This document provides information on cleft lip and palate, including definitions, classifications, embryology, problems, and management. It defines cleft lip and palate as an abnormal separation in oral-facial tissue that occurs due to incomplete formation during fetal development. Treatment requires a multidisciplinary approach from prenatal diagnosis through adulthood and aims to address functional, aesthetic, and developmental issues through procedures such as cheilorrhaphy, palatorrhaphy, and alveolar bone grafting. Successful management of cleft lip and palate patients presents ongoing challenges due to the variety of impairments and extended treatment time required.

1. Cleft Lip and Palate
Dr.Chahat puri
Intern (H.D.C)
Sundernagar.(H.P.)

2. Contents
 Introduction
 Definition
 Incidence
 Etiology
 Embryology
 Classification
 Problems
encountered
 Management

3. Introduction
 Orofacial clefts are the most common oro-
facial anomaly in newborn infants and the
second commonest congenital abnormality.
 Affecting approx one in every 800 births
worldwide
 Non “life-threatening” abnormality,
 Can have significant effect on maternal
bonding.
 A small proportion of oro-facial clefts may be
associated with a genetic syndrome .

4. Definition
 A cleft lip or palate
is an abnormal
separation in the
oral-facial region
that happens
because tissue of
the mouth or lip
does not form
correctly in fetal
development.

5. Incidence
 For Clefts affecting the Lip only or Lip and
Palate (CL[P]), males are more commonly
affected than females (approx 2-1).
 Clefts palate alone (CP) is found in approx
1 in 2000; females are more often affected
than males.
 CL[P] varies between different ethnic
populations.

6. Etiology / Causes
 1.GENETIC:-
 Mutated Inherited Genes (gene=top,
mutation=bottom)
 2.ENVIRONMENTAL:-
 Teratogens :-Known risk in taking
certain types of drugs during
pregnancy .
 Link to maternal smoking.
 Alcohol use.
 Debate on the role of folic acid.
 3.OTHER SYNDROMES:-
 Stickler’s syndrome,
 Patau and Down syndrome

7. Embryology
 Primary Palate- Triangular area of hard
palate anterior to incisive foramen to point
just lateral to lateral incisor teeth
 Includes that portion of alveolar ridge and
four incisor teeth.
 Secondary Palate- Remaining hard palate
and all of soft palate

8. Embryology
 Primary Palate
 Forms during 4th to 7th week of Gestation
 Two maxillary swellings merge
 Two medial nasal swelling fuse
 Intermaxillary Segment Forms:
Labial Component(Philtrum)
Maxilla Component(Alveolus + 4 Incisors)
Palatal Component(Triangular Primary
Palate)

9. Embryology
 Secondary Palate
 Forms in 6th to 9th weeks of gestation
 Palatal shelves change from vertical to
horizontal position and fuse
 Tongue must migrate antero-inferiorly

10. Cleft Formation
 Cleft result in a deficiency of tissue
 Cleft lip occurs when an epithelial bridge fails
 Clefts of primary palate occur anterior to
incisive foramen
 Clefts of secondary palate occur posterior to
incisive foramen
 Secondary Palate closes 1 week later in
females
 Cleft of lip increases likelihood of cleft of palate
because tongue gets trapped.

11. Unilateral Cleft Lip
 Nasal floor communicates with oral cavity
 Maxilla on cleft side is hypoplastic.
 Columella is displaced to normal side
 Nasal ala on cleft side is laterally, posteriorly,
and inferiorly displaced
 Lower lat on cleft side -lower, more obtuse
 Lip muscles insert into ala and columella.

12. Palatal Clefts
 Soft palate muscles insert on posterior
margin of remaining hard palate rather
than midline raphe.
 Associated Dental Abnormalities
 Supernumery Teeth- 20%
 Dystrophic Teeth- 30%
 Missing Teeth- 50%
 Malocclusion- 100%

13. Classification
 DAVIS AND RICHIE (1922) ON ANATOMICAL
BASIS:-
 Group I- Pre alveolar clefts
(unilateral , bilateral and median.)
 Group II- post alveolar clefts
 Group III- complete alveolar clefts.
(unilateral , bilateral and median.)

14.  VEAU (1931) CLASSIFICATION:-
 Group I:-clefts of soft palate only.
 Group II:-clefts of hard & soft palate.
 Group III:-complete unilateral cleft.
 Group IV:-complete bilateral alveolar
clefts.

16.  KERNAHAN’S CLASSIFICATION

17.  FOGH ANDERSON CLASSIFICATION
(1942):-
 Divided into
Group – 1:-
• LIP
• Unilateral
• Bilateral
Group – 2:-
 Lip + palate
 Unilateral
 Bilateral
Group – 3:-
• Palate extending upto the incisive foramen.

18. Of those with CL[P]…..
approx 30% involved the lip+/-alveolus, and
70% involved lip and palate
GMC JAMMU

19. Of those with CP.....
approx 30% involved the soft palate only
and 70% involved hard and soft palate

20.  LAHSHAL CLASSIFICATION:-
 Given by Okriens in 1987.
L : Lip
A : Alveolus
H : Hard Palate
S : Soft Palate
H : Hard Palate
A : Alveolus
L : Lip
 Based on the fact that cleft of lip, alveolus and
hard palate can be bilateral and clefts
involving soft palate are usually unilateral.

