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Cleft Case Chief Complaint Brief History (I) Present Illness

This document summarizes the chief complaint and medical history of a patient born with a cleft lip and palate. It notes that the patient underwent surgery for cleft lip as an infant and cleft palate as a child. On examination, residual issues were found including an alveolar cleft, occlusal discrepancies, possible velopharyngeal incompetence, nasal deformity, and maxillary hypoplasia. The provisional diagnosis reflects the history of cleft lip and palate surgery with these residual issues.

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ArchanaShenoy
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61 views

Cleft Case Chief Complaint Brief History (I) Present Illness

This document summarizes the chief complaint and medical history of a patient born with a cleft lip and palate. It notes that the patient underwent surgery for cleft lip as an infant and cleft palate as a child. On examination, residual issues were found including an alveolar cleft, occlusal discrepancies, possible velopharyngeal incompetence, nasal deformity, and maxillary hypoplasia. The provisional diagnosis reflects the history of cleft lip and palate surgery with these residual issues.

Uploaded by

ArchanaShenoy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Cleft case

Chief complaint

Brief History

(i) Present illness


 Patient was born in a
 Born by ------------- delivery
 h/o use of any medication during prenatal period by mother
 At birth patients parent noticed the child to be having a defect in
 Operated for cleft lip at -------- of age at
 Operated for cleft palate at ---------- of age at
 Any other surgery
(ii) Past Medical History
 Under went surgery as mentioned above
 H/O hospitalization as above
 Drug allergy
 H/O blood transfusion

(iii) Past dental History


 Orthodontic treatment
 Periodontal treatment
 Endodontic/ Conservative treatment

(iv) Personal History


 Deleterious oral habits
 Diet
 Para functional habits
 LMP

(v) Family History


 Both parents alive and healthy
 No h/o of similar type of problem in family
 Age of the parents at the time of birth

General Examination

 Built
 Gait and posture
 Motivated to seek treatment
 Signs of systemic illness viz. pallor, cyanosis, icterus, dyspnoea,
clubbing, or lymphadenopathy
 Vitals

Maxillofacial examination (Extra-oral examination)

Frontal analysis

 Facial form : ---------------------------- (H:W 1.33-1.35:1, Bigonial width is


30% less than Bizygomatic width)
 Transverse dimension OR 1/5 (Helix -Lateral canthus - Medial canthus -
Medial canthus - Lateral canthus - Helix) : Disproportion in ---------------
1/5
 Facial symmetry ------------------- (Glabella - Nasal bridge - Nasal tip -
Mid pt of philtrum – Dental midline – Pogonion ( Dental midline
coinciding skeletal )

 Vertical relations ( Trichion – Glabelle – Subnasal – Menton )


i) U1/3 rd ------
ii) M1/3rd-----------
iii) L1/3rd ---------
iv) L1/3rd : 1/3rd ( Subnasal – Stomion superioris)
v) L2/3rd ( Subnasal – Stomion inferioris)
 Scleral show ( M1/3rd)
 Cheek bone – Nasal base – Lip contour :
 Nasolabial groove--------
 Alarfacial groove-------
 Naso-orbital valley---------
 Upper lip length----------- (20+-2mm)
 Lower lip length--------- (40+-2mm)
 Ratio of ULL : LLL
 Upper vermillion border length-----
 Lower vermillion border length------ ( Normally 25% more)
 Interlabial gap:
 Incisal show:
 Occlusal canting ---------- Cranially/Caudally
 Chin puckering ( hypertonic mentalis)
 Mentolabial sulcus-----
 Interincisal mouth opening
 Mandibular movements
 Motor deficit:
 Path of closure:
 TMJ :
Eyes:
 ICD :
 IPD:
 Palpebral width
 Alar base coinciding medial canthus
 Corner of mouth coinciding Iris

Nose:
 Asymmetrical due to ---- alar slump
 Slumping of the alar dome ----- side
 Nasal base contour is distorted ------
 Nasal tip & mid line deviated ------
 Linear scar mark ----- ala
 Distorted columella ------
 Nasal tip projection (Glabella – Infratip break ------- % Infratip break –
Alar scroll) normally 55-60%
 Vertical ala columella relationship ( Infratip break – upper edge of
nostril : upper tip of nostril – base of nose)
 Columella lobule relationship (normally 2:1)
 Formation of isosceles triangle-------
 ------- Linear/oblique scar mark ----- ala
 Nasal dorsum ------ mm
 Nasal lobule ---- mm
 Nasal midline shifted to ----- by -----
Lips:
 Scar mark ----- upper lip
 Notching ------ upper lip
 Extent-----
 Direction------
 Thickness------
 Colour------
 Shape-------
Profile Anlysis

 Glabella : ----------------------
 Supraorbital projection: Normal, frontal bossing (5-10 mm beyond globe)
 Projection of nasal bridge ----- mm anterior to the globe ( 5-8 mm)
 Globe projection --------- (0-2 mm ahead of infraorbital rim)
 Globe projection ----- mm (8-12 mm ahead of lateral orbital rims)
 Soft tissue Profile type: -------------------------------
 Soft tissue Facial type: Posteriorly/ anteriorly divergent
 Nasal dorsum: straight/concave/convex
 Absence of supratip break
 Absence of infratip braek
 Columella : Straight / distorted
 Nasolabial angle : acute
 Protruded/ retruded lower lip (Upper lip 3+-1mm & Lower lip 2+- 1 mm
ahead of Subnasal pogonion line)
 Lower lip chin angle ( Normal is 130º)
 Cervicomental angle ------- (Normal is 110º)
 Chin throat distance---- mm ( Norla is 42+-6 mm)
 Retruded/protruded chin
 Proportionate upper & lower vermillion borders
 FMPA : increased / decreased
 Obtuse gonial angle increased
Speech
 Lisping
 th/ dh sounds
 Consonants m/ n/ ng
 Air escape while saying “pa pa pa”
 Velopharyngeal competence

Intra-oral examination

 Oral hygiene ---------


 Teeth present-------
 Occlusion : -----------
 Oblique linear cleft disrupting the continuity of the alveolus between
 Anched mucosa adjacent to labial frenum confirming to cusp of anterior
tooth
 Palatine rugae
 Uvula
 Scarring in soft palate
 Velopharyngeal defect
 Lesser segment in maxillary arch placed palatally
 Deep palatal vault
 Step between alveolar segment anterior & posterior (L)
 Distorted U shaped mandibular arch
 Tongue & buccal mucosa normal
 Oblique linear cleft disrupting the continuity of the alveolus between
 Bony discontinuity in the cleft region
 No bony support below the cleft
 Fibrous bands palpated
 Tongue & buccal mucosa normal

Provisional diagnosis

 Operated case of --------- cleft lip and palate with


1. Residual alveolar cleft
2. Oocclusal discrepency
3. Velopharyngeal incompetence
4. Nasal deformity
5. Maxillary hypoplasia

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