Cleft Lip

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Cleft Lip Palate

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introduction

• Facial clefting is the second most common
  congenital deformity (after clubfoot).
• Affects 1 in 750 births
• Problems are cosmetic, dental, speech,
  swallowing, hearing, facial growth, emotional

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Prevalence

• CL/P is more common than CP and varies by
  ethnicity.
• CL/P
• High in American Indians and Asians (1/500
  newborns)
• Low in American blacks (1/2000 newborns)
• Intermediate level in Caucasians (1/1000
  newborns)
• More common in male
• Isolated CP occurs in only 1/2500 newborns , does
  not display variation by ethnicity and more
  common in female.

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Cleft Lip

• Complete closure at 35 days postconception
• 7 weeks from the LMP.
• Lateral nasal, median nasal, and maxillary
  mesodermal processes merge.
• Failure of closure can produce unilateral,
  bilateral, or median lip clefting.
• Left side unilateral cleft is the most common.

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Cleft Palate

• Lack of fusion of the palatal shelves.
• Abnormalities in programmed cell death may
  contribute to lack of palatal fusion(?).
• Isolated disruption of palate shelves can occur
  after closure of the lip
• Palatal closure is not completed until 9 weeks
  post-conception.

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emberology

• Primary Palate- Triangular area of hard palate
  anterior to incisive foramen to point just
  lateral to lateral incisor teeth
• Includes that portion of alveolar ridge and four
  incisor teeth.
• Secondary Palate- Remaining hard palate and all
  of soft palate

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embryology

• Primary Palate
• Forms during 4th to 7th week of Gestation
• Two maxillary swellings merge
• Two medial nasal swelling fuse
• Intermaxillary Segment Forms
  Labial Component (Philtrum)
  Maxilla Component (Alveolus 4
  Incisors) Palatal Component(Triangular
  Primary Palate)

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embereology

• 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

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anatomy

• Hard Palate
• Bones Maxilla( Palatine Processes)
  Palatine Bones(Horizontal Lamina)
• Blood Supply Greater Palatine Artery
• Nerve Supply Anterior Palatine Nerve

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Anatomy

• Soft Palate
• Fibromuscular shelf attached like a shelf to
  posterior portion of hard palate
• Tenses, elevates, contacts Passavants Ridge
• Muscles Tensor Veli Palatini(CNV), Levator
  Veli Palatini(Primary Elevator), Musculus Uvulae,
  Palatoglossus, Palatopharyngeus(CN IX and X)

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Etiology

• Several agents that are associated with an
  increased frequency of midfacial malformation.
• Genetics
• Medications phenytoin, sodium valproate,
  methotrexate.
• With corticosteroids there is no evidence of an
  increase in malformations.
• Possible association could not be excluded

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Etiology

• Cigarette smoking
• Noted with mothers of children with facial
  clefting, both CL/P and CP.
• Teratogenesis has been attributed to hypoxia as
  well as a component of tobacco (cadmium).
• Alcohol
• Associated with an increased risk of fetal facial
  clefting.
• Alterations in cell membrane fluidity or reduced
  activity of specific enzymes such as superoxide
  dismutase.
• Folate deficiency
• Contributes to a range of birth defects.
• Evidence is emerging for a similar association
  with the development of CL/P.

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Cleft formation

• Cleft result in a deficiency of tissue
• Cleft lip occurs when an epithelial bridge fails
• Clefts of primary palate occur anterior to
  incisive foramen
• Clefts of secondary palate occur posterior to
  incisive foramen

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                   Unilateral incomplete                    Unilateral complete                    Bilateral complete
                   Incomplete cleft palate                    Unilateral complete lip and palate                    Bilateral complete
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Examples of Cleft Palate

• Cleft of Back Soft Palate
• Cleft of Soft Palate
• Cleft of Soft and Hard Palate
• Cleft of Soft and Hard Palate and Cleft Lip

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treatment

• Feeding
• respiratory tract and ear infection
• Orthodontic
• Surgery

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Surgery

• Cleft lip repair role of ten ( wt 10 pounds,
  age 10 weeks and 10 gm /ds litter haemoglobin)
• Cleft palate repair at 10 month to 18 months .
• Cp repair before speeking