21. Symptoms
 Separation of the
lip (picture)
 Separation of the
palate (roof of the
mouth)
 Nasal distortion
 Recurring ear
infections

22. Symptoms (cont.)
 Failure to gain
weight
 Nasal regurgitation
when bottle feeding
 Poor speech
 Misaligned teeth
 Growth retardation
(picture)

23. PROBLEMS ASSOCIATED
 Ear infections
top picture (right=normal,
left=infected)
 Hearing loss
 Dental cavities
 Displaced teeth (bottom
picture)
 Poor speech
 Lip deformities
 Nasal deformities

24. Cleft Lip and Palate patients present a multitude
of problems:
Functional Impairment
• Feeding problems:-Suckling and
Swallowing
• Speech
• Hearing
• Malocclusion
• Respiratory infections
• General physical development
• Mental development.

25. Aesthetic Compromise
• Physiological
implications
• Sociological
implications

26. DIAGNOSIS.
 ULTRASONOGRAPHY IN
PREGNANT FEMALES MAY
REVEAL THE PRESENCE OF
CLEFTS.

27. Ultra Sound at 18th Week
of Pregnancy

28. MANAGEMENT
 Successful treatment requires a MULTI
DISCLIPLINARY APPROACH
 Starts with antenatal diagnosis and continues
till adulthood.
 NORTHERN AND
YORKSHIRE CLEFT
LIP AND PALATE
SERVICES CRITERIA.

29. MANAGEMENT PROTOCOL
 BEFORE BIRTH:-ANTENATAL
DIAGNOSIS,ULTRASONOGRAPHIST AND
OBSTETRICIAN.
 IMMEDIATELY AFTER BIRTH:-PAEDRIATIC
CONSULATION,COUNSELLING,FEEDING
INSTRUCTIONS.(PRE SURGICAL
ORTHOPEDICS)
 BIRTH-5 WEEKS:-MULTIDISCIPLINARY
MEETING.
 6-10 WEEKS:-CLEFT LIP REPAIR,2-3 DAY
STAY,MILLARD RULE OF 10,REMOVAL OF

30.  12-16 WEEKS-REVIEW AND POST OP,
ENT
ASSESSMENT.
 6-18 MONTHS-SURGICAL REVIEW.
 18 MONTHS – 6 YEARS:-ENT AND PEDIATRIC
,DENTAL ASSESMENT.
 6-12 YEARS:-LATE PRIMARY / EARLY MIXED:-
ENT,ORTHODONTIST,PEDODONTIST,
PLASTIC SURGEON,PSYCHOLOGIST.
 12-18 YEARS:-LIP
REVISION,RHINOPLASTY,OSTEOTOMY,DENT
AL IMPLANTS.
 20 YEARS:-LOCAL COLLECTION AND FULL

31.  STAGE OF TREATMENT:-
 NEONATAL PERIOD-immediate counselling,
feeding , pre surgical orthopedics ,lip repair
,palate repair.
 TODDLER PERIOD:-speech therapy ,
hearing/ear infections.
 GRADE SCHOOL PERIOD:-orthodontic
management , ABG ,psychological growth.
 TEENAGE PERIOD:- orthognathic surgeries,
Rhinoplasty.

32. Pre surgical plates, moulding
plates, feeding plates…….
Dr. Christine Underhill 12th July 2008

33.  TREATMENT
 Primary management:-
Primary management is done by:-
• Millard rotational flap
• Langenback’s operation
• Wardill’s operation
Cleft palate only:-
• Soft palate only- one operation at 6
months
• Soft palate & hard palate -two operation
soft palate at 6 months  hard palate
at 15-18 months.

34. 
 Cleft palate and cleft lip:-
• Unilateral:- 2 operation:-
• Cleft lip an soft palate at 5-6 months.
• Hard palate and gum pad with or
without lip at 15-18 months.
• Bilateral:- 2 operation:-
• Cleft lip and soft palate at 4-5 months.
• Hard palate and gum pad with or
without lip at 15-18 months

35. Cheilorrhaphy
 Surgical correction of cleft lip deformity.
 Early operative procedure used to correct cleft
deformities.
 Cleft lip disrupts the important circumoral
orbicuralis oris musculature.
 Objectives :-1.Functional-restore normal
function and arrangement of muscle.
 2.Esthetic.-normal anatomic
structures,cupid bow and philtrum.

36. Surgical technique
 Different for different types of clefts.
 In unilateral cases,unaffected side serve as a
guide for lip length and symmetry.
 Lips closed in linear fashion.
 Restore symmetry not only to lip but also to
the nasal tip.
 First and the most important steps in
correcting nasal deformity.

37. A

38. Palatorrhaphy
 Performed in one operation,but occsaionally
performed in two also.
 Two operations:-soft palate closure
(staphylorrhaphy) performed first followed by
hard palate closure(uranorrhaphy).
 OBJECTIVES:-speech and degluttion
correction.
 Surgical techniques includes:-Hard palate
closure
 Soft palate closure.

39. Hard palate closure(Von
langenbeck operation)

40. Variations of langenbeck

42. Triple layered soft tissue
flap

43. Wardill operation

44. Alveolar bone grafting (ABG)
 Provides continuity of alveolar ridge.
 Provides bone for canine to erupt .
 Osseous support for adjacent teeth
 Majority of canines erupt spontaneously…
others require surgical exposure often in
combination with orthodontics.
 The erupting teeth often appear to then
stimulate the formation of new alveolar bone

45. Secondary surgical
procedures.
 Performed after initial repair of cleft defects in
an effort to improve speech or correct residual
defects.
 Commonly used technique to improve
velopharyngeal competence secondarily is the
palatal flat procedure.
 Another technique is the placement of an
implants behind the posterior pharyngeal wall
to bring it anteriorly.

46. Conclusion
 Cleft Lip and Palate are common congenital
deformities that often affect speech, hearing,
and cosmesis; and may at times lead to airway
compromise.
 Oro facial clefts require a multidisciplinary
approach
 Treatment extends over many years and risks
exhausting patient cooperation
 Need to keep the patients best interests in
mind…

47. THANK YOU