By:

Dr. Dwaika Prasad Bajgai

Layout
 Introduction
 Incidence
 Classification
 Embryological Background
 Etiology
 Diagnosis
 Problems of individuals with clefts
 Treatment of Cleft Lip and Palate
 Specialties involved in the treatment of Cleft Lip and Palate
 Timings of surgical repair
 Cheilorraphy
 Palatorrhaphy
 Alveolar Cleft Grafts
 Secondary Surgical Procedures
 Valopharyngeal Insufficiency
Introduction
What is Cleft Lip and Palate?
Congenital abnormal space or gap in the upper lip,
alveolus and palate
Incidence

More common in south far Asians:
1 in 500
Less frequent in Africans:
1 in 2000
Prevalence in Europeans and Americans:
1 in 750

*Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A.
Epidemiology of cleft lip and cleft palate in Pakistan. Otolaryngol Clin
North Am. 2007 Feb; 40(1):27-60
Incidence
Boys are more affected than girls by 3:2
Cleft Lip and Palate occur twice as often in boys as in
girls
Isolated Clefts of Palate are more often in girls
75% of Clefts are Unilateral, rest are Bilateral
Left side is more involved than right side
Embryological Background
Head and Neck of 4-Week Old Embryo

Glossopharyngeal
nerve
Vagus nerve

Trigeminal nerve

Facial nerve
Embryological Background
Development of the Lip:
 Unpaired Frontonasal
Prominence
 Medial and Lateral Nasal
prominences
 2 maxillary prominences
 2 mandibular
prominences
Embryological Background
Fusion defects can occur anywhere between these
prominences
The defect in the fusion between the frontonasal
and maxillary will lead to cleft lip
Embryological Background
Development of Palate:
 We have two parts of two different embryonic origins:
 1 ) primary palate : the triangular part of hard palate anterior to incisor foramen
which originate from the premaxilla ( frontonasal prominences).
 develop between 4th and 8th week of gestation
 2 ) secondary palate : remaining part of the hard palate and all soft palate
posterior to incisor foramen which comes from palatine shelves of the maxillary
prominences
 develop between 8th and 12th week of gestation
Embryological Background
 Various theories have been given for its
development.
1. Alteration in intrinsic palatal shelf force
2. Failure of tongue to drop down
3. Non fusion of shelves
4. Rupture of cyst formed at the site of fusion
Classification
We classify as the follows:
 its combined (cl+cp) or isolated cleft(cl or cp)?

 is it unilateral or bilateral?

 is it complete (if it cross the nasal philtrum) or

incomplete ( if it doesn’t cross the nasal
philtrum.
Classification Systems
 Lip

Alveolus

Primary
Palate
Hard Palate (Maxillary)

Hard Palate (Palatine)

Soft Palate

Karnahan’s Classification
Millard’s Modification of
Karnahan’s Classifcation
 L = Lip (right) Kriens “LAHSHAL”
A = Alveolus (right)
H = Hard Palate (right)
S = Soft Palate (median)
H = Hard Palate (left)
A = Alveolus (left)
L = Lip (left)

Capital letter = complete cleft

Lowercase letter = incomplete cleft
“.” or “-” = normal

Examples
LA….l = complete right cleft lip and alveolus,
incomplete left cleft lip
LAHS = complete right unilateral cleft lip, alveolus,
hard, and soft palate
Other

Types
Microform Cleft:
of Clefts
 May look like
 a little dent in the red part of the lip
 a scar from the lip up to the nostril.
 Muscle tissue underneath the cleft
can be affected and may require
surgery
 Submucous Cleft Palate:
 Midline deficiency or lack of
muscular tissue
 Often a submucous cleft palate is
associated with a bifid or cleft uvula
 Posterior nasal spine is almost always
missing
 Speech Problems are common
Prenatal

