Cleft Palate Flashcards
Define Cleft lip and palate
- Most common cranio-facial abnormality in human.
- 1 in 700 live births in UK
- CP often associated with syndromes
Incidence
- Unilateral CLP - 25%
- CP - 50%
- bilateral CLP - 10%
- CL - 10%
- Submucosa cleft 5%
Sex distribution Incidence
- Unilateral CLP male : female 2:1
- CP male : female 2:3
- CL male : female 2:1
Racial bias incidence
- Japanese > Caucasian > Afro Caribbean
- Unilateral clefts more common on left - L:R 2:1
- 15% cleft associated with other syndromes
CP is 15% associated Other syndromes like?
- Sticklers
- Van der Woudes
- Pierre Robin Sequence
- Downs
- Di George/ 22 q
Aetiology of CLP
- Unknown , Polygenic and multifactorial.
- Genetics - few single genes known e.g IRF 6 mutation leading to Van der woude syndrome. CL OR PALATE with lower lip pitting.
- Environmental e.g. Retinoids, anti folate drugs, temperature, hypoxia , seasonal, maternal smoking ( first trimester) , diet , Vitamin B6 deficiency .
Genetic risks
- Unaffected parents with 1 effected child:
Risk of next child being affected : CLP 1:25(4%) CP 1:80. - 1 affected parent :
Risk of first child being affected : CLP 1:50 (2%). - 1 affected parent and child :
Risk of second child being affected: CLP 1:10 (10%) - 2 affected parents
Risk of first child being affected: CLP 3:5 (60%)
CSAG - Clinical standard advisory group 1998
- 57 centres 50% operating <5 Clefts a year
- Outcome was poor , re organised
- managed clinical network
- South wales and south west
- Bristol and Swansea
- 100 new births per years
Overall care - Team Approach
Management involve many specialties.
- Corrective Surgery ( Plastics, OMFS - Oral maxillofacial surgeon.
- Speech (SLT)
- Hearing ( Audiologist, ENT)
- Dental ( Paediatric, Orthodontic, Restorative).
- Psychological
Prenatal diagnosis
- CL can be detected with ultrasound scanning but the palate is more difficult to detect.
- Due to head position and small size of the face not usually reliable until at least week 15 IU.
Time scale.
- 3/12 months Lip repair
- 6-9/12 palate repair
- 5 yrs Audit records
- 8-11 yrs Alveolar Bone graft
- 10 Audit records
- 15 Audit records
- 20 Audit records
Classification
- There are many e.g. Veau, Kernahan and Stark but it is easier to describe cleft.
- A - No cleft
- B - Celft lip
- C- unilateral complete Cleft lip and palate
- D- Bilateral Complete cleft lip and palate
- E- Cleft palate
Children with born with cleft palate have many problems which may include:
- Feeding- Cannot suckle because negative intra - Oral pressure cannot be created)
- hearing
- Speech
- Disruption of facial growth.
- Disruption of dental development
- Dental anomalies
- Dental caries
- Psychosocial
- morbidity and mortality associated with treatment
Feeding -
- Contact within 24hours
- Specialist nursing
- breast feeding rarely possible
- Use special soft bottle
- Sympathetic support
- Haberman - soft bottle
Dental issue
- Hypodontia
- Supernumaries
- Hypoplasia
- Microdontia
- Delayed eruption of teeth on cleft side
- increased incidence of ectopic canine.
- Increased incidence of impacted 6.
- Increased incidence of crossbite (19%).
- Dental caries - GDP preventative treatment is essential and should start in first year of life.
How to treat it?
- Lip surgery - usually at 3months
- Soft hard palatal surgery - Usually in the first year of life.
- Alveolar bone grafting ( Unites major and minor segments in clefts of lip and palate) - usually around age of 7-8 yrs. the graft also allows the canine to erupt in bone.
Lip repair
- 3/12 months
- Correct muscle layer
- Aesthetic
- Functional e.g. Millard , Delaire
Palate repair
- 6-9/12 months
- Close hard palate
- Velopharyngeal competence
- Function - speech
Orthodontic treatment
1- Pre surgical orthopaedic
2- Pre bone graft orthodontics
3- Orthodontic
4- Orthodontic with osteotomies
Pre- Surgical Orthopaedics
- Help with growth
- facilitate feeding
- Reduce gap aiding surgery
- Birth to 3 months / 6months
- Questionable benefit ?
Factors in cleft palate speech
- Nasal emission
- Nasal turbulence
- Hyper-nasality
- Nasal grimace
Speech cleft type characteristics
- Anterior error
- Posterior error
- Non oral error and passive error
2- Alveolar bone grafting -
- Alveolar defect
-Repair ONF - Alar base support
- One part of maxilla for Osteotomy
- Continuity of dental arch
- stabilise pre maxilla BCLP
- increase restorative options
Pre bone graft Orthodontics
- Expand upper arch laterally
- Correct anterior x bite
- Split incisors in BCLP patient
Donor site for bone grafting
- Iliac crest
- Tibia
- Mandible symphysis
- Cranium
- Rib
- Bio- oss (avoid).
Growth - South west
- 25% Osteotomies
- BCLP > UCLP
- Male > Female