleft lip with cleft palate is reported as 1.5 to 3 times as frequently as isolated cleft lip.,2.Incidence,In China,the in
6、cidence is about 1.8/1000,and the condition occurs more frequently in males than females.,3.Etiology,The cause of clefts is not understood very well.Whilst we know what happens,we do not know why.Parental ageDrug use Infections during pregnancySmoking or/and drinking during pregnancyHeredity,Family
7、History X-ray,microwavedeficiency of vitamin C,D,BEnvironmental Factors,5.Types of cleft lip,Although many classifications have been proposed,we prefer to use definitive and descriptive terms in order to avoid confusion:1.According to the position:A cleft lip may be unilateral or bilateral.upper lip
8、 cleft and Left-sided occurrence are more frequent than the lower and the right side.A median cleft and clefts of the lower lip are extremely rare.,5.Types of cleft lip,2.According to the extent:The cleft may vary in extent,being either incomplete or complete.1)A complete cleft lip:is one in which t
9、he cleft extends through the floor of the nostril.This type is almost invariably accompanied by an alveolar or palatal cleft.2)An incomplete lip cleft:often varies merely a nothing of the vermilion border,to one that extends partway up toward the threshold of the nostril.Occasionally shows a scarcel
10、y perceptible notching of the vermilion border and a slight grooving of the skin surface,indicating an imperfect muscular union beneath.,Unilateral cleft lip,Unilateral complete cleft lip,Unilateral incomplete cleft lip,Unilateral incompletecleft lip,Unilateral incompletecleft lip,Unilateral Complet
11、e Cleft Lip,lb,Bilateral cleft lip,bilateral incomplete cleft lip,bilateral complete cleft lip,bilateral mixed cleft lip,Bilateral Complete Cleft Lip,17-year-old girl with bilateral cleft lip and cleft palate,Bilateral cleft lip/palate,Bilateral cleft lip/palate,bilateral mixed cleft lip,5.Presentin
12、g Features,Deformity and dysfunction arising from primary abnormality will lead to:Separation of the lip abnormal facial developmentspeech anomalies:usually not serousairway abnormalitiesFeeding problems psycho-social difficulties:associated with aesthetic and functional deficiencies,In almost every
13、 lip cleft there is an associated nasal disfigurement.This usually,but not always,varies in severity in direct proportion to the width of the cleft.Thus an incomplete cleft may exhibit only a slight spreading and flatness of the affected nostril,while in a wide bilateral cleft the nostrils are extre
14、mely flattened and distorted the nasal tip retracted,and the nasal columella shortened,The muscles of the mouth in cleft lip fail to meet in the midline and thus seek other attachments.These substitute attachments prevent the muscles from becoming fully functional,and their development is incomplete
15、.,6.Treament,1.Team approach,The management of clefts requires the participation of the following experienced specialists:a surgeon:such as a plastic surgeon,an oral/maxillofacial surgeon,a craniofacial surgeon,or a neurosurgeon an audiologist:who assesses hearing a pediatric dentist or other dental
16、 specialist:such as a prosthodontist,who makes prosthetic devices for the mouth);,an orthodontist:who straightens the teeth and aligns the teeth and jaws.a geneticist:who screens patients for craniofacial syndromes and helps parents and adult patients understand the chances of having more children w
17、ith these conditions,Team approach,a nurse:who helps with feeding problems and provides ongoing supervision of the childs healthan otolaryngologist:an ear nose and throat doctor,or ENTa pediatrician:to monitor overall health and development,Team approach,Team approach,a psychologist or other mental
18、health specialist:to support the family and assess any adjustment problemsa speech-language pathologist:who assesses not only speech but also feeding problemsand other necessary specialists:who treat specific aspects of complex craniofacial anomalies.,Team Members,2.surgical repair of cleft lip,Timi
19、ng of Operation:selecting a suitable time to operate on the cleft lip varies from surgeon to surgeon.Some clinics prefer operating on the infants immediately following birth,preferably within 48 hours,even 24hours.Others consist that the surgery should be delayed for a minimum of 8 to 10 weeks follo
20、wing the birth.,rule of tens,Although there are still many different opinions,the most accepted standpoint is that lip repair should be carried out when the childs general health and weight permit the safe induction of general anesthesia.anesthesia.The time-honored“rule of tens”is a useful guide to
