CLEFT LIP AND

PALATE

Literature Reading
Anne Indrawati

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Introduction
The most congenital malformation of the head
and neck
Evaluation and management require a long-
term comprehensive and multidisiplinary
program
Have numerous associated problems
Cleft lip with/without C P 1:1000 1 :2000
-In native americans 3,6/1000 birth &
- in Asians, whites and black 0,4/1000 birth

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In Cleft palate is constant among ethnic group
Sex ratio: Male :female
Cleft Lip with or without 2 : 1
Cleft Palate (isolated) 1:2
Prevalence of cleft in cleft population is as
follow: 45% cleft lip, alveolus and palate
25% cleft lip only or lip and alveolus
30% cleft of secondary palate

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Introduction

Can be subcatategorized as syndromic and non

syndromic
The etiology of syndromic clefts may be single
gene transmission (mendelian inheritance) ,
chromosomal aberrations (trisomi,deletions or
tranlocation), teratogenic (talidomide,etanol),
and enviromental (maternal diabetic melitus)

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Embriology

Normal embriologic : 2 Phase

o I 4 5 weeks gestation
upper lip,nose and primary palate or premaxilla
(anterior incisive foramen)
o II 8-9 weeks gestation
Secondary palate(posterior foramen)

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 Embriology

Malformation cleft on anterior (lip

and alveolus) or cleft on posterior
(secondary palate only), or both of them
The classic submucous cleft of the
soft palate (bifid uvula, midline
diastasis of levator m.,loss of posterior
nasal spine or notching)

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Embriology

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Embriology

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Embriology

Understanding cleft embriologies allows an

understanding of cleft clasiffication
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Classification

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 ANATOMY

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ANATOMY
Greater Palatine foramen:
-a greater palatine artery
-a greater palatine nervus

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Anatomical Deformity & Facial Growth
1 Cleft Lip Deformity
A.Defect in Unilateral Cleft Lip
Depens on degree of the cleft, the orbicularis
oris muscle, blood supply and innervation
INCOMPLETE muscle fiber are intact (hypo-
plastic across the width of the cleft)

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Anatomical Deformity & Facial Growth
DEFECT: (for COMPLETE)
1. The orbicularis muscle is oriented
upward,parallel to cleft margins, and the
orbicularis sfingter is disrupted
2. The maxilla is hipoplastic on the cleft side
3. The nasal ala on cleft side is
inferioly,posteriorly and laterally displaced
4. The collumella is displaced to the cleft
side
5. The medial crus is shorter and the lateral
crus is longer on cleft lower lateral
cartilage (LLC)
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 Anatomical Deformity & Facial Growth
6. The dome on the cleft side is lower, resulting in alar
flattening and horizontal nostril shape

7. The alveolar defect passes through the developing

dentition

8. The nasal floor is absent

9. The caudal septum is deviated to the non cleft side

and there is an obstructing septal spur on the cleft
side

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 Anatomical Deformity & Facial Growth
B.Defect in Bilateral Cleft Lip:
1. Muscle fibers are absent in prolabial segment
2. The levator palatini muscles is primarily responsible
for elevating the palate
3. The vermilion is absen in prolabial segment
4. The prolabial segment has
disminished blood supply
5. The prolabium is under
develop vertically and over

develop horizontally
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Anatomical Deformity & Facial Growth

6.The columella is short

7.The nasal floor absent bilaterally

8.The central portion of alveolar arch is displaced

anterioly and superiorly

9.The premaxilla is mobile

10.The nasal tip is widened

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Anatomical Deformity & Facial Growth
2. Defect in Cleft Palate

1. The velopharyngeal sling is disrupted;the muscle

insert into the medial margin of the cleft and
posterior hard palate
2. The cleft may involve only the soft palate, the
hard palate (secondary palate),or the complete
primary and secondary palate.
3. The nasal and oral cavity comunicated freely,
resulting in velopharyngeal insufficiency.
4. A submucous cleft palate may be difficult
diagnose
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Anatomical Deformity & Facial Growth
The classic physical finding are :
Zona pellucida (hyperlucent gray area in midline soft
palate),Bifid uvula,Notch in posterior hard palate
Nasopharyngoscopy during speech is the most
sensitive diagnostic tool

