Cleft 11/26 Flashcards
1925-1950?
designing a surgical procedure to establish better anatomic result
1960 to present?
emphasis placed on etiology
speech and swallowing function of? general
soft palate
submucous cleft
general
in the muscle
vascular deformaties within this scope
yes
incidence of cleft lip or cleft lip and palata
caucasian 1 in 1,000 births
blacks 1 in 2000
asains 1 in 500 births
incidence in cleft palate only
1 in 2000 births
isolated clefft palate is not ratiall influenced
is cleft palate only racial influenced?
no
incidence of clefting in USA
due to?
1 in 750 births
this is the overall ratio of clefts occurring in the USA
due to mixed gene pool
developing countries incidence
some locations increases to 1 in 350
involves different contaiminents
- environmental and health issues
- needs are greater
relative in family that has a cleft? incidence?
increases
the 750 incidence increases
genetic – incidence of future clefting is evident
palate alone with femal male
2:1
female to male
so female isolated palate
so female to male ratio is very different for the isolated cleft palate patient
incidence with genetics
less than 40% of CL alone or CL/P deformities are genetic origin
less than 20% of isolated CP deformatities are of genetic origin
NUTRIOTION ?
yes – FOLIC ACID DEFICIENCY – neural tube deformaties
food chain contaminatnts
- insecticides – DDT
- defoliants (agent orange)
NUTRIOTION ?
yes – FOLIC ACID DEFICIENCY – neural tube deformaties
food chain contaminatnts
- insecticides – DDT
- defoliants (agent orange)
etiology breakdown
heredity parental age maternal factors nutrition tetragogenic drugs
etiologc maternal factors
hyperemsis – underlying medical problem
threatened abortion- underlying medical problem
measles
stress - endogenous cortisone release
smoking – pregnant women who smoke, and whose fetus carries a particular gene, may be increasing their chances that the baby will be born with a cleft palate
drugs involved in etiology
salicytates
cortisone
barbiturates
dilantin
benzodiazepines
at 8 weeks?
the cleft lip deformaty is complete
cleft lip and alveouls deformity complete at?
cleft palate deformity complete at?
cleft lip and alveolus = 8 weeks
cleft palate deformity = 11 weeks
feeding and airway concerns
general
early on these are big problems
implication on ear?
yes – eustachian tube openings
96% of all cleft children will have MIDDLE ear problem
- altered relationship b/w the tensor and levator muscles and the opening of the eustachian tubes
prone to fluid buildup and infections
cannot equalze pressure in middle ear
treat with placement of myringotomy tubes
hearing loss a real problem *
with feeding what is a common problem?
how to manage
aspiration is a common problem
- semi-upright position
- soft lamb niples
- enlarge nipple opening with an X
- syringe or nasogastric tube (rare)
- hyperalimentation (rare)
manage at baby age of cleft patient
appliance
- passive - using an obturator
active
- orthopedic – appliance
manage at baby age
appliance
- passive - using an obturator – closes the whole
active
- orthopedic – appliance
orthopedic appliance because
no teeth yet – to move the alveolus segment without the tooth yet
ACTIVE – MOVES SEGMENTS
- regular remodeling needed for all appliances to compensate for movement and growth
appliance technique
custom trey
impression technique with the guaze rap around
impression taken soon after birth
insert appliance within first 24 to 8 hours
airway problem with these patients
usually only a problem in pierre robin patients
face down position
tongue/ lip adhesion surgery
nasogastric tube as an airway
tracheotomoy - try to avoid
active appliance uses
orthopedic movement
- fits on the alveolus
- mechanically move it
regular remodeling needed to compensate for movement and growth
latham appliance is a type of
active
and fixed
can be unilateral or bilateral (can attempt to bring pre-maxilla back into place)
use pins and put into the maxillary palate
makes closing the whole in future surgeries easier because bringing the pieces closer together
NAM
nasoalveolar molding
- improve the nasal anatotmy and the alveoulus
active but removable
like the other ones but with nasal components
secured with to face with elastics and tape
sleeps and eats with it
change tape everyday
NAM objectives
reduce the severity of cleft lip, nose, and alveolus prior to surgical repair
- approximate lip segments
- decrease nasal base width
- achieve convexity of nasal cartilages
- elongate the columella (of nose)
- approximate alveolar segments
standard approach in surgical management
can do it when? start with?
