oral surgery

This lecture is really confusing. I emailed him to ask for his lecture.

Sanford Ratner

Cleft Deformities

Facial Clefting

Results from perturbations in signaling centers producing alterations in:

Timing

Rate

Outgrowth

Of facial primordial growth

CLP

Cleft lip and palate is characterized by a vertical defect in the oro-nasal complex, resulting in direct communication between the nose and the mouth. It is one of the most common birth defects in US

Af am: 1:2000

Cac 1: 1000

Asian 1:500

Cleft lip .29:1000

Cleft palate .39:1000

More males have cleft lip than females

More females have cleft palate

Left side: right: bilateral 6:3:1

Asso syn

Downs

Pierre robin

Apert’s syndrome

Crouzon’s

Treacher Collins

Hemi-facial microsomia

Goldenhars

Skicklers

Etiology

genetic contribution to facial morphogenesis plays a role in syndromes asso with CLP-poorly understood. Transforming growth factor-alpha. Retinoic acid receptor – alpha

envi modifying role may effect genetic activation/repression in non-syndromic CLP. Tobacco, anti-epileptic drugs, etc.

Clefting of lip can interfere with palate closure. Isolated clefting of palate is etiologically independent entity from CLP

Genetic involvement

Two hypoth

multi factorial threshold model: major genes, minor genes, environment, developmental

single major gene with reduced penetrance (less than 40% CLP are directly genetic in origin

familial incidence

· both parents unaffected : 0.1% chance for first child

· first child affected: 4% chance for 2^{nd child}

· two affected kids: 9% first child CLP

· one parent: 4% first child

· 1st child: 17% second child

· Both parents affected: 60% chance for all kids

Etiology:

Meckel 1808-failure of the facial primordial to fuse between the fifth and eighth week: FUSION.

Primordial come together by forces of growth. As move together, they touch. And epi degenerates and mesothelium flow thru area and have normal tissues and then u have fusion complete. If epithelium does not degenerate, you get cleft.

2nd theory:

Stark: pieces actually do come together, but not strong enough to stay together (FISSION)

Mx growth

Four mx movements

forward

ant

verti elongation

transverse expansion

growth

· the membranous sutures of the face must be responsive:

· the Vomerine-palatal suture is vital for adequate forces to be transmitted to the developing mx. Scarring of the suture will inhibit all aspects of growth.

· (if upset suture of vomer, mx won’t growth properly)

Clft class

normal bi-palate

unilateral CL

unilateral CLP-incomplete

bilateral CLP-incomplete

CP-incomplete

Unilateral CLP-Complete

Veau classification

Stage I: incomplete CP

Stage II: more

Stage III

Stage IV

The "Y" (Kernahan)

1,4 lip

2,5: alveolus

3,6:

Cleft lip

Cleft palate

Cleft alveolus:

Cleft lip

Unilateral

Microform

Minimal

Complete

Bilateral

Microform: full thickenus off mucosa, muscle never got across. Must open area up and close cleft lip together

Minimal: doesn’t go half way up lip

Incomplete: goes half way up or more

Complete

Anatomy: lip

Musculature:

orbicularis oris: eighth muscle components, arising from modioli at either end of mouth

superior and inferior horizontal band

oblique bands: allow to take lips up and out. (cleft pts can’t bring out but can bring up.) horizontal fibers can bring lips together

anat-cleft lip

normal anat is askew with deviation of philtrum, cupsids bow, tubercle

lateral lip element exhibits vertical discrepancy

mesodermal deficiency: muscle never grew across so can’t fn properly

the muscles remain underdeveloped

cleft palate

class

submucous cleft: cleft of hard palate under mucosa.

uvula

soft palate

soft and hard palate

palate anat:

· tensor palatine

· palatal-glossus, levator, uvular, etc:

· all are imp in speech.

Cleft palate

Cleft soft palate demonstrates abnormal muscle insertion a the post edge of the hard palate, leading to dysfunction of muscles. CAN"T SPEAK.

The valvular system is a continuum of movement that allows sound to be modified thru a change in pressure. Get Otitis media. Can’t equalize pressure. So lose hearing

Goals of palatal surgery

Release abnormal muscle insertion

Establishment of muscle continuity

Correct orientation of the velum to serve as a dynamic sling

Establish functional velo-pharyngeal valve mechanism to allow closure between oral pharynx and nasal pharynx.

Cleft palate:

Vertical deficiency, retrodisplaced

Transverse displacement

Cleft alveolus

Mx alveolus is frequently involved in the cleft lip and palate deformity. It routinely presents as a subtle fistula in the labial vestibule following the repair of the lip.

Complaints

Food and fluid come out of nose

Inability to suck or blow

Poor ability to keep teeth clean

Decayed or deformed front teeth

Missing or extra teeth in the cleft site

Lack of boney support of adjacent teeth

Mobility and deformity of primary palate

Lack of support for nose and lip

Alv cleft

stabilitze mx arch-consolidat to one jaw

establish functional nasal airway

close oro-nsal fistula

get osseous volume to support teeth

eliminate depressed alar base

allow for dental rehab

techniques

· primary gingivoperiosteoplasty- should not be done

· primary alveolar bone grafting- do at time of lip repair.

· secondary gingivoperiosteoplaty-should not be done

· secondary alveolar bone grafting- done at a later time.

Cleft deformity

Depends of type of cleft

Facial characteristics

To understand the facial patterns of CP: questions

does the unoperated cleft ind have same faial growth potential as non cleft ind

do all unoperated cleft types have same growth potential?

Unrepaired

· Skeletal: mx protrusion. No md. Diff.

· Dental- cleft segment has tendency to rotate medially with cuspid crowss bite occurrence.

Effect of lip repair

skeL: ant mx is molded with reduction of protrusion. No md. Diff. overall appear is like non-cleft ind.

Dental;mx and md incisors became more up right.. get post crossbite.

Unrepaired CPO

Skel: mx and md retrusion. Md has steep plane angle

Dent: no effect

Palatal repair-CPO

Skel: no effect on ant postion, however decreased vert ht

Decrease md palne due to rotation. Get more of class III relationship

Dental: see much greater post crossbite. (transverse growth of mx is restricted)

Unrepaired UCLP

Skel: mx is normal but md is rotated backwards

Dental: collapse of segments, get post crossbite

Repaired lip

Mx retruded compared to unodperated cleft lips. Md unaffected. ANB is smaller than unoperated clefts but still pos

Dental: no incr in ant crossbite. But yes post crossbite

Lip and palate repair

Skel: class III

dentL ant crossbite and post cross bite

findings:

mx and md with repaired clefts are related to the presence of the cleft itself. Means: these pts with class III: thought it was result of surgical interference. They have class III because that’s what they have, not what the surgeons are doing.

Multidisciplinary team

Geneticist

Plastic reconstructive surgieon

Oral and mx facial surgeon

Otorhinolaryngologist

Audiologist

Speech and language path

Pediatric dentist

Orthodontist

Psychologist

Pediatrician

Social worker

Management

Immed after birth: feeding,

1-4wks;

Alv bone grafting repair: usually done at age 8 and 9 since canines haven’t erupted yet. so now, do cleft repair at 5-6