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Anatomical Deformity & Facial Growth

3. Facial Growth
The facial skeleton is frequently deformed
in patients with cleft lip and palate
Collapse the alveolar arches, midface
retrussion and resultant malocclusion
There is controversy regarding the
relationship between surgical procedures
and maxillary growth in term of the
sequencing of surgical effect on
maxillofacial growth, the various surgical
tehniques and experience
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 Protruding premaxilla;
collapse alveolar arches

Previously repair cleft lip

and palate; reduce midface
growth

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Management
General Phylosophy
1. The care of cleft is complex and should be
coordinated cleft team
2. Counseling of parents
3. Feeding difficulties
4. Airway issues may required early management
5. Speech problems are found in 25 %
6. Cleft palate is associated with COME ( 95%)
7. Patient with CL+/-P will required surgical
procedures throughout their childhood and
into adolescense
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Management Early Presurgical Treatment
Feeding plate Preoperative orthopaedic

The feeding plate functions

simultaneously as an orthodontic
treatment device: realigment of
the maxillary segments and molding
of alveolar arch
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Management Preoperative diagnostic
General Examination candidate for surgery,
checking for evidence of an infection, deficience
vitamin
Anatomical factors (Unilateral/bilateral,
complete/incomplete, etc)
Standart photographic views (face from the front,
intra oral views of maxillary arch)
Radiographic examination (upper jaw in patients
with bilateral and bilateral total cleft)
Jaws model
Timing & Technique
for repair
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Timing for CLEFT SURGERY

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Management SURGICAL REPAIR
Characteristic Natural Lip

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 Management SURGICAL REPAIR
Cleft Lip Repair
Ideally, the operation should be design to meet
following criteria:
1. Accurate approximation of skin, muscle, and mucosa
2. An inconspicuous scar.
3. Symmetric lip length.
4. Creation of a symmetric Cupids bow
5. Creation of a philtrum dimple,and a labial sulcus
6. Symmetric nostril and collumella
7. Easy adaptability of the procedure to various cleft
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Management SURGICAL REPAIR
LIP ADHESION
A Lip adhession convert a complete cleft into an
incomplete cleft lip, allowing the definitive lip
repair.(2-4 weeks of age)
Indication :
1. Wide unilateral complete cleft of lip,alveolus, and
palate with initial closure by convensional might
produce undue tension on suture lip
2. Symmetric wide bilateral complete cleft with an
extremely protruding premaxilla
3. To introduce symmetry to ansymmetryc bilateral
cleft lip.

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Advantages :
- Convert complete to incomplete cleft
- Improves alveolar arch alignment
- Posible prolabial growth
- Assist with feeding
- Psychologic benefit to parents

Disadvantage:
- Increased scar tissue
- Additional operation

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 Management Surgical technique
Unilateral Lip
adhesion

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Management SURGICAL REPAIR
Bilateral Lip adhesion

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Management SURGICAL REPAIR
Cleft Lip Repair
Timing:
1.Traditional-10 weeks
(rule of ten)
2.early repair 4-6weeks

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Management SURGICAL REPAIR
Cleft Lip Repair

If no medical contraindication, and lip adhesion

has not been performed previously, definitive
repair 10-14 weeks of age (In USA : Rule of
Ten)
The Millard Rotation advancedment rotates the
medial lip segment downward and advanced the
lateral lip segment (Most commmon repair in USA)

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Management SURGICAL REPAIR
Cleft Lip Repair
The Tennisan Randall triangular flap utilizes a
lateral, inferior based triangular flap and z-
plasty transposition
Advantages include utility with wide cleft and
minimal discarding of tissue
Disadvantages include Z shaped scar and lack of
flexibility with need for precise measurements
Initial treatment of nasal deformity should
occur at time of primary cleft repair (primary
rhinoplasty)

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Management SURGICAL REPAIR
Unilateral Cleft Lip Repair ( Complete)
Rotation Advanced Method- Millard

