Cleft Lip and Palate

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Cleft Lip and Palate

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1. Cleft Lip and Palate Dr. T. R. Stevenson Division Head, Oral and Maxillofacial Surgery Faculty of Medicine and Dentistry University of Alberta

2. What is a Cleft? a fissure or elongated opening, especially one occurring in the embryo or derived from a failure of parts to fuse during embryonic development

3. Variations of Cleft Lip and Palate

4. Embryology Palate forms between 5th and 6th week Maxillary processes form maxilla and cheeks Palatal processes form hard and soft palate Lateral nasal processes form part of nose and upper lip Disruption in the fusion of any of the above processes can cause a cleft

5. Embryology

6. Incidence of Cleft Lip & Palate Most common oral-facial deformity 250,000 in North America Over-all incidence 1:600- 750 Native American 1:300 African 1:2000 Caucasian 1:750 Asian 1:500

7. Distribution of Cleft Lip & Palate Cleft lip 21% Cleft lip and palate 46% Males > females (2:1) Left > right > both (6:3:1) Cleft palate 33% females > males (2-4:1) Submucous clefts 1:1200

8. Famous People with Clefts John Henry (Doc Holliday) Tutankhamen Tad Lincoln Stacey Keach

9. Etiology of Cleft Lip & Palate Usually multifactorial: genetic and environmental Isolated deformity: CL&P 85%, CP 58% Disease of the mother Parental age, viral infections, emotional stress, ETOH, smoking, poor nutrition, GH deficiency Drugs Dilantin, accutane, aminophylline, diazepam, anti-emetics, opiates, ASA

10. Etiology of Cleft Lip & Palate Social class Lower socioeconomic level Inadequate prenatal care Genetic Factors Multifactorial Incidence varies among different racial groups Twins are higher in monozygotic than dizygotic Family history Associated with other syndromes

11. When Cleft Lip and Palate Occurs Most serious congenital abnormality to affect oral-facial area Can be catastrophic to parents and patient Need for an informed explanation and reassurance Initial appearance can be grotesque Feeding and swallowing difficulty Affects long term dental-facial growth Psychological problems Protracted therapy course, multiple operations to repair Speech therapy

12. Cleft Lip and Palate Early repair can mean happy youth and healthy social life In some countries not all patients have access to early repair Isolation Lack of education opportunities Lack of work opportunities Social outcasts

13. Psychosocial Issues: initial Must address from onset of care Birth of a child alone is a time of family adjustment Especially stressful with CL&P Parents express sadness, guilt, anger and fear Feeding difficulty, loss of ability to breast feed Concern of accessing professional & community services Financial concerns Stress of surgery and the unknown

14. Psychosocial Issues: longer term Concerns about teasing, peer acceptance Speech difficulties Can become introverted Increased risk of learning and behaviour problems Children become part of decision process Functioning in an appearance-conscious culture Fear of future surgeries High level of compliance needed for obturators, orthodontics, orthognathic surgery (burnout)

15. Cleft Team Members Plastic Surgeon Pediatrician Geneticist Speech Therapist/ Pathologist Oral and Maxillofacial Surgeon Pediatric Dentist General Dentist Orthodontist Social Worker Psychologist Audiologist Parents

16. Treatment Sequence CL&P Neonatal (first four weeks) First year Second year 2nd to 6th year 6th to 12th year 12th to 18th year

17. Treatment Sequence CL&P Neonatal (first four weeks) Pediatric and nursery care Parental involvement, education and counselling Treatment planning Dental obturator if required First Year Preparation for surgery Social and family planning Primary lip repair Dental, ENT and speech considerations

18. Treatment Sequence CL&P Second Year Primary cleft palate repair Speech and hearing evaluation Management of ear infections, myringotomy tubes Second to sixth year Pharyngeal flap, if required Dental evaluation and care ENT evaluation and care Educational assessment General care

19. Treatment Sequence CL&P Sixth to twelfth year Speech and hearing care Dental, prosthetic and orthodontic care Psychological, educational evaluation and intervention Esthetic, secondary surgery if indicated Alveolar cleft bone grafting Twelfth to eighteenth year Orthodontic and orthognathic therapy if indicated Cosmetic counselling Social counselling, vocational needs Group therapy Major restorative (prosthetics, implants etc.)

20. Treatment Outcomes

21. Treatment Outcomes

22. Surgical Phase

23. Surgical Phase

24. Operation Smile

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