1、 Cleft Lip and Cleft Palate NormalLipWithAnatomicalTermsvVermilion:Thelowermarginoftheupperlipiscalledthevermilionandischaracterizedbyitsrosycolor.vCupidsbow:ThetermCupidsbowisusedtodescribetheconcaveordippedportionofthevermilionborderinthecenteroftheupperlipvTubercle:vPeakoftheCupidsbow:vPhiltrum/p
2、hiltraldimple:Theportionoftheupperlipbetweenthetwophiltralcolumnsisknownasthephiltrumvphiltralcolumnsorlines:Abovethecenteroftheupperlipisadimplecalledthephiltraldimple,andtheraisedridgesoneithersideofthisdimplearethephiltralcolumnsorlinesNormalLipWithAnatomicalTermsTypesoffacialclefts Cleft lip Med
3、ian cleftLateral Facial CleftOblique Facial CleftMedianFacialCleftLateralFacialCleft(HemifacialMacrosomia)BilateralObliqueFacialCleftCleft Lip 1.DefinitionofcleftpalatevCleftlip,sometimescalledharelip,isacongenitalmalformationofembryonicoriginthataffectsthelip.Itoccursbyitselfortogetherwithanalveola
4、rorpalatalcleft.2.IncidencevTheincidenceoforalcleftsvariesfrom1to2.21/1000.vTheincidenceofcleftlipvariesacrossraces(approximately1to1000forwhitesand0.41forblacksinUnitedStates).vMalepreponderanceismarkedinthemoresevereorcompletecleftlip,themale:femaleratiobeingapproximately3:2.vInmostseriescleftlipw
5、ithcleftpalateisreportedas1.5to3timesasfrequentlyasisolatedcleftlip.2.IncidencevInChina,theincidenceisabout1.8/1000,andtheconditionoccursmorefrequentlyinmalesthanfemales.3.EtiologyThecauseofcleftsisnotunderstoodverywell.Whilstweknowwhathappens,wedonotknowwhy.vParentalagevDrugusevInfectionsduringpreg
6、nancyvSmokingor/anddrinkingduringpregnancyvHeredity,FamilyHistoryvX-ray,microwavevdeficiencyofvitaminC,D,BvEnvironmentalFactors5.TypesofcleftlipAlthoughmanyclassificationshavebeenproposed,weprefertousedefinitiveanddescriptivetermsinordertoavoidconfusion:v1.Accordingtotheposition:Acleftlipmaybeunilat
7、eralorbilateral.upperlipcleftandLeft-sidedoccurrencearemorefrequentthanthelowerandtherightside.Amediancleftandcleftsofthelowerlipareextremelyrare.5.Typesofcleftlipv2.Accordingtotheextent:Thecleftmayvaryinextent,beingeitherincompleteorcomplete.1)Acompletecleftlip:isoneinwhichthecleftextendsthroughthe
8、floorofthenostril.Thistypeisalmostinvariablyaccompaniedbyanalveolarorpalatalcleft.2)Anincompletelipcleft:oftenvariesmerelyanothingofthevermilionborder,toonethatextendspartwayuptowardthethresholdofthenostril.Occasionallyshowsascarcelyperceptiblenotchingofthevermilionborderandaslightgroovingoftheskins
9、urface,indicatinganimperfectmuscularunionbeneath.UnilateralcleftlipUnilateralcompletecleftlipUnilateralincompletecleftlipUnilateralincompletecleftlipUnilateralincompletecleftlipUnilateralCompleteCleftLiplbBilateralcleftlipbilateralincompletecleftlipbilateralcompletecleftlipbilateralmixedcleftlipBila
10、teralCompleteCleftLip17-year-oldgirlwithbilateralcleftlipandcleftpalateBilateralcleftlip/palateBilateralcleftlip/palatebilateralmixedcleftlip5.PresentingFeaturesDeformityanddysfunctionarisingfromprimaryabnormalitywillleadto:vSeparationofthelipvabnormalfacialdevelopmentvspeechanomalies:usuallynotsero
11、usvairwayabnormalitiesvFeedingproblemsvpsycho-socialdifficulties:associatedwithaestheticandfunctionaldeficienciesvInalmosteverylipcleftthereisanassociatednasaldisfigurement.Thisusually,butnotalways,variesinseverityindirectproportiontothewidthofthecleft.Thusanincompletecleftmayexhibitonlyaslightsprea
