Cleft Lip And Palate
Question 1. Write a short note on the cleft lip.
Or
Describe briefly cleft lip
Or
Write in short about cleft lip.
Answer. Her cleft lip results from abnormal median nasal and maxillary process development.
Cleft lip Causes
- Increase parenteral age.
- Infection during pregnancy.
- Smoking and steroid therapy during pregnancy.
- Trauma and psychological stress during pregnancy.
Read And Learn More: General Surgery Questions and Answers
Types Of Cleft Lip
- Central: It is very rare and occurs due to the failure of the fusion of two median nasal processes (Hare’s lip).
- Lateral: It is the most common variety, there is a cleft between the frenum and the lateral part of the upper lip.
This is due to the imperfect fusion of the maxillary process with the median nasal process. Lateral variety can be unilateral or bilateral
- Complete or incomplete: In case of complete variety, the cleft lip extends to the nose. In incomplete variety, the cleft does not extend up to the nostrils.
- Simple or compound: A simple cleft lip is only cleft in the lip while compound refers to cleft lip associated with a cleft in the alveolus.
Cleft lip Clinical Features
- The patient has difficulty in sucking.
- Defective speech is present, i.e. patient is unable to speak words such as B, F, M, P, and V
- Presence of soft tissue mass in between the ends of bone which unites tongue to lip.
- In hare lip cleft lies in the middle of the lip.
- In incomplete cleft lip, extension is from the nostril to some distance forward
- In complete cleft lip, extension is from nostril to palate.
Cleft lip Treatment
- Millard’s criteria are used to undertake surgery for cleft lip,i.e. Rule of ten, i.e. 10 pounds in weight; 10 weeks old; 10 g% hemoglobin.
- If the cleft lip is bilateral and is extensive two surgeries should be done to close the cleft.
Surgery on one side should be done first and later on after a few weeks surgeries on the second side are done. - Millard’s rotation advancement technique is commonly used. In this correction of both lip and nasal deformity is done.
Realigning muscles and lips and their correct anatomical position is an important part of this repair.
In this method, a tilted cupid bow is rotated downwards following a curved incision extending to the columella.
This allows rotation of the misplaced cupid’s bow and philtrum dimple in a normal position.
A high rotation gap created is filled with a triangular flap which consists of skin muscle and mucosa from the upper part of the lateral side of the cleft.
The resultant scar is hidden inside the nose or follows the natural line of philtrum. - Hagedorn LeMesurier repair: In this method medial lip element should be lengthened by introducing the quadrilateral flap which is developed from the lateral lip element.
- Tennison Randall repair: In this, a cut is given on the lower one-third of the lip to correct the upward tilt of cupid’s bow by placing a Z-shape wire.
The gap is filled with a triangle of skin, muscle, and mucosal flips from the lower end of the lateral lip element. This resultant scar is a Zigzag scar. - Proper postoperative management like control of infection, training for sucking, swallowing, and speech therapy should be done.
Principles of Cleft Lip Repair
- Rule of 10 should be fulfilled.
- Before six months it should be operated.
- Infection should not be present.
- Millard advancement flap is used for unilateral cleft lip repair.
- Bilateral cleft lip repair can be done either in single or two stages.
- One-stage bilateral cleft lip repair is done using the Veau III method.
- Proper markings are made before surgery and the incision should be over full thickness flap.
- Often 1:2,00,000 adrenalin injection is used to achieve hemostasis.
- Three-layer lip repair should be done, i.e. mucosa, muscle, and skin.
- Cupid’s bow should be horizontal.
- The continuity of the white line is maintained.
- Vermilion notching should not be present.
Question 2. Write a short note on the cleft palate.
Answer. The palate is formed from the Y- Y-shaped fusion of premaxilla and two palatine processes.
Imperfect fusion of these processes or developmental anomalies results in cleft palate.
Cleft palate Types
Complete cleft palate
- Failure of fusion of the palatine process and premaxilla results in a complete cleft palate.
- The nasal cavity and the mouth are interconnected.
- This may be unilateral or bilateral.
Incomplete cleft palate
- When the fusion of three components of the palate takes place.