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Management SURGICAL REPAIR
Unilateral Cleft Lip Repair

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 Millard rotation- Advancement
Repair

Advantage Disadvantage
Flexible Requires experience surgeon
Minimal tissue discarded Possible excessive tension
Good nasal access Extensive underlining required
Camouflaged suture line Vertikal scar contraktur
Tendency to small nostril

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Management SURGICAL REPAIR
Unilateral Cleft Lip Repair

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 UNILATERAL CLEFT LIP REPAIR
TENNISON-RANDALL'S DESIGN

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Management SURGICAL REPAIR
Bilateral Cleft Lip Repair

1. The goals surgical repair identical to

those in unilateral cleft
2. The bilateral cleft can be closed in a single
procedure, which offers the following
advantages : increased lip and nasal
symmetry, mucosa lined labial sulcus, good
orbicularis oris muscle function

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 Management SURGICAL
REPAIR
Bilateral Cleft Lip Repair
3.The bilateral defect can be repair in
stages : widest cleft repaired first,
second cleft repaired several months
later, Staged repair result in poor
orbicularis oris muscle function, Lip can
eventually be to long,Trifurcation scar
beneath collumella is difficult to
camouflage

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Management SURGICAL REPAIR
Bilateral Cleft Lip Repair

Required two stages if there is asymmetric bilateral

cleft lip (rotated premaxilla). Sometimes need
presurgical orthopedic before definitive repair
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Management SURGICAL REPAIR
Bilateral Cleft Lip Repair

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Management SURGICAL REPAIR
Bilateral Cleft Lip Repair

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Management SURGICAL REPAIR
Cleft Palate
Repair

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 Management SURGICAL REPAIR
Timing Operation :
Consider the effect for : speech,maxillofacial
growth, occlusion, and anatomical factor.
The Anatomical factors are: Cleft type, width,
degree of protrussion of premaxilla-prolabial,
collaps alveolar,etc

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Management
Cleft Palate Repair

Many methods for

PALATOPLASTY
Selected case

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Management SURGICAL REPAIR
Palatoplasty technique

The Schweekendiek two stage repair closes the

sof palate cleft and leaves the hard palate cleft
for obturation with a prothesis until delayed
closure at 4 to 5 years. Minimal disturbance of
facial grwoth. Requires frequent chages of
prothesis. Result in significant speech disorder if
not properly obturated. Not frequently used. 52
Management SURGICAL REPAIR
Palatoplasty technique

Von Langenbacecks palatoplasty advances bipedicle

mucoperiosteal flaps : Easy to perform,Decreased
denuded palatal bone, does not provide increased
palatal length
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Management SURGICAL REPAIR
Palatoplasty technique

V-Y Push Back Palatoplasty retrodisplaces two

posteriorly based mucoperiosteal flaps by a V to Y
closure techq: Lengthens the palate, Leaves a large,
raw palatal surface
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Management SURGICAL REPAIR
Palatoplasty technique

Two Flap Palatoplasty (Bardach) utilizes two

posterioly placed mucoperiosteal flap that extend to
the alveolar cleft. Good for complete cleft of
palatal/alveolus
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Management SURGICAL REPAIR
Palatoplasty technique

The Furlow Palatoplasty utilizes a double reversing Z

plasty of musculomucosa and mucosa only flaps to
repair the palatal cleft. Usually used for submucosal
or soft palate cleft. Good speech results with proper
muscle aligment. Dificult for wide cleft
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Management SURGICAL REPAIR
Unilateral Cleft Palate

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Management SURGICAL REPAIR
Unilateral Cleft Palate Repair

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 Management SURGICAL REPAIR
Unilateral Cleft Palate Repair

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Management SURGICAL REPAIR
Bilateral Cleft Palate Repair

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Management SURGICAL REPAIR
Cleft Palate Repair

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Management SURGICAL REPAIR
Cleft Palate Repair

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Further Management
Associated problems :
1. SPEECH : VPI, Fistula
- Generally avoided for aproximately 6-12
months after repair 80% good speech
production