12、dingandflatnessoftheaffectednostril,whileinawidebilateralcleftthenostrilsareextremelyflattenedanddistortedthenasaltipretracted,andthenasalcolumellashortenedvThemusclesofthemouthincleftlipfailtomeetinthemidlineandthusseekotherattachments.Thesesubstituteattachmentspreventthemusclesfrombecomingfullyfun
13、ctional,andtheirdevelopmentisincomplete.6.Treament1.TeamapproachThemanagementofcleftsrequirestheparticipationofthefollowingexperiencedspecialists:asurgeon:suchasaplasticsurgeon,anoral/maxillofacialsurgeon,acraniofacialsurgeon,oraneurosurgeonanaudiologist:whoassesseshearingapediatricdentistorotherden
14、talspecialist:suchasaprosthodontist,whomakesprostheticdevicesforthemouth);vanorthodontist:whostraightenstheteethandalignstheteethandjaws.vageneticist:whoscreenspatientsforcraniofacialsyndromesandhelpsparentsandadultpatientsunderstandthechancesofhavingmorechildrenwiththeseconditionsTeamapproachvanurs
15、e:whohelpswithfeedingproblemsandprovidesongoingsupervisionofthechildshealthvanotolaryngologist:anearnoseandthroatdoctor,orENTvapediatrician:tomonitoroverallhealthanddevelopmentTeamapproachTeamapproachvapsychologistorothermentalhealthspecialist:tosupportthefamilyandassessanyadjustmentproblemsvaspeech
16、languagepathologist:whoassessesnotonlyspeechbutalsofeedingproblemsvandothernecessaryspecialists:whotreatspecificaspectsofcomplexcraniofacialanomalies.TeamMembers2.surgicalrepairofcleftlipTimingofOperation:selectingasuitabletimetooperateonthecleftlipvariesfromsurgeontosurgeon.Someclinicspreferoperat
17、ingontheinfantsimmediatelyfollowingbirth,preferablywithin48hours,even24hours.Othersconsistthatthesurgeryshouldbedelayedforaminimumof8to10weeksfollowingthebirth.ruleoftensvAlthoughtherearestillmanydifferentopinions,themostacceptedstandpointisthatliprepairshouldbecarriedoutwhenthechildsgeneralhealthan
18、dweightpermitthesafeinductionofgeneralanesthesia.anesthesia.vThetime-honored“ruleoftens”isausefulguidetothetimingofsurgery:Accordingtothisrule,liprepairshouldbecarriedoutwhenthechildhasattainedaweightof10pounds,is10weeksold,andhasahemoglobinconcentrationhigherthan10milligram/dl.TimingofOperationinch
19、inav1.Unilateralcleftlip:36monthsoldv2.Bilateralcleftlip:612monthsoldvThePurposeofRepair:a.Restorationofnormal/nearnormalanatomyb.Restorationofnormal/nearnormalfunctionc.Promotionofnormal/nearnormaldevelopmentresultinginsatisfactory2.surgicalrepairofcleftlipvThepurposeis,ofcourse,torestoretheanatomi
20、cpartstotheirproperpositionstopromotenormalgrowthanddevelopment.vAneffectiverepairmustrealignthevermillionandCupidsbowofthelip,reconstructtheupperlipandphiltrum,andreapproximatetheorbicularisorismusclewithintherepair.2.surgicalrepairofcleftlipCriteriaforliprepairvAccurateskin,muscle,andmucousmembran
21、eunionvSymmetricalnostrils,SymmetricalnostrilfloorsvSymmetricalvermillionbordervPreservationofthecupidsbowvAminimalscar2.surgicalrepairofcleftlipvAnesthesia:Generalanesthesiaisused.2.surgicalrepairofcleftlip(takingunilateralliprepairasanexample)vmethodsofunilateralliprepair:Tennision-RandallMethod(T
22、riangularflapmethod)Millardmethod:(Rotation-advancementmethod)ItisthemostpopulartechniqueforunilateralcleftlipdescribedbyMillard.Millardmethodthefirststep:MarkingsvMidlinenadir2vPeaksofCupidsbow1,3vNewCupidsbowpeakoncleftside4vTheextentofrotationcurve5vCommissures6,7vAlarbaseoncleftside8vTheincision
23、ismadealongline6-3,3-5and8-7-4Millardmethodthesecondstep:MakingTheincisionvTheincisionismadealongline6-3,3-5and8-7-4vArotationincisiononthemedialsidepermitstheentireCupidsbowcomponenttodropdownintothenormalposition.vTheflapBhelpstopullthecolumellaandmembranousseptumintoposition.vThedefectbetweenAand