Diagnosis
Cleft lip can be easily diagnosed
by performing ultrasonography in
the second trimester
 Diagnosing a cleft palate with
ultrasonography is very difficult
 Three-dimensional imaging has
been introduced to prenatal
ultrasonography diagnostics of
cleft anomalies
Diagnosis
 Advantages of Prenatal
Diagnosis:
1. Time for parental education
2. Time for parental psychological
preparation
3. Opportunity to investigate other
associated anomalies
4. Gives parents the choice of
continuing the pregnancy
5. Opportunity for fetal surgery
Etiology
“Actually no one knows exactly what causes clefts”
Multiple factors may be involved, like:
 Genetics (inherited characteristic) from one or both parents
.
 Environmental factors
 Drugs: corticosteroids (anti-inflammatory), phenytoin
(anticonvulsant), retinoid.
 Infections: like rubella during pregnancy.
 Alcohol consumption, smoking, hypoxia during pregnancy,
some of dietary and vitamins deficiencies (like folic acid
and vitamin A deficiency)
 Maternal Age
GENETICS
CL/P
 Normal parents, one child with CL/P  4% risk CL/P in next child
 Normal parents, two kids with CL/P  9% risk CL/P in next child
 One parent CL/P, no affected kids  4% risk CL/P in next child
 One parent CL/P, one child CL/P  17% risk CL/P in next child
 Risk of CL/P in siblings increases with severity of deformity
 - child with unilateral CL  risk CL/P next child 2.5%
 - child with bilateral CL/P  risk CL/P next child 5.7%
CP
 Normal parents, one child with CP  2% risk of CP in next child
 Normal parents, 2 children with CP  7% risk of CP in next child
 Parent with CP, no affected children  6% risk for next child
 Parent with CP, one child with CP  15% risk for next child

• All infants with clefs must be evaluated for presence of other

anomalies
• Associated nomalies are more common in infants with isolated CP
 Nonsyndromic Cleft

Pierre Robin Sequence is the most

common associated nonsyndromic
anomaly
 is a relative term describing the small
size of the lower jaw ) and
Glossoptosis (is a medical condition
and abnormality which refers to the
downward displacement or retraction
of the tongue)
 Syndromic Cleft
Common Syndromes
Stickler (25% of syndromic CP) –
 autosomal dominant type 2 collagen gene
 Pierre Robin, ocular/hearing/joint malformations

Velocardiofacial (Shprintzen’s) – 15% of syndromic CP

 Autosomal dominant, variable expressivity, CATCH
22 – Deletions at 22q11,
 Facial, cardiovascular, immunologic, developmental
anomalies

Van der Woude’s (19% of syndromic CL/P and CP)

