Cleft Palate

Question 1

Define Cleft lip and palate

Answer 1

• Most common cranio-facial abnormality in human.
• 1 in 700 live births in UK
• CP often associated with syndromes

Question 2

Incidence

Answer 2

• Unilateral CLP - 25%
• CP - 50%
• bilateral CLP - 10%
• CL - 10%
• Submucosa cleft 5%

Question 3

Sex distribution Incidence

Answer 3

• Unilateral CLP male : female 2:1
• CP male : female 2:3
• CL male : female 2:1

Question 4

Racial bias incidence

Answer 4

• Japanese > Caucasian > Afro Caribbean
• Unilateral clefts more common on left - L:R 2:1
• 15% cleft associated with other syndromes

Question 5

CP is 15% associated Other syndromes like?

Answer 5

• Sticklers
• Van der Woudes
• Pierre Robin Sequence
• Downs
• Di George/ 22 q

Question 6

Aetiology of CLP

Answer 6

• Unknown , Polygenic and multifactorial.
• Genetics - few single genes known e.g IRF 6 mutation leading to Van der woude syndrome. CL OR PALATE with lower lip pitting.
• Environmental e.g. Retinoids, anti folate drugs, temperature, hypoxia , seasonal, maternal smoking ( first trimester) , diet , Vitamin B6 deficiency .

Question 7

Genetic risks

Answer 7

• Unaffected parents with 1 effected child:
  Risk of next child being affected : CLP 1:25(4%) CP 1:80.
• 1 affected parent :
  Risk of first child being affected : CLP 1:50 (2%).
• 1 affected parent and child :
  Risk of second child being affected: CLP 1:10 (10%)
• 2 affected parents
  Risk of first child being affected: CLP 3:5 (60%)

Question 8

CSAG - Clinical standard advisory group 1998

Answer 8

• 57 centres 50% operating <5 Clefts a year
• Outcome was poor , re organised
• managed clinical network
• South wales and south west
• Bristol and Swansea
• 100 new births per years

Question 9

Overall care - Team Approach
Management involve many specialties.

Answer 9

• Corrective Surgery ( Plastics, OMFS - Oral maxillofacial surgeon.
• Speech (SLT)
• Hearing ( Audiologist, ENT)
• Dental ( Paediatric, Orthodontic, Restorative).
• Psychological

Question 10

Prenatal diagnosis

Answer 10

• CL can be detected with ultrasound scanning but the palate is more difficult to detect.
• Due to head position and small size of the face not usually reliable until at least week 15 IU.

Question 11

Time scale.

Answer 11

• 3/12 months Lip repair
• 6-9/12 palate repair
• 5 yrs Audit records
• 8-11 yrs Alveolar Bone graft
• 10 Audit records
• 15 Audit records
• 20 Audit records

Question 12

Classification

Answer 12

• There are many e.g. Veau, Kernahan and Stark but it is easier to describe cleft.
• A - No cleft
• B - Celft lip
• C- unilateral complete Cleft lip and palate
• D- Bilateral Complete cleft lip and palate
• E- Cleft palate

Question 13

Children with born with cleft palate have many problems which may include:

Answer 13

• Feeding- Cannot suckle because negative intra - Oral pressure cannot be created)
• hearing
• Speech
• Disruption of facial growth.
• Disruption of dental development
• Dental anomalies
• Dental caries
• Psychosocial
• morbidity and mortality associated with treatment

Question 14

Feeding -

Answer 14

• Contact within 24hours
• Specialist nursing
• breast feeding rarely possible
• Use special soft bottle
• Sympathetic support
• Haberman - soft bottle

Question 15

Dental issue

Answer 15

• Hypodontia
• Supernumaries
• Hypoplasia
• Microdontia
• Delayed eruption of teeth on cleft side
• increased incidence of ectopic canine.
• Increased incidence of impacted 6.
• Increased incidence of crossbite (19%).
• Dental caries - GDP preventative treatment is essential and should start in first year of life.

Question 16

How to treat it?

Answer 16

• Lip surgery - usually at 3months
• Soft hard palatal surgery - Usually in the first year of life.
• Alveolar bone grafting ( Unites major and minor segments in clefts of lip and palate) - usually around age of 7-8 yrs. the graft also allows the canine to erupt in bone.

Question 17

Lip repair

Answer 17

• 3/12 months
• Correct muscle layer
• Aesthetic
• Functional e.g. Millard , Delaire

Question 18

Palate repair

Answer 18

• 6-9/12 months
• Close hard palate
• Velopharyngeal competence
• Function - speech

Question 19

Orthodontic treatment

Answer 19

1- Pre surgical orthopaedic
2- Pre bone graft orthodontics
3- Orthodontic
4- Orthodontic with osteotomies

Question 20

Pre- Surgical Orthopaedics

Answer 20

• Help with growth
• facilitate feeding
• Reduce gap aiding surgery
• Birth to 3 months / 6months
• Questionable benefit ?

Question 21

Factors in cleft palate speech

Answer 21

• Nasal emission
• Nasal turbulence
• Hyper-nasality
• Nasal grimace

Question 22

Speech cleft type characteristics

Answer 22

• Anterior error
• Posterior error
• Non oral error and passive error

Question 23

2- Alveolar bone grafting -

Answer 23

• Alveolar defect
  -Repair ONF
• Alar base support
• One part of maxilla for Osteotomy
• Continuity of dental arch
• stabilise pre maxilla BCLP
• increase restorative options

Question 24

Pre bone graft Orthodontics

Answer 24

• Expand upper arch laterally
• Correct anterior x bite
• Split incisors in BCLP patient

Question 25

Donor site for bone grafting

Answer 25

- Iliac crest - Tibia - Mandible symphysis - Cranium - Rib - Bio- oss (avoid).

Question 26

Growth - South west

Answer 26

- 25% Osteotomies - BCLP > UCLP - Male > Female