cl-cp commprehensive

1. CLEFT LIP & PALATE
EMBRYOLOGY
&
MANAGEMENT
Dr SD Sanyal
Wg Cdr RD Bavdekar
Cl Spl Surg & Plastic surgeon

2. EMBRYOGENESIS

5. Lip
Formation of Stomatodaeum
Appearance of FN process & Mandibular
arches
Maxillary & Mandibular processes develop

6. Lip
Formation of Nasal placodes
Medial and Lateral nasal processes form
Both nasal processes fuse together & with the
Maxillary process

7. Lip
Upper lip is formed
Lower lip is formed by the fusion of the B/L
Mandibular processes

9. Palate
Palatal processes arise from the maxillary
processes
Premaxilla develops from the FN process
B/L Palatal processes fuse with post border of
the Premaxilla

10. Palate
B/L palatal processes fuse together in the
midline
Fusion proceeds ant to post
Medial edge of the palatal processes fuse with
the free end of nasal septum

11. Incidence
• Cleft lip and palate 1:600
• Isolated cleft palate 1:1000
• Oriental (1:500) > black (1:2000)
• Cleft lip alone: 15 per cent
• Cleft lip and palate: 45 per cent
• Iisolated cleft palate: 40 per cent
• Cleft lip/palate predominates in males
• Cleft palate alone more common in females
• Unilateral cleft lip - left side in 60 %

12. Etiology
• Familial
• Protein & vit deficiency
• Rubella infection
• Radiation
• Drugs : Steroids, Phenytoin, Diazepam
• Syndromes
- Downs

13. Muscle Rings of Face

14. CLASSIFICATION

17. Nagpur Classification

18. LAHSHAL System
• Describes site, size and extent, as well as type
of cleft
• Complete clefts of the lip, alveolus and hard
and soft palate designated as capitals
- L, A, H and S
• Incomplete clefts recorded in lower case
letters
• Microform clefts documented with asterisks

20. DAVIS & RITCHIE
• Three groups according to position of cleft in
relation to alveolar process:
• Group I – Pre alveolar clefts:
- Unilateral cleft lip
- Bilateral cleft lip
- Median cleft lip
• Group II - Post alveolar clefts:
- Cleft hard palate alone
- Cleft soft palate alone
- Cleft soft palate and hard palate
- Sub mucous cleft

21. DAVIS & RITCHIE
• Group III-Alveolar clefts:
- Unilateral alveolar cleft
- Bilateral alveolar cleft
- Median alveolar cleft

22. VEAU Classification
• Group I (A) - Defects of the soft palate only
• Group II (B) - Defects involving the hard palate and soft
palate extending not further than the incisive foramen,
thus involving the secondary palate alone
• Group III (C) – Complete unilateral cleft, extending
from the soft palate to the alveolus, usually involving
the lip
• Group IV (D) - Complete bilateral clefts, resembles
Group III but is bilateral. When cleft is bilateral, pre-
maxilla is suspended from the nasal septum

23. Management
• Primary management
• Surgery
• Secondary management

24. Primary Management
Antenatal Diagnosis:
• Antenatal diagnosis of cleft lip U/L or B/L :
- US scan after 18 weeks of gestation
• Isolated cleft palate :
- Antenatal scan has no role
• Plastic surgery referral & counselling

25. Primary Management
Feeding :
• Most babies feed well
• Soft bottles
• Modified teats
• Feeding plates

27. Primary Management
Airway:
• Major airway obstruction uncommon
• During feeding and sleep
• Intermittant episodes – Prone nursing
• Persistant – Retained nasopharyngeal
intubation
• Labioglossopexy

28. Surgery
• Aims:
- Normal appearance of lip, nose and face
- Normal speech
- Dentition and facial growth within normal
range

29. Surgery
Millard Criteriae for cleft lip:
-10 months of age
- 10 weeks old
- 10gm % Hb
Cleft palate :
-10 kgs weight
- 10-18mths old
- 10gm% Hb

30. Principles of cleft lip repair:
- Proper pre-surgical skin markings
- Full thickness skin incisions
- 1: 200000 Adr
-Skin incisions developed to restore
tissues to normal position
-Ms continuity achieved by sub-
periosteal undermining over ant
maxilla
-Nasolabial ms anchored to pre-
maxilla
- Oblique muscles of orbicularis oris
sutured to the nasal spine
- Horizontal fibres of orbicularis oris
are sutured to achieve a functional
sphincter
- Three layer repair
- Horizontal Cupid’s bow
- Continuity of whiteline
- No vermilion notching
Principles of cleft palate repair :
- Mobilisation and re-
construction of aberrant soft
palate musculature
- Closure of hard palate with
minimal dissection and scar
formation
- O2 stage closure ensuring
physiological anrrowing of the
cleft

31. Timing of Surgery
Cleft lip alone :
- U/L: One operation at 3–6 months
- B/L :One operation at 4–5 months
Cleft palate alone :
Soft palate only : One operationat 6 months
Soft and hard palate:Two operations
- Soft palate at 6 months
- Hard palate at 15–18 months

32. Timing of Surgery
Cleft lip and palate :
• U/L : Two operations
- Cleft lip and soft palate at 5–6 months
- Hard palate and gum pad +/- lip revision at 15–18 months
• B/L : Two operations
- Cleft lip and soft palate at 4–5 months
- Hard palate and gum pad +/- lip revision at 15–18 months

34. Secondary Management
Hearing :
• Serous Otitis Media
• SNHL
• Early audiological assessment – 1 yr
• ABR & Tympanomometry
• Role of Myringotomy & grommet insertion

35. Secondary Management
Speech :
• Initial assessment by 18 months
• Velopharyngeal incompetence:
- Hypernasal speech
- Soft palate dysfn
• Articulation defects:
- Due to VP incompetence or poor dental occlusion
• Speech:
- Speech therapy and speech training devices

36. Secondary Management
Dental :
• Delayed development & eruption
• Abnormal morphology
• Hypo/hyperdontia
• Regular dental check up
• Flouride supplementation & use of fissure
sealants
• Dietary advice

37. Secondary Management
Secondary surgery :
• Orthodontic & orthognathic surgery
• Alveolar bone grafts
• Lip revision
• Rhinoplasty

38. THANK YOU