24、BisthenfilledbytheadvancementflapCfromthelateralside.Advancementofthelateralflapcrotatesthealaintopositionandcorrectsthedeformityofthenostril.Millardmethodthesecondstep:suturevThelongitudinalincision5-3followsandimitatesthenaturallineofaphiltralcolumn.vTheZ-plastyintheupperportionofthelipishiddenint
25、heshallowandinthecreaselinesofthenostrilfloor.vThemuscleandsubcutaneoussuturesshouldbecarefullyapplied.vUnilateralCleftlipontheleftside.vTo repair a cleft lip,the surgeon will first make an incision on each side of the cleft from the lip to the nostril.vThe cleft lip is then drawn together and stitc
26、hed to create a normal cupids bow shape to the upper lip.vThe scar left after surgery will gradually fade with time.The scar left after surgery The scar left after surgeryCleft Palate1.DefinitionofcleftpalatevCleftpalateisacongenitalmalformationofembryonicoriginthataffectthepalate.Itoccursbyitselfor
27、togetherwithanalveolarorlipcleft.2.IncidenceofcleftpalatevTheincidenceofcleftlipandpalatevarieswithdifferentraces.vTheincidenceofcleftpalatealoneis1outof2,500peopleaccordingtoreportsfromADA.BreakdownofFacialClefts3.EtiologyvAswithcleftlip,theetiologyofcleftpalateismultifactorial.vAnimalmodelshavedem
28、onstratedthatvitaminA,corticosteroids,andphenytoinproducecleftpalatewhengiveninpregnancy.4.Classificationv1.Cleftofthesoftpalateonlyv2.Incompletecleftofpalate:extendingnofurtherthantheincisiveforamen.1342v3.Completeunilateralcleft:extendingfromtheuvulatotheincisiveforameninthemidline,thendeviatingto
29、onesideandusuallyextendingthroughthealveolusatthepositionofthefuturelateralincisortooth.v4.Completebilateralcleft:resemblingtype3withtwocleftsextendingforwardfromtheincisiveforamenthroughthealveolus.1342CleftofthesoftpalateonlyCompleteunilateralcleftCompletebilateralcleftCompletebilateralcleftUnilat
30、eralcompletecleftlipandpalateBilateralcompletecleftpalateandlipBilateralcleftlipandpalateBilateralcleftlipandpalateVelopharyngealclosurevDuringspeechandswallowingthepalatemovesbothsuperiorlyandposteriorlyagainsttheposteriorpharyngealwalltoseparatetheoralpharynxandnasalpharynx.ThisiscalledVelopharyng
31、ealclosure.vWhenpalateiscleft,however,notonlyisthereinadequateVelopharyngealclosurebut,inaddition,theopeninginthepalatepermitstheairstreamtopasspartlythroughthenose.Thus,theairstream,passingthroughbothnasalandoralcavities,cannotbealteredproperlytoproducethenormalsounds.5.SymptomsvSeparationofthepala
32、tevSpeechand/orlanguageproblem:NasalvoicevRecurrentearinfectionsvNasalregurgitationsduringbottlefeedingvPsychologicalproblems:oftheadolescentoradultpatientsandpatientsfamilies.Feeding bottles and teats for babies born with cleft lip and/or palatevAninfantwithacleftwillhaveproblemssuckingascommunicat
33、ionwiththenasalcavitywillallowairtopassintotheoralcavityinsteadofdrawingmilkfromafeedingbottleorthebreast.Thus,squeezablebottleswithadirectionalteat,oravariable-flowteatandpump-actionvalve,arerequiredvTheCleftLipandPalateAssociationrecommendsthatnormalfeedingmethodsshouldbeencouraged.6.Treament1.Tea
34、mApproach2.TimingofoperationvInChina,surgeonsmostcommonlycarryoutthesurgicalrepairofcleftpalatewhenthepatientis3yearsold,whateverincompleteorcomplete,unilateralorbilateral.3.AimofoperationvTheultimateaimofcleftpalatesurgeryistoproduceapalatethatisabletofulfillthetwomainfunctionsofthenormalhardandsof