- It starts from the uvula and then backward.
Various types
- Bifi uvula
- The whole length of the soft palate is bifid.
The whole length of the soft palate and the posterior part of the hard palate are involved.
Effects Of Cleft Palate
- Interferers with swallowing and speech.
- Unable to make the constant sound like B, P, D, K, and T.
- Teeth: Upper incisors may be small maxilla tends to be smaller. Teeth are crowded.
- Nose: Oral organisms contaminate the upper respiratory mucous membrane.
- Hearing: Even with repair, acute and chronic hearing problems can occur.
Management of Cleft Palate
- The cleft palate is usually repaired in l2–l8 months. Early repair causes retarded maxillary growth. Late repair causes speech defects.
- Both soft and hard palates are repaired.
- Abnormal insertion of tensor palati is released. Mucoperiosteal flps are raised in the palate which is sewn together.
- If maxillary hypoplasia is present, then osteotomy of the maxilla is done. With orthodontic teeth extraction and alignment of dentition is done.
- Regular examination of the ear, nose, and throat during the follow-up period, i.e. postoperative speech therapy.
- Whenever complicated problems are present, a staged surgical procedure is done.
- Wardill-Kilner pushback operation or V—Y pushback palatoplasty by raising mucoperiosteum flps based on greater palatine vessels.
V—y Pushback Palatoplasty or Wardill Kilner Push Back Palatoplasty
- In this palate is infiltrated by a 1:2 adrenaline saline solution.
- Both mucoperiosteal flps are raised, one from either side of palatal shelves and then nasal layers should be mobilized.
- Closure of the palate is done in three layers, i.e. nasal layer, muscle layer, and oral layer.
- In this procedure, palatal lengthening is achieved by V Y plasty.
The hook of the hamulus can be fractured to relieve tension on the suture line by relaxing the tensor palate muscle.
Cleft Palate Secondary Management
- Hearing support is given using hearing aids if the defect is present; control of otitis media.
- Speech problems occur due to velopharyngeal incompetence; articulation problems also can occur.
Speech therapy is given. It is corrected by pharyngoplasty, pyeloplasty, and speech devices. - Dental problems like uneruption and unalignment are common.
They should be corrected by proper dentist opinion and reconstructive surgery. - Orthodontic management with alveolar bone graft, and maxillary osteotomy is done in 8–11 years.
- Veloplasty, dental implants, rhinoplasty, orthognathic surgeries etc.
Question 3. Write a short note on orthodontic treatment of cleft lip and palate.
Answer. One of the clinical features common to cleft lip and palate is a constricted and distorted maxillary arch.
The more severe the cleft, the more severe the arch deformity due to collapse.
Orthodontic treatment is necessary to correct the deformity.
Orthodontic treatment should be started during mixed dentition and continued through the permanent dentition.
Permanent teeth especially, those adjacent to the cleft are malposed, often severely rotated, and poorly calcified.
They certainly need to be orthodontia.
If extracted, especially the supernumerary one.
Even with complete orthodontic treatment, there is maxillomandibular *discrepancy, which may need surgical correction in the form of maxillary advancement with or without mandibular pushback, with or without *genioplasty.
Question 4. Write about pathogenesis, classification, and structural and functional problems of cleft lip and palate. Write a note on principles of management.
Answer.
Pathogenesis of Cleft lip and Cleft Palate
- Cleft lip results from abnormal development of the medial nasal process and maxillary process.
- A cleft palate occurs due to the fusion of two palatine processes.
- Defect in the fusion of lines between the premaxilla and palatine processes of the maxilla one on each side.
- When the premaxilla and both palatine processes do not fuse, it leads to complete cleft palate.
- Incomplete fusion of all three components leads to incomplete cleft palate.
Functional and Structural Problems of Cleft Lip and Cleft Palate
- Difficulty in sucking and swallowing
- Speech is defective especially in the cleft palate, mainly to phonating B,D,K, P,T, and G
- Altered dentition or supernumerary teeth
- Recurrent upper respiratory tract infection
- Respiratory obstruction
- Hypoplasia of maxilla
- Cosmetic problem
- Chronic otitis media and middle ear problems.