Diagnosis of Velopharyngeal Insufficiency

- VPI result in hypernasal speech and nasal
escape in CP even after repair

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 Treatment VPI:
-Initial speech trainning
-Failure of speech th/ (6-12 months) a
dental obturator or surgical procedure
-Pharyngeal implants and rolls can create an
artificial passavants ridge( Inj of
Teflon paste)
-Pharyngeal flap utilizes a posterior
pharyngeal mucosa/muscle flap to create
two lateral ports (ideal in patients with
good lateral wall motion and poor AP
motion)
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Treatment VPI:
Timing : 6 or 7 years of age (after an
adequate period of intensive speech
theraphy and full evaluation)
Need Tracheostomy

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Further Management
Pharyngeal flap
Post op : liquid diet for
3 weeks.
Operative risk :
Bleeding from donor site
Stenosis of lateral airway
portals

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Further Management Pharyngeal flap

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 Fistula
Nasolabial fistula
-Local mucopriosteal flaps
(+/- bone graft)
-Delayed until afterchilds
permanent incisors have
fully errupted

Oronasal fistula

- Closed surgical (two flaps)

- Obturator
- soft dental wax 68
Further Management

2. OTOLOGIC DISSEASE
1. Virtually all patients with cleft palate have
middle ear disease
2. The incidence of middle ear disease decreases
with age
3. Factor contributing to eusthachian tube
dysfunction in CP include :
ineffective tubal, dilatatation of tensor veli
palatini secondary to muscular hypoplasia and
malposition and Nasoharyngeal reflux and
contamination
4. Ventilation tube are placed
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 HIGHLIGHT

Cleft lip and palate are the most common

congenital malformations involving the head and
neck, and a cleft palate team approach best
provides long-term multidisciplinary management.
Cleft lip and palate occurs in 1 of 1,000 births;
cleft palate alone occurs in 1 of 2,000 births.
Clefts occur in children with recognizable
syndromes or as an isolated deformity
(nonsyndromic)

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 HIGHLIGHT

Complex genetic and environmental

interactions are present in most
nonsyndromic clefts.
Lip and palate embryologic development
occurs in two phases: the first beginning at
4 to 5 weeks (lip, nose, premaxilla) and the
second beginning at 8 to 9 weeks
(secondary palate).

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 HIGHLIGHT

The relative prevalence of cleft types

include complete cleft lip, alveolus, and
palate, 45%; cleft lip with or without cleft
alveolus, 25%; and clefts of the secondary
palate only, 30%.
Critical psychosocial and nutritional issues
should be addressed in the neonatal period
or even prenatally.

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 HIGHLIGHT

The rule of tens is used to determine

suitable age for lip repair: the infant is at
least 10 weeks old, weighs about 10 pounds,
and has a hemoglobin of 10 g.
Cleft palate repair is usually performed at
8 to 12 months of age as long as the child is
gaining weight and growing in a normal
fashion.

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 HIGHLIGHT

In many cases, ongoing evaluation and

management are needed and determined by the
cleft palate team members. This can include
surgical correction of secondary lip and nasal
deformities, dental and orthodontic care, speech
therapy (for both treatment and assessment for
articulation errors, compensatory errors, and
velopharyngeal incompetence), routine otologic
and audiologic care, and orthognathic surgery

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 Celah bibir dan palatum

Labioskisis Labiopalatoskis Palatoskisis Palatoskisis

18
bln Dewas
a
- BB 10 > 16
pon Timpanometri
thn
- Umur
10 mgg
- Hb 10
OME (-) OME (+)
Timpanometri

ProtudingMaksila -Nasofari
ngoskopi
OME (-) OME (+) -Nasalens
-Analisis
suara

Grome
(-) (+) t Palatoplasti Pasang
Gromet
3-4 thn
Orthodonti
Speech
Therapy
Labio Prosthodonti
plasti
VP I VP I (-)
Palatoplasti
Nasofaringoskopi Faringoplasti
Nasalens Rinoplasti
(Cleft Lipnose)
Faringo Baik
20/03/17 76
plasti
OME: Otitis Media Efusi