 Autosomal dominant
 CL/P or CP with bilateral lower lip pits
Problems Associated With Cleft Lip
and Palate
Feeding
Dental problems
Nasal Deformity and Esthetic Problems
Ear Problems
Speech Difficulties
Associated Anomalies
Feeding Difficulties
Cleft lip= makes it more difficult for an infant to
suck on a nipple
Cleft Palate= may cause formula or breast milk to
be accidently taken up into the nasal cavity
Inability to create negative pressure inside oral
cavity
Frequent regurgitations
Upper respiratory tract infections
Dental Problems
 Local Dental Problems:
 Congenitally Missing teeth, Hypodontia, Hyperdontia, Oligodontia
 Presence of natal and neonatal teeth
 Anamalies of tooth morphology like microdontia, macrodontia etc
 Fused teeth
 Enamel Hypoplasia
 Poor periodontal support, early loss of teeth
 Gemination, Dilacerations
 Orthodontics Problems:
 Class III tendency
 Anterior and Posterior Cross bite
 Spacing and crowding
Nasal Deformity and Esthetic
Problems
Facial Disfigurements
Poor nasal shape
Scar marks of surgeries
Poor lip function during speech
Poor dental alignment and smile
Ear Problems
Middle ear disease - 22% to 88%
Conductive hearing loss and chronic suppurative otitis
media may result
Repeated tympanostomy tube placement
Why do cleft kids have eustachian
tube dysfunction?
Abnormal curvature of the eustachian tube lumen
Cephalometric data - width and angulation of the
skull base with respect to the eustachian tube are
different
Abnormal insertions of the tensor and levator veli
palatini muscles into the cartilages and skull base
Palatal muscle dysfunction
Speech Problems:
Hearing loss hampers proper development of speech
Velopharyngeal Insufficiency (VPI)
Abnormal air
Poor pronunciation of Bilabial, Labiodental,
Linguoalveolar sounds
 Schedule of Treatment
Birth:
 Initial Assessment
8-9 Year:
 Initial interventional
 Pre-surgical assessment Orthodontics
 Preparation for alveolar bone
3 Month: grafting
 Primary Lip repair
10 Year:
9-18 month:  Alveolar Bone Grafts
 Palate Repair
12-14 Year:
2 Year:  Definite Orthodontics
 Speech assessment
16 Year:
3-5 Year:  Nasal Revision Surgery
 Lip Revision Surgery
17-20 Year:
 Orthognathic Surgery
Multidisciplinary Cleft Lip And
Palate Team
 Genetic Scientist
 Pediatrician
 Pedodontist
 Orthodontist
 Oral and Maxillofacial Surgeon
 Prosthodontist
 ENT Surgeon
 Plastic Surgeon
 Psychiatrist
 Speech Therapist
 Social Worker
Feeding
 Cleft lip= makes it more difficult for an infant to suck on a nipple
 use special nipples to allow the baby to latch properly (either
pump or use formula)

 Cleft Palate= may cause formula or breast milk to be accidentally

taken up into the nasal cavity
 don’t feed baby without palatal obturator (prosthetic palate)
 feed in an upright position to keep milk from coming out of
the nose
 Mead Johnson/Enfamil Cleft Feeder Special Needs Feeder /
Haberman Feeder

Pigeon Feeder Dr. Brown’s Natural

Flow to relieve gas
Presurgical Orthopeadics:
1. Reduces the size of cleft; Aids in Surgery
2. Partial obturation aids in feeding
3. Parental Reassurance at a crucial time

Maxillary Strapping
Nasoalveolar Moulding Appliances (NAM)
 Require orthopedic
repositioning of the nasal
cartilages, columella, nasal tip,
and lateral wall of the vestibule

 Presurgical infant nasal

remodelling  nasal molding

 Nasal molding by post surgical

nasal stenting

 Facial taping  2 to 3 months

BILATERAL CLEFT LIP
The most challenging condition
1. The premaxilla is extremely
protrusive

2. The premaxilla and

prolabium can be of
variable size

3. The columella is
deficient/almost
nonexistent

4. The palatal shelves are

collapsed
Protrusive maxilla 
imperative to be
repositioned

Premaxillary orthopedics
with inraoral aplliance

Denture adhesive

Elastic strap
Latham Appliance
Rule of Ten
 Primary repair- repaired at approximately 10 weeks
The surgeon usually uses the “Rule of Ten”
The child weighs 10 pounds
The child has a hemoglobin of at least 10 grams
The child has a white count of no higher than 10,000
The child is at least 10 weeks of age
Surgical Techniques
Cleft Lip Repair
 unilateral
 rotation-advancement
flap developed by
Millard
complications
 dehiscence
 infection
 excess tension
Surgical Techniques
Cleft Lip Repair
 bilateral
 bilateral rotation
advancement with
attachment to premaxilla
mucosa
Cleft Palate Repair - Timing
Dorf and Curtin
10% occurrence of articulation errors when palatoplasty
was completed by 1 year
86% incidence of articulation errors when repair was
complete after 1 year
Haapanen and Rantala –
Significantly fewer children in the groups repaired
before 18 months had hypernasal speech, articulation
errors, or required secondary surgery to correct speech
Cleft Palate Repair
Schweckendick’s Primary Veloplasty
V-Y Pushback
Von Langenbeck Palatal Repair
Furlow Palatoplasty
Cleft Palate Repair
Schweckendick’s Primary Veloplasty