Question 5. Write briefly on the classification of cleft lip and palate defects.
Answer. The following are the classifications:
Davis and Ritchie (1922)
Group I: Prealveolar cleft.
Group II: Post alveolar cleft.
Group III: Alveolar cleft.
Cleft lip Veau (1931)
- Group I: Cleft of soft palate only
- Group II: Cleft of the hard and soft palate extending no further than the incisive foramen, thus involving the secondary palate alone.
- Group III: Complete unilateral cleft, extending from uvula to the incisive foramen, thus the uvula to the incisive foramen in the midline, then deviating to one side and usually extending through the alveolus at the position of the future lateral incisor tooth
- Group IV: Complete bilateral cleft, resembling Group III with two clefts extending from the incisive foramen through the alveolus.
Cleft lip Kernahan And Stark (1958)
- Incomplete cleft of secondary palate
- Complete cleft of secondary palate
- Incomplete cleft of primary and secondary palate
- Unilateral complete cleft of primary and secondary palate.
- Bilateral complete cleft of the primary and secondary palate.
Cleft lip Harkins and Associates (1962)
Cleft or primary palate:
Cleft lip
- Unilateral: Right, left (Extent; one-third, two-thirds, complete)
- Bilateral: Right, left (Extent: one—third, two thirds, complete)
- Median (Extent: one-third, two-third, complete)
- Prolabium: Small, medium, large
- Congenital scar: Right, left, median (one-third, two-thirds, complete)
Cleft of the alveolar process
- Unilateral: Right, left (Extent: one-third, two-thirds, complete)
- Bilateral: Right, left (Extent: one-third, two-thirds, complete)
- Median (Extent: one-third, two-thirds, complete)
- Submucous: Right, left, median
- Absent incisor tooth
Cleft of the palate:
Soft palate
- Posteroanterior: One-third, two-thirds, complete
- Width: Maximum
- Palatal shortness: None, slight, moderate, marked
- Submucous cleft (Extent: one-third, two-thirds, complete)
Hard palate
- Posteroanterior (Extent: one-third, two-thirds, complete)
- Width: Maximum (mm)
- Vomer attachment: Right, left, absent
- Submucous cleft (Extent: one-third, two-thirds, complete)
Mandibular process clefts:
- Lip extent: One-third, two-thirds, complete
- Mandible (Extent: one-third, two-thirds, complete)
Lip pits: Congenital lip sinuses
- Naso-ocular: Extending from the nasal region towards the medial canthus
- Oro-ocular: Extending from the angle of the mouth towards the palpebral fissure
- Oro-aural: Extending from the angle of the mouth towards the tragus of the ear.
Question.6. Describe the development of the face and various congenital abnormalities of the lip and palate.
Or
Write briefly on the development of the face.
Answer.
Development Of Face
The face is derived from the following structures that lie around the stomatodeum, i.e.
- Frontonasal process
- The first pharyngeal (or mandibular) arch of each side.
- At this stage, each mandibular arch forms the lateral wall of the stomatodaeum.
- This arch gives off a bud from its dorsal end. This bud is called the maxillary process.
It grows ventromedial cranial to the main part of the arch which is now called the mandibular process. - The ectoderm overlying the frontonasal process soon shows bilateral localized thickenings, that are situated a little above the stomatodeum. These are called the nasal placodes.
The formation of these placodes is induced by the underlying forebrain. The placodes soon sink below the surface to form nasal pits. - The pits are continuous with the stomatodeum below.
The edges of each pit are raised above the surface.
The medial raised edge is called the medial nasal process and the lateral edge is called the lateral nasal process.
Development Of Lower Lip
Mandibular processes of the two sides grow towards each other and fuse in the midline.
They now form the lower margin of the stomatodeum.
If it is remembered that the mouth develops from the stomatodeum, it will be readily understood that the fused mandibular processes give rise to the lower lip and to the lower jaw.
Development Of Upper Lip
Each maxillary process now grows medially and fuses, first with the lateral nasal process and then with the medial nasal process.
