唇裂腭裂CLEFTLIPANDPALATE.ppt

1、 cleft lip and cleft palate normal lip with anatomical termsvvermilion :the lower margin of the upper lip is called the vermilion and is characterized by its rosy color. vcupids bow : the term cupids bow is used to describe the concave or dipped portion of the vermilion border in the center of the u

2、pper lip vtubercle:vpeak of the cupids bow:vphiltrum/philtral dimple: the portion of the upper lip between the two philtral columns is known as the philtrumvphiltral columns or lines: above the center of the upper lip is a dimple called the philtral dimple, and the raised ridges on either side of th

3、is dimple are the philtral columns or linesnormal lip with anatomical termstypes of facial clefts cleft lip median cleftlateral facial cleftoblique facial cleftmedian facial cleft lateral facial cleft(hemifacial macrosomia)bilateral oblique facial cleftcleft lip 1.definition of cleft palatevcleft li

4、p, sometimes called harelip, is a congenital malformation of embryonic origin that affects the lip . it occurs by itself or together with an alveolar or palatal cleft.2. incidencevthe incidence of oral clefts varies from 1 to 2.21/1000 .vthe incidence of cleft lip varies across races(approximately 1

5、 to 1000 for whites and 0.41 for blacks in united states).vmale preponderance is marked in the more severe or complete cleft lip , the male : female ratio being approximately 3:2. vin most series cleft lip with cleft palate is reported as 1.5 to 3 times as frequently as isolated cleft lip.2. inciden

6、cevin china, the incidence is about 1.8/1000 ,and the condition occurs more frequently in males than females.3. etiology the cause of clefts is not understood very well. whilst we know what happens, we do not know why.vparental agevdrug use vinfections during pregnancyvsmoking or/and drinking during

7、 pregnancyvheredity , family history vx-ray,microwavevdeficiency of vitamin c,d,bvenvironmental factors5.types of cleft lip although many classifications have been proposed, we prefer to use definitive and descriptive terms in order to avoid confusion:v1.according to the position: a cleft lip may be

8、 unilateral or bilateral .upper lip cleft and left-sided occurrence are more frequent than the lower and the right side. a median cleft and clefts of the lower lip are extremely rare. 5.types of cleft lipv2. according to the extent: the cleft may vary in extent, being either incomplete or complete.

9、1) a complete cleft lip : is one in which the cleft extends through the floor of the nostril. this type is almost invariably accompanied by an alveolar or palatal cleft . 2) an incomplete lip cleft :often varies merely a nothing of the vermilion border, to one that extends partway up toward the thre

10、shold of the nostril. occasionally shows a scarcely perceptible notching of the vermilion border and a slight grooving of the skin surface ,indicating an imperfect muscular union beneath.unilateral cleft lip unilateral complete cleft lipunilateral incomplete cleft lipunilateral incompletecleft lipun

11、ilateral incompletecleft lipunilateral complete cleft liplb bilateral cleft lip bilateral incomplete cleft lip bilateral complete cleft lip bilateral mixed cleft lipbilateral complete cleft lip17-year-old girl with bilateral cleft lip and cleft palate bilateral cleft lip/palate bilateral cleft lip/p

12、alate bilateral mixed cleft lip5. presenting features deformity and dysfunction arising from primary abnormality will lead to :vseparation of the lip vabnormal facial developmentvspeech anomalies: usually not serousvairway abnormalitiesvfeeding problems vpsycho-social difficulties: associated with a

13、esthetic and functional deficienciesvin almost every lip cleft there is an associated nasal disfigurement. this usually, but not always, varies in severity in direct proportion to the width of the cleft. thus an incomplete cleft may exhibit only a slight spreading and flatness of the affected nostri

14、l, while in a wide bilateral cleft the nostrils are extremely flattened and distorted the nasal tip retracted, and the nasal columella shortenedvthe muscles of the mouth in cleft lip fail to meet in the midline and thus seek other attachments. these substitute attachments prevent the muscles from be

15、coming fully functional, and their development is incomplete.6.treament1.team approach the management of clefts requires the participation of the following experienced specialists: a surgeon : such as a plastic surgeon, an oral/maxillofacial surgeon, a craniofacial surgeon, or a neurosurgeon an audi