21、the timing of surgery:According to this rule,lip repair should be carried out when the child has attained a weight of 10 pounds,is 10 weeks old,and has a hemoglobin concentration higher than 10 milligram/dl.,Timing of Operation in china,1.Unilateral cleft lip:36 months old2.Bilateral cleft lip:612 m
22、onths old,The Purpose of Repair:a.Restoration of normal/near normal anatomy b.Restoration of normal/near normal function c.Promotion of normal/near normal development resulting in satisfactory,2.surgical repair of cleft lip,The purpose is,of course,to restore the anatomic parts to their proper posit
23、ions to promote normal growth and development.An effective repair must realign the vermillion and Cupids bow of the lip,reconstruct the upper lip and philtrum,and reapproximate the orbicularis oris muscle within the repair.,2.surgical repair of cleft lip,Criteria for lip repairAccurate skin,muscle,a
24、nd mucous membrane unionSymmetrical nostrils,Symmetrical nostril floorsSymmetrical vermillion borderPreservation of the cupids bow A minimal scar,2.surgical repair of cleft lip,Anesthesia:General anesthesia is used.,2.surgical repair of cleft lip(taking unilateral lip repair as an example),methods o
25、f unilateral lip repair:Tennision-Randall Method(Triangular flap method)Millard method:(Rotation-advancement method)It is the most popular technique for unilateral cleft lip described by Millard.,Millard method the first step:Markings,Midline nadir 2Peaks of Cupids bow 1,3New Cupids bow peak on clef
26、t side 4The extent of rotation curve 5Commissures 6,7Alar base on cleft side 8The incision is made along line 6-3,3-5 and 8-7-4,Millard method the second step:Making The incision,The incision is made along line 6-3,3-5 and 8-7-4 A rotation incision on the medial side permits the entire Cupids bow co
27、mponent to drop down into the normal position.The flap B helps to pull the columella and membranous septum into position.The defect between A and B is then filled by the advancement flap C from the lateral side.Advancement of the lateral flap c rotates the ala into position and corrects the deformit
28、y of the nostril.,Millard method the second step:suture,The longitudinal incision 5-3 follows and imitates the natural line of a philtral column.The Z-plasty in the upper portion of the lip is hidden in the shallow and in the crease lines of the nostril floor.The muscle and subcutaneous sutures shou
29、ld be carefully applied.,Unilateral Cleft lip on the left side.,To repair a cleft lip,the surgeon will first make an incision on each side of the cleft from the lip to the nostril.,The cleft lip is then drawn together and stitched to create a normal cupids bow shape to the upper lip.,The scar left a
30、fter surgery will gradually fade with time.,The scar left after surgery,The scar left after surgery,Cleft Palate,1.Definition of cleft palate,Cleft palate is a congenital malformation of embryonic origin that affect the palate.It occurs by itself or together with an alveolar or lip cleft.,2.Incidenc
31、e of cleft palate,The incidence of cleft lip and palate varies with different races.The incidence of cleft palate alone is 1 out of 2,500 people according to reports from ADA.,Breakdown of Facial Clefts,3.Etiology,As with cleft lip,the etiology of cleft palate is multifactorial.Animal models have de
32、monstrated that vitamin A,corticosteroids,and phenytoin produce cleft palate when given in pregnancy.,4.Classification,1.Cleft of the soft palate only2.Incomplete cleft of palate:extending no further than the incisive foramen.,3.Complete unilateral cleft:extending from the uvula to the incisive fora
33、men in the midline,then deviating to one side and usually extending through the alveolus at the position of the future lateral incisor tooth.4.Complete bilateral cleft:resembling type 3 with two clefts extending forward from the incisive foramen through the alveolus.,Cleft of the soft palate only,Co
34、mplete unilateral cleft,Complete bilateral cleft,Complete bilateral cleft,Unilateralcomplete cleft lip and palate,Bilateral complete cleft palate and lip,Bilateral cleft lip and palate,Bilateral cleft lip and palate,Velopharyngeal closure,During speech and swallowing the palate moves both superiorly
35、 and posteriorly against the posterior pharyngeal wall to separate the oral pharynx and nasal pharynx.This is called Velopharyngeal closure.,When palate is cleft,however,not only is there inadequate Velopharyngeal closure but,in addition,the opening in the palate permits the air stream to pass partl
