唇裂腭裂CLEFTLIPANDPALATE.ppt.ppt

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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”