16、ologist : who assesses hearing a pediatric dentist or other dental specialist: such as a prosthodontist, who makes prosthetic devices for the mouth);van orthodontist : who straightens the teeth and aligns the teeth and jaws.va geneticist : who screens patients for craniofacial syndromes and helps pa

17、rents and adult patients understand the chances of having more children with these conditionsteam approachva nurse : who helps with feeding problems and provides ongoing supervision of the childs healthvan otolaryngologist : an ear nose and throat doctor, or entva pediatrician : to monitor overall h

18、ealth and developmentteam approachteam approachva psychologist or other mental health specialist: to support the family and assess any adjustment problemsva speech-language pathologist : who assesses not only speech but also feeding problemsvand other necessary specialists : who treat specific aspec

19、ts of complex craniofacial anomalies.team members2. surgical repair of cleft lip timing of operation : selecting a suitable time to operate on the cleft lip varies from surgeon to surgeon. some clinics prefer operating on the infants immediately following birth, preferably within 48 hours, even 24ho

20、urs. others consist that the surgery should be delayed for a minimum of 8 to 10 weeks following the birth.rule of tensvalthough there are still many different opinions, the most accepted standpoint is that lip repair should be carried out when the childs general health and weight permit the safe ind

21、uction of general anesthesia. anesthesia.vthe time-honored “rule of tens” is a useful guide to the timing of surgery: according to this rule, lip repair should be carried out when the child has attained a weight of 10 pounds, is 10 weeks old, and has a hemoglobin concentration higher than 10 milligr

22、am/dl .timing of operation in china v1. unilateral cleft lip : 36 months oldv2. bilateral cleft lip : 612 months old v the purpose of repair: a. restoration of normal/near normal anatomy b. restoration of normal/near normal function c. promotion of normal/near normal development resulting in satisfa

23、ctory2. surgical repair of cleft lipvthe purpose is, of course, to restore the anatomic parts to their proper positions to promote normal growth and development. van effective repair must realign the vermillion and cupids bow of the lip, reconstruct the upper lip and philtrum, and reapproximate the

24、orbicularis oris muscle within the repair. 2. surgical repair of cleft lip criteria for lip repairvaccurate skin, muscle, and mucous membrane unionvsymmetrical nostrils, symmetrical nostril floorsvsymmetrical vermillion bordervpreservation of the cupids bow va minimal scar2. surgical repair of cleft

25、 lipv anesthesia : general anesthesia is used.2. surgical repair of cleft lip(taking unilateral lip repair as an example) v methods of unilateral lip repair: tennision-randall method ( triangular flap method ) millard method : ( rotation-advancement method ) it is the most popular technique for unil

26、ateral cleft lip described by millard. millard method the first step : markingsvmidline nadir 2vpeaks of cupids bow 1,3vnew cupids bow peak on cleft side 4vthe extent of rotation curve 5vcommissures 6,7valar base on cleft side 8vthe incision is made along line 6-3,3-5 and 8-7-4 millard method the se

27、cond step : making the incisionvthe incision is made along line 6-3,3-5 and 8-7-4 va rotation incision on the medial side permits the entire cupids bow component to drop down into the normal position.vthe flap b helps to pull the columella and membranous septum into position.vthe defect between a an

28、d b is then filled by the advancement flap c from the lateral side.advancement of the lateral flap c rotates the ala into position and corrects the deformity of the nostril.millard method the second step : suture vthe longitudinal incision 5-3 follows and imitates the natural line of a philtral colu

29、mn.vthe z-plasty in the upper portion of the lip is hidden in the shallow and in the crease lines of the nostril floor. vthe muscle and subcutaneous sutures should be carefully applied.vunilateral cleft lip on the left side.abdominopvto repair a cleft lip, the surgeon will first make an incision on

30、each side of the cleft from the lip to the nostril.vthe cleft lip is then drawn together and stitched 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.definition of cle

31、ft palatevcleft palate is a congenital malformation of embryonic origin that affect the palate . it occurs by itself or together with an alveolar or lip cleft.2.incidence of cleft palatevthe incidence of cleft lip and palate varies with different races.vthe incidence of cleft palate alone is 1 out o

32、f 2,500 people according to reports from ada.breakdown of facial clefts3. etiology vas with cleft lip, the etiology of cleft palate is multifactorial. vanimal models have demonstrated that vitamin a, corticosteroids, and phenytoin produce cleft palate when given in pregnancy. 4.classification v1.cle