- close lip at birth - rule of 10’s (10 weeks old 10 lb 10 grams hemoglobin) – can do the surgey
- close hard and soft palate at 18 months
- pharyngeal flap at 5 years for speech
- alveolar cleft bone graft prior to cuspid eruption at about 7-9 years
- orthognathic surgery 14-18 years old
- cosmetic surgery - 21 years (lip reversion, rhinoplasty, etc)
after close lip?
next?
when?
18 months - close the palate
primary goals for cleft lip surgey
establish good lip form
establish good lip function
restore nasal form
restore good facial contour
primary goals of cleft palate surgery
establish competent velopharyngeal (soft palate and pharynx function) mechanism
separate oral from nasal cavities - for improved speech and deglutition
improved eustachian tube function - to preserve hearing
preservation of facial growth - esthetics
allow for a functional occlusion / esthetic dentition
one sibling
one parent
sibling and parent for CL/P or CP
predicted increases in occurence rate of clefting in families where relatives have the deformity
one sibling and one parent lower than if sibling and parent
male vs female with cleft lip or cleft lip/ palate vs cleft alone
cleft palate alone = 2:1 female
cleftin alone is 20% male and 12% female
cleft lip /palate is 48% male and 20% female
basically the opposite for cleft palate alone with 2:1 female
these show 2:1 for male
nutritional defomrity that is key in deformaties
folic acid - neural tube deformaties
timeline in cleft lip or alveolus
MP starts medial movement at 5 weeks
at 6 weeks MP and MNP reach each other
LNP= superior to become alar of nose at 6 weeks
MNP gives rise to
lip, alveolus, and primary palate (CL/ ALV form at junction of MNP ad MP)
formation of CL and ALV when?
ENTIRE PROCESS IS COMPLETE AT 8 WEEKS
muscle layer of the lip comes from?
MESODERM - therefore the mesoderm must migrate under the epithelium to prevent the epithelium from breaking donw and forming a cleft
mesoderm importtance and epithelium?
the MESODERM MUST MIGRATE COMPLETELY ACORSS TEH JUNCTION BETWEEN THE MNP AND MP at the 6-8 WEEK
so the MESODERM SOLIDIFIES THE JUNCTION
cleft lip deformity at what stage? palate?
lip = 8 weeks in utero
palate = 11 weeks in utero
formation of the palate and implication
tongue lies between the two palatal shelves in utero
as head of fetus begins to straighten at about 10 weeks – tongue drops down
this allows palatal processes to meet in the midline with the VOMER
VOMER + 2 PALATAL PROCESS = TRIPARTITE mmetting and forms PALATE and is complete at 11 WEEKS IN UTERO
implication of ealy developmental deformity
nutrition is key
but may not even know pregnant at 8 weeks and 11 weeks
confirmation of clefting
ultra sound can confirm – can notice this on the ultra sound
non surgical care of cleft patient
MULTIPLE DISCIPLINE
- genetic counseling
- parental care
- pediatrics
- nutrition / feeding
- audiology
- speech pathology
- orthodontics
breast feeding?
YES - this works
- the breast obturates the cleft and allows for the sucking action
millard technique aka and used for?
rotation and advancement flaps
- for cleft lip surgery
- mobilize skin, musle, and mucosa
- close in three layers without tension
- mucosa, muscle over and skin
implication of bilateral lip surgery
NO MESODERM in the prolabium and therefore no muscle in this section
- the muscle turns superiorly and fuses with the piriform aperture
no muscle so big stretch involved to bring across
need to have muscle on one side attaching to muscle on the other side
palatal closure techniques
- von langenbeck - horshoe shaped oral layer flap
- push back tech
3 .furlow technique
- vomer flap
procedure
need two layers in nose and mouth
soft palate - 3 layers - the two plus a muscle layer
surgical closure of cleft palate technique
- identify the extent of the deformity
- identify usable tissue
- develop and mobilize flaps
- 2 in hard palate (nasal and oral layers)
- 3 in soft palate (nasl, muscle, and oral) - reorient muscle in soft palate and close in layer without tension