36、y through the nose.Thus,the air stream,passing through both nasal and oral cavities,can not be altered properly to produce the normal sounds.,5.Symptoms,Separation of the palate Speech and/or language problem:Nasal voiceRecurrent ear infections Nasal regurgitations during bottle feeding Psychologica
37、l problems:of the adolescent or adult patients and patients families.,Feeding bottles and teats for babies born with cleft lip and/or palate,An infant with a cleft will have problems sucking as communication with the nasal cavity will allow air to pass into the oral cavity instead of drawing milk fr
38、om a feeding bottle or the breast.Thus,squeezable bottles with a directional teat,or a variable-flow teat and pump-action valve,are required The Cleft Lip and Palate Association recommends that normal feeding methods should be encouraged.,6.Treament,1.Team Approach,2.Timing of operation,In China,sur
39、geons most commonly carry out the surgical repair of cleft palate when the patient is 3 years old,whatever incomplete or complete,unilateral or bilateral.,3.Aim of operation,The ultimate aim of cleft palate surgery is to produce a palate that is able to fulfill the two main functions of the normal h
40、ard and soft palate.1.the first is to maintain a mechanical partition between the oral and nasal cavities,thereby preventing the introduction of foreign bodies into the nasal cavity,with the consequent possibility of infection of nose and middle ear.,2.the second function of palate is its participat
41、ion in speech production,or we can say to gain adequate velopharyngeal closure.,3.Method of operation(taking incomplete cleft as an evample),V-Y Retroposition(“push-back”)ProcedureGeneral anesthesia is used and the palate is injected with 0.25%lidocaine with 1:200,000 epinephrine solution to reduce
42、blood loss.,A.outline of incision.B.The flaps are raised.C.Suture of the mucous membrane.D.Position of the flaps at the completion of the operation.,The surgeon makes an incision along both sides of the cleft.,Tissue is drawn together from both sides of the cleft to rebuild the roof of the mouth.,Be
43、fore and after surgery,SPEECH THERAPY,The effect of a cleft lip and palate on speech is very variable and not always related to the type or extent of the original problem.Generally however,a cleft lip without a cleft palate rarely has any effect on speech.Sometimes if the cleft lip involves both sid
44、es,or if the gum is also affected,there may be some minor speech difficulties.,SPEECH THERAPY,Children with cleft lip and palate commonly need speech therapy.Speech production requires coordination of the tongue,hard and soft palate.This coordination is achieved by the movement of the muscles within
45、 the tongue and soft palate.Children with cleft palate have an abnormal insertion and movement of the muscles within the soft palate.They may also have poor coordination of the tongue movements and its placement.This results in an abnormal speech requiring speech therapy.,Treatment Goal of Speech Th
46、erapy,The goal of speech therapy is to elimination of the patients particular speech disorders by the time the child enters kindergarten.,Method,Activities for therapy should be done in a natural and fun way where possible and parents should not place the child under pressure.Here are some guideline
47、s recommended to parents:1.Talk to your child from a very early age.Do not just do an activity;talk your child through it,e.g.at bathtime,“heres the soap/water/towel etc.”,“Mammy is washing”,“washing hands/face/toes etc.”.,2.Name everyday items such as cup,spoon,plate,car,door,dog,bricks etc.for you
48、r child to help him/her to understand and use vocabulary.3.Going through simple picture books and naming the various items helps vocabulary.4.Pretend play with teasets,dolls,shops,dressing up etc.is a great fun activity in which your child can learn lots of simple vocabulary and sentences.Again talk
49、 your child through the activity e.g.“dolly is eating”,“eating cake”,“pouting the tea”,“heres the cup etc”.,5.Telling simple stories from picture books is very helpful and enjoyable.Adapt language suitable to the child rather than using the book rigidly.6.Singing little songs and nursery rhymes also
50、 helps to develop language.,A review of the literatures on speech therapy reveals that in the best centers around the world,the chance of attaining normal speech following cleft palate repair is about 80%.Although this figure may not seem to be very high,it is a reflection of the current state of th