35、tpalate.v1.thefirstistomaintainamechanicalpartitionbetweentheoralandnasalcavities,therebypreventingtheintroductionofforeignbodiesintothenasalcavity,withtheconsequentpossibilityofinfectionofnoseandmiddleear.v2.thesecondfunctionofpalateisitsparticipationinspeechproduction,orwecansaytogainadequatevelop
36、haryngealclosure.3.Methodofoperation(takingincompletecleftasanevample)vV-YRetroposition(“push-back”)ProcedurevGeneralanesthesiaisusedandthepalateisinjectedwith0.25%lidocainewith1:200,000epinephrinesolutiontoreducebloodloss.vA.outlineofincision.B.Theflapsareraised.C.Sutureofthemucousmembrane.D.Positi
37、onoftheflapsatthecompletionoftheoperation.vThe surgeon makes an incision along both sides of the cleft.vTissue is drawn together from both sides of the cleft to rebuild the roof of the mouth.BeforeandaftersurgerySPEECH THERAPYvTheeffectofacleftlipandpalateonspeechisveryvariableandnotalwaysrelatedtot
38、hetypeorextentoftheoriginalproblem.Generallyhowever,acleftlipwithoutacleftpalaterarelyhasanyeffectonspeech.Sometimesifthecleftlipinvolvesbothsides,orifthegumisalsoaffected,theremaybesomeminorspeechdifficulties.SPEECH THERAPYvChildrenwithcleftlipandpalatecommonlyneedspeechtherapy.Speechproductionrequ
39、irescoordinationofthetongue,hardandsoftpalate.Thiscoordinationisachievedbythemovementofthemuscleswithinthetongueandsoftpalate.Childrenwithcleftpalatehaveanabnormalinsertionandmovementofthemuscleswithinthesoftpalate.Theymayalsohavepoorcoordinationofthetonguemovementsanditsplacement.Thisresultsinanabn
40、ormalspeechrequiringspeechtherapy.TreatmentGoalofSpeechTherapyvThegoalofspeechtherapyistoeliminationofthepatientsparticularspeechdisordersbythetimethechildenterskindergarten.MethodvActivitiesfortherapyshouldbedoneinanaturalandfunwaywherepossibleandparentsshouldnotplacethechildunderpressure.Hereareso
41、meguidelinesrecommendedtoparents:v1.Talktoyourchildfromaveryearlyage.Donotjustdoanactivity;talkyourchildthroughit,e.g.atbathtime,“heresthesoap/water/toweletc.”,“Mammyiswashing”,“washinghands/face/toesetc.”.v2.Nameeverydayitemssuchascup,spoon,plate,car,door,dog,bricksetc.foryourchildtohelphim/hertoun
42、derstandandusevocabulary.v3.Goingthroughsimplepicturebooksandnamingthevariousitemshelpsvocabulary.v4.Pretendplaywithteasets,dolls,shops,dressingupetc.isagreatfunactivityinwhichyourchildcanlearnlotsofsimplevocabularyandsentences.Againtalkyourchildthroughtheactivitye.g.“dollyiseating”,“eatingcake”,“po
43、utingthetea”,“heresthecupetc”.v5.Tellingsimplestoriesfrompicturebooksisveryhelpfulandenjoyable.Adaptlanguagesuitabletothechildratherthanusingthebookrigidly.v6.Singinglittlesongsandnurseryrhymesalsohelpstodeveloplanguage.vAreviewoftheliteraturesonspeechtherapyrevealsthatinthebestcentersaroundtheworld
44、thechanceofattainingnormalspeechfollowingcleftpalaterepairisabout80%.Althoughthisfiguremaynotseemtobeveryhigh,itisareflectionofthecurrentstateoftheart.vThegreatesttragedyisthatallofthesechildrenaresufferingnotbecausetheywerebornwithacleft,butbecausetheywerebornpoor.Toopoortopayforasimplecurethathas
45、beenaroundfordecades.vHelpingthesechildrenisthemissionofTheSmileTrain.Wehelpprovidefreecleftsurgeryandrelatedtreatmentforchildrenwhowouldotherwiseneverreceiveit.Aimof“the smile trainthe smile train”vInaslittleas45minutes,andforaslittleas$250,wecanhelpgivethesechildrennotjustanewsmilebutasecondchanceatlife.vWitheverycleftwerepair,werestorealife.vWitheverydoctorwetrain,wehelpacommunitytakeonemoresteptowardself-sufficiency.vWitheverysmilewedeliver,webringhopeanddignity!Aimof“the smile trainthe smile train”