Incisions made in soft palate

Muscle bundles released from the posterior hard
palate and rotated
Reconstruction of levator sling
Closure of mucosal layers separately
Cleft Palate Repair
V-Y Pushback (WARDILL OPERATION)

Two uni-pedicled flaps (greater palatine artery) and one or two

anteriorly based pedicled flaps
Posterior flaps rotated in a V-Y advancement technique -
increasing the length of the palate
Nasal mucosa not closed
Improved speech results compared with bipedicled techniques
Indicated for incomplete clefts
Von Langenbeck Operation:
Cleft Palate Repair
Furlow Palatoplasty

Lengthens the soft palate

Reconstructs the muscle sling.
Also commonly used to correct velopharyngeal insufficiency in
patients with submucous cleft palate
Speech outcomes are improved compared with other
palatoplasty techniques.
How

do you manage ear disease?
96% of children with cleft
palate required tympanostomy
tube placement
50% of these children required
repeat tympanostomy tube
placement.
Frequency of otitis media
decreases as the child with CP
ages
Audiology and tympanometry
as well as exams / clinical
history
Orthodontic Treatment of
Transitional Dentition
 The purpose the dentition adjacent to cleft has to
be orthodontically repositioned to prepare the
cleft side for the secondary alveolar bone graft
 Preparing the maxillary arch for a bone graft (6-12
months) :
1. Bonded edgewise appliance
2. Supported with a maxillary expander quad helix
expander
Alveolar Bone Grafting
Primary Bone Grafting
Bone graft done at the time of primary cheiloplasty
Bone graft done during the first 2 years of life
Bone graft done prior to the eruption of the primary
canine
Secondary Bone Grafting
Done before eruption of the permanent canine
Usually when the root of the canine is 1/3 to 2/3
formed
Usually between ages 8-10
In CLP dental age is usually behind chronological age
Quadhelix to expand prior to
ABG
angle brackets to keep roots away
from cleft
Alveolar Bone Grafting
1. Provide bone for the eruption and/or orthodontic
repositioning of teeth
2. Closure of oro-nasal fistulas
3. Support and elevation of the alar base
4. Stabilization of the pre-maxilla in bilateral cases
5. Provide continuity of the alveolar ridge
Types of bone grafts
 Autogenous
 Cancellous- iliac crest
 Cortical- calvarium, mandible
 Cortico-cancellous- iliac, rib, tibia, mandible
 *Allogeneic
 Graft resorbs, remodels, may contribute to osteoinduction and
osteoconduction
 **Alloplast
 Bone grows into, around alloplast
 No active osteoinduction but some osteoconduction
 Teeth do not erupt through alloplast

*Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary alveolar clefts in humans- A
preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987
**Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect in a primate model. J Oral
Maxiilofac Surg 47:946-952, 1989
Alveolar Bone Grafting
Alveolar Bone Grafting

Preoperative Cleft Defect Postoperative Bone Graft

Orthodontic Treatment For Permanent Dentition

•Correction of anterior
crossbite
•Arch expansion
Quad Helix
Expansion screws
Orthognathic Surgery
Midfacial Advancement
 LeForte osteotomies
 leave vascular pedicle
attached in back of
maxilla - prevents
necrosis
Rhinoplasty
Rhinoplasty Age =17-20
 standard techniques
 tip projection
 alar rotation
 columellar length
Surgical Management of
Velopharyngeal Insufficiency
Major Goals of Surgery
• Close the gap or hole between the roof of the
mouth and the nose.
• Reconnect the muscles that normally make the
palate work.
• Make the repaired palate long enough so that when
the muscles are working, the palate can perform its
function properly.
Velopharyngeal Insufficiency VPI
Wardill Operation: WY push back
Dorrance and Brown’s – U shaped push back
palatoplasty
Prosthetic Management of VPI
Thank You!