The median and lateral nasal processes also fuse. In this way, the nasal pits are cut off from the stomatodeum.
The maxillary processes undergo considerable growth.
At the same time, the frontonasal process becomes much narrower from side to side, with the result that the two external nares come close together.
The stomatodeum is now bounded above by the upper lip which is derived as follows:
- The mesodermal basis ofthe lateral part ofthe lip is formed from the maxillary process. The overlying skin is derived from the ectoderm covering this process.
- The mesodermal basis of the median part of the lip (called philtrum) is formed from the frontonasal process.
The ectoderm ofthe maxillary process, however, overgrows this mesoderm to meet that of the opposite maxillary process in the midline. As a result, the skin of the entire upper lip is innervated by maxillary nerves.
The muscles of the face are derived from the mesoderm of the second branchial arch and are therefore supplied by the facial nerve.
Development Of Nose
The nose receives contributions from the frontonasal process and the medial and lateral nasal processes of the right and left sides.
External nares are formed when the nasal pits are cut off from the stomatodeum by the fusion of the maxillary process with the medial nasal process.
External nares gradually approach each other.
Mesoderm becomes heaped up in the median plane to form the prominence of the nose.
‘Simultaneously, a groove appears between the regions of the nose and the bulging forebrain.
As the nose becomes prominent the external nares come to open downwards.
The external form of the nose is thus established.
Development Of Cheeks
After the formation of the upper and lower lips, the stomatodeum (which can now be called the mouth) is very broad.
In its lateral part, it is bounded above by the maxillary process and below by the mandibular process.
These processes undergo progressive fusion with each other to form the cheeks.
Development Of Eye
The region of the eye is first seen as an ectodermal thickening, the lens placode, which appears on the ventrolateral side of the developing forebrain, lateral and cranial to the nasal placode.
The lens placode sinks below the surface and is eventually cut- off from the surface ectoderm.
The developing eyeball produces a bulging in this situation.
The bulging of the eyes is at first directed laterally and lies in the angles between the maxillary processes and the lateral nasal processes.
With the narrowing of the frontonasal process, they come to face forward.
The eyelids are derived from folds of ectoderm formed above and below the eyes, and by mesoderm enclosed within the folds.
Development Of External Ear
The external ear is formed around the dorsal part of the first ectodermal cleft.
A series of mesodermal thickenings (often called tubercles or hillocks) appear on the mandibular and hyoid arches where they adjoin this cleft.
The pinna (or auricle) is formed by the fusion of these thickenings.
Development Of Nasal Cavities
Nasal cavities are formed by extension of the nasal pits. These pits are at first in open communication with the stomatodeum.
Soon the medial and lateral nasal processes fuse and form a partition between the pit and the stomatodeum.
This is called the primitive palate and is derived from the frontonasal process.
The nasal pits now deepen to form the nasal sacs which expand both dorsally and caudally.
The dorsal part of this sac is, at first, separated from the stomatodeum by a thin membrane called the bucconasal membrane (or nasal fi). This soon breaks down.
The nasal sac now has a ventral orifice that opens on the face (anterior or external nares) and a dorsal orifice that opens into the stomatodeum (primitive posterior nasal aperture).
The two nasal sacs are at first widely separated from one another by the frontonasal process.
However, the frontonasal process becomes progressively narrower.
This narrowing of the frontonasal process, and the enlargement of the nasal cavities themselves, bring them closer together.
This intervening tissue becomes much thinned to form the nasal septum.
The ventral part of the nasal septum is attached below to the primitive palate.
More posteriorly the septum is at first attached to the bucconasal membrane, but on disappearance of this membrane it has a free lower edge.
The nasal cavities are separated from the mouth by the development of the palate.
The lateral wall of the nose is derived, on each side, from the lateral nasal process.
The nasal conchae appear as elevations on the lateral wall of each nasal cavity.
The original olfactory placodes form the olfactory epithelium that lies in the roof, and adjoining parts of thin walls, of the nasal cavity.
Congenital abnormalities of lip and Palate
Following are the congenital abnormalities oflip and palate:
- Congenital lip pits
- Commissural lip pits
- Double lip
- Cleft lip and cleft palate.
