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Oral Surgery > Cleft 11/26 > Flashcards

Cleft 11/26 Flashcards

1
Q

1925-1950?

A

designing a surgical procedure to establish better anatomic result

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2
Q

1960 to present?

A

emphasis placed on etiology

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3
Q

speech and swallowing function of? general

A

soft palate

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4
Q

submucous cleft

general

A

in the muscle

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5
Q

vascular deformaties within this scope

A

yes

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6
Q

incidence of cleft lip or cleft lip and palata

A

caucasian 1 in 1,000 births

blacks 1 in 2000

asains 1 in 500 births

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7
Q

incidence in cleft palate only

A

1 in 2000 births

isolated clefft palate is not ratiall influenced

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8
Q

is cleft palate only racial influenced?

A

no

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9
Q

incidence of clefting in USA

due to?

A

1 in 750 births

this is the overall ratio of clefts occurring in the USA

due to mixed gene pool

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10
Q

developing countries incidence

A

some locations increases to 1 in 350

involves different contaiminents

  • environmental and health issues
  • needs are greater
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11
Q

relative in family that has a cleft? incidence?

A

increases
the 750 incidence increases

genetic – incidence of future clefting is evident

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12
Q

palate alone with femal male

A

2:1
female to male

so female isolated palate

so female to male ratio is very different for the isolated cleft palate patient

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13
Q

incidence with genetics

A

less than 40% of CL alone or CL/P deformities are genetic origin

less than 20% of isolated CP deformatities are of genetic origin

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14
Q

NUTRIOTION ?

A

yes – FOLIC ACID DEFICIENCY – neural tube deformaties

food chain contaminatnts

  • insecticides – DDT
  • defoliants (agent orange)
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15
Q

NUTRIOTION ?

A

yes – FOLIC ACID DEFICIENCY – neural tube deformaties

food chain contaminatnts

  • insecticides – DDT
  • defoliants (agent orange)
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16
Q

etiology breakdown

A 
heredity 
parental age
maternal factors
nutrition
tetragogenic drugs
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17
Q

etiologc maternal factors

A

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

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18
Q

drugs involved in etiology

A

salicytates

cortisone

barbiturates

dilantin

benzodiazepines

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19
Q

at 8 weeks?

A

the cleft lip deformaty is complete

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20
Q

cleft lip and alveouls deformity complete at?

cleft palate deformity complete at?

A

cleft lip and alveolus = 8 weeks

cleft palate deformity = 11 weeks

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21
Q

feeding and airway concerns

general

A

early on these are big problems

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22
Q

implication on ear?

A

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 *

23
Q

with feeding what is a common problem?

how to manage

A

aspiration is a common problem

  • semi-upright position
  • soft lamb niples
  • enlarge nipple opening with an X
  • syringe or nasogastric tube (rare)
  • hyperalimentation (rare)
24
Q

manage at baby age of cleft patient

A

appliance
- passive - using an obturator

active
- orthopedic – appliance

25
Q

manage at baby age

A

appliance
- passive - using an obturator – closes the whole

active
- orthopedic – appliance

26
Q

orthopedic appliance because

A

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

27
Q

appliance technique

A

custom trey
impression technique with the guaze rap around

impression taken soon after birth

insert appliance within first 24 to 8 hours

28
Q

airway problem with these patients

A

usually only a problem in pierre robin patients

face down position
tongue/ lip adhesion surgery
nasogastric tube as an airway

tracheotomoy - try to avoid

29
Q

active appliance uses

A

orthopedic movement

  • fits on the alveolus
  • mechanically move it

regular remodeling needed to compensate for movement and growth

30
Q

latham appliance is a type of

A

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

31
Q

NAM

A

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

32
Q

NAM objectives

A

reduce the severity of cleft lip, nose, and alveolus prior to surgical repair

  1. approximate lip segments
  2. decrease nasal base width
  3. achieve convexity of nasal cartilages
  4. elongate the columella (of nose)
  5. approximate alveolar segments
33
Q

standard approach in surgical management

can do it when? start with?

A
  1. close lip at birth - rule of 10’s (10 weeks old 10 lb 10 grams hemoglobin) – can do the surgey
  2. close hard and soft palate at 18 months
  3. pharyngeal flap at 5 years for speech
  4. alveolar cleft bone graft prior to cuspid eruption at about 7-9 years
  5. orthognathic surgery 14-18 years old
  6. cosmetic surgery - 21 years (lip reversion, rhinoplasty, etc)
34
Q

after close lip?
next?
when?

A

18 months - close the palate

35
Q

primary goals for cleft lip surgey

A

establish good lip form

establish good lip function

restore nasal form

restore good facial contour

36
Q

primary goals of cleft palate surgery

A

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

37
Q

one sibling
one parent
sibling and parent for CL/P or CP

A

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

38
Q

male vs female with cleft lip or cleft lip/ palate vs cleft alone

A

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

39
Q

nutritional defomrity that is key in deformaties

A

folic acid - neural tube deformaties

40
Q

timeline in cleft lip or alveolus

A

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

41
Q

MNP gives rise to

A

lip, alveolus, and primary palate (CL/ ALV form at junction of MNP ad MP)

42
Q

formation of CL and ALV when?

A

ENTIRE PROCESS IS COMPLETE AT 8 WEEKS

43
Q

muscle layer of the lip comes from?

A

MESODERM - therefore the mesoderm must migrate under the epithelium to prevent the epithelium from breaking donw and forming a cleft

44
Q

mesoderm importtance and epithelium?

A

the MESODERM MUST MIGRATE COMPLETELY ACORSS TEH JUNCTION BETWEEN THE MNP AND MP at the 6-8 WEEK

so the MESODERM SOLIDIFIES THE JUNCTION

45
Q

cleft lip deformity at what stage? palate?

A

lip = 8 weeks in utero

palate = 11 weeks in utero

46
Q

formation of the palate and implication

A

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

47
Q

implication of ealy developmental deformity

A

nutrition is key

but may not even know pregnant at 8 weeks and 11 weeks

48
Q

confirmation of clefting

A

ultra sound can confirm – can notice this on the ultra sound

49
Q

non surgical care of cleft patient

A

MULTIPLE DISCIPLINE

  • genetic counseling
  • parental care
  • pediatrics
  • nutrition / feeding
  • audiology
  • speech pathology
  • orthodontics
50
Q

breast feeding?

A

YES - this works

- the breast obturates the cleft and allows for the sucking action

51
Q

millard technique aka and used for?

A

rotation and advancement flaps
- for cleft lip surgery

  1. mobilize skin, musle, and mucosa
  2. close in three layers without tension
    - mucosa, muscle over and skin
52
Q

implication of bilateral lip surgery

A

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

53
Q

palatal closure techniques

A
  1. von langenbeck - horshoe shaped oral layer flap
  2. push back tech

3 .furlow technique

  1. vomer flap
    procedure

need two layers in nose and mouth

soft palate - 3 layers - the two plus a muscle layer

54
Q

surgical closure of cleft palate technique

A
  1. identify the extent of the deformity
  2. identify usable tissue
  3. develop and mobilize flaps
    - 2 in hard palate (nasal and oral layers)
    - 3 in soft palate (nasl, muscle, and oral)
  4. reorient muscle in soft palate and close in layer without tension

Oral Surgery (26 decks)

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