3. Introduction
• Cleft lip and palate is a congenital birth defect which is characterized by
complete or partial cleft of lip and/or palate.
• Cleft lip & palate is the second most common congenital anomaly.
• Not life threatening unless associated with other syndrome.
• First described by Hippocrates (400 BC).
4. Incidence
• The approximate incidence worldwide is 1 in 700 live births.
• Gender: Cleft lip is more common among males and cleft palate is more common
among females.
• Race: Mongoloids have the highest incidence about (4.9 / 1000), while Negroids
have the least incidence by (0.4 / 1000).
• Laterality: Unilateral = 80 %, Bilateral = 20 %.
• Side: Among unilateral clefts, clefts involving left side are seen in 70% of cases.
5. Embryological Background
• Development of facial structures starts at the end of 4th week by fusion of
5 facial prominences :
1. Unpaired frontonasal process.
2. Paired maxillary processes.
3. Paired mandibular processes.
6. Embryological Background
• Frontonasal process will form: frontal bone and covering soft tissue, nasal
bone and soft tissue, premaxilla and philtrum.
Premaxilla: is the central part of the maxilla that carrying the four incisor teeth.
Philtrum: is the median depressed part of the upper lip.
• The 2 maxillary processes will form the 2 maxillary bones and the lateral
sides of the upper lip.
• The 2 mandibular processes give rise to the 2 sides of the mandible and the
lower lip.
7.
8. Embryological Background
So that;
• The upper lip is formed
from 3 embryological
origins: frontonasal
process (gives the
philtrum) and 2 maxillary
process (give the lateral
parts of the upper lip).
9. Embryological Background
• The palate is formed also from three
embryological origins: frontonasal process
(gives the premaxilla), and 2 maxillary
processes (give the 2 palatine bones).
• Cleft lip and palate occurs due to failure
of fusion between one or more of these
processes.
10. Etiology
Genetic Disorders:
• Due to chromosomal defect.
• Increased incidence with positive consanguinity between parents.
Environmental factors:
• Maternal exposure to radiation.
• Malnutrition and folic acid deficiency.
• Viral infections (e.g. rubella virus).
• Drugs (e.g. Anti-emetics, Anti-epileptics, retinoic acid)
• Smoking and Alchol abuse.
11. Classification
Cleft Lip:
1- According to laterality :
A- Unilateral
B- Bilateral
2- According to length:
A- Complete (reach the base of the nostrils)
B- Incomplete.
12. Classification
Cleft Palate:
1- Cleft of the primary palate:
A-Unilateral
B- bilateral
2- Cleft of the secondary palate:
A- Cleft uvula
B- Cleft soft palate
C- Intermaxillary cleft
16. Diagnosis
(Prenatal Diagnosis)
• Advantages of prenatal cleft diagnosis:
1. Psychological preparation for parents to have realistic expectations.
2. Parent education for cleft management.
3. Preparation for neonatal care and feeding.
4. Opportunity to investigate other abnormalities.
5. Possibility of fetal surgery.
18. Diagnosis
(Postnatal Diagnosis)
• Cleft lip and palate is diagnosed by inspection on examination.
• The first presentation of the baby with cleft palate is repeated nasal regurgitation of
milk and repeated chocking.
• General examination of the baby to exclude other congenital anomalies.
• Investigations are done for the baby aiming at:
1. Diagnose other anomalies.
2. Diagnose associated complications.
3. Pre-operative Fitness assessment.
21. Complications
2- Chest problems
• Regurgitation of milk and fluids into the
nasal cavity associated with fluid
regurgitation in the airways.
• This leads to repeated attacks of bronchitis
and pneumonia.
22. Complications
3- Ear problems
• Fluid also may regurgitate through the
Eustachian tube to the middle ear that
leads to repeated otitis media.
• Repeated attacks of otitis media if not
treated well, may lead to hearing loss.
25. Complications
6- Speech problems
• Babies with cleft palate have a problem in articulation not phonation.
• Unable to pronounce the letters that depend on elevation of the soft palate.
• Nasal twang of speech.
Nasal twang may be permanent if the cleft palate is not corrected before the age
of 18 months.
26. Complications
7- Psychological problems
• Psychological stress is exerted not only over the child, but also over the
parents.
• Parents counseling is a very important step in the management.
27. Complications
8- Associated anomalies
• Other anomalies may be present in cases of cleft lip and palate and should be
searched for as early as possible as they may be life threatening:
• Ear and eye anomalies.
• Congenital heart diseases.
• Vertebral anomalies
• Renal anomalies.
• Limb anomalies.
• Mental retardation.
28. Complications
8- Associated anomalies
Associated Syndromes
• More than 100 syndrome may contain cleft lip and palate, the most common are:
1. Down’s Syndrome
2. Wardenburg’s syndrome
3. Vander Woude’s syndrome
4. Pierre Robin syndrome
5. Treacher collins syndrome
30. Management
(schedule for treatment)
1- Prenatal management:
• Complete history of gestation and maternal health.
• Genetic studies.
• Parent counseling and education.
• Psychotherapy and social workers.
31. Management
(schedule for treatment)
2- After birth to 3 months:
• Infant assessment
• Treatment of life threatening anomalies.
• Instructions of feeding.
• Pediatrician visits.
• Pre-surgical lip adhesion
32. Management
(schedule for treatment)
3- (3 months of age):
• Primary Surgical lip repair.
• After the role of 10 (10 pounds of Wt, 10
weeks of age, 10 gm./dl of Hg, and 10
WBC)
• Millard technique is the most widely used
(rotation-advancement flap).
33. Management
(schedule for treatment)
4- (9 to 18 months):
• Repair of the cleft palate.
• Von – Langenbeck palatoplasty is the most
commonly used procedure.
34. Management
(schedule for treatment)
5- (2 to 6 years):
• First orthodontic step for arch relationships, cross bites correction and
malocclusion.
• Speech therapy
• ENT - monitor the ear condition.
• Secondary repair of the lip (if needed).