Congenital lip Pits
It is also known as a congenital fistula.
Congenital lip Pathogenesis
It occurs due to the failure of the union of the embryonic sulcus of the lip which leads to persistent lateral sulci on the embryonic mandibular arch.
Congenital Lip Clinical Features
- It more commonly occurs in females.
- The vermilion border of the lip is commonly involved. The lower lip is involved.
- Lips appear swollen
- The lesion is present in the form of depression.
- On palpation, mucous secretion is seen from the base of the lip pit.
Congenital lip Treatment
Surgical excision is done.
Commissural lip Pits
They are mucosal invagination which arises at the vermilion border of the lip.
Commissural lip Pathogenesis
Its occurrence is due to the failure of normal fusion of embryonic maxillary and mandibular processes.
Commissural Lip Clinical Features
- Males are commonly affected
- It presents as a unilateral or bilateral pit at the corners of the mouth on the vermilion border
- Its size ranges from a shallow depression to an open tract measuring 4 mm
- On palpation, less amount of saliva oozes out.
Commissural Lip Treatment
Surgical excision is done.
Double Lip
It is a fold of excessive tissue over the inner mucosa of the lip.
Double Lip Pathogenesis
It arises during the second week of gestation because of the persistence of the sulcus between pars glabrosa and pars villosa of the lip.
Double Lip Clinical Features
- The inner aspect of the lip is involved.
- At times when the upper lip becomes tensed, the double lip gives the appearance of a cupid bow.
Double Lip Treatment
Surgical excision is done.
Question 7. Write a short note on the management of a case of unilateral cleft lip and palate repair.
Answer.
Management of a Case of unilateral Cleft lip repair
- For unilateral cleft lip repair most commonly used methods are Millard’s rotation advancement flp and Tennison Randall’s triangular flp method.
- Millar’s cleft lip repair is done by rotating local nasolabial flps.
- The majority of surgeons follow Millard criteria or “Rule of 10”,i.e. at the time of repair hemoglobin should be more than 10 g%, age is 10 weeks, weight is more than 10 pounds and total leukocyte count is less than 10,000/cu mm.
Millard Rotation Advancement Flap
In this, a tilted cupid bow is rotated downwards following a curved incision extending to the columella.
This allows rotation of the misplaced cupid’s bow and philtrum dimple in a normal position.
The high rotation gap created is filled with a triangular flap which consists of skin muscle and mucosa from the upper part of the lateral side of the cleft.
The resultant scar is hidden inside the nose or follows the natural line of the philtrum.
Tennisonrandall triangular Flap repair
In this, a cut is given on the lower one-third of the lip to correct the upward tilt of cupid’s bow by placing a Z-shape wire.
The gap is filled with a triangle of skin, muscle, and mucosal flips from the lower end of the lateral lip element.
In this resultant scar is a Zigzag scar.
Question 8. Write brief notes on the treatment of cleft lip.
Answer.
Following is the treatment of cleft lip:
- Millard’s criterion is used to undertake surgery for cleft lip, i.e. rule of ten, 10 pounds in weight; 10 weeks old; 10 g% hemoglobin.
- If the cleft lip is bilateral and is extensive two surgeries should be done to close the cleft. Surgery on one side should be done first and later on, after a few weeks surgery on the second side is done.
- Millard’s rotation advancement flap technique is commonly used.
In this correction of both lip and nasal deformity is done.
Realigning muscles and of lips and their correct anatomical position is an important part of this repair.
In this technique, the medial lip element is rotated inferiorly and the lateral lip element is advanced into the resulting upper lip defect.
The columellar flap is then used to create a nasal sill. - Hagedorn-LeMesurier repair: In this method, the medial lip element should be lengthened by introducing the quadrilateral flap which is developed from the lateral lip element.
- Tennyson-Randall repair: In this method medial lip element is lengthened by introducing a triangular flap from the inferior portion of the lateral lip element.
- Proper postoperative management like control of infection, training for sucking, swallowing, and speech therapy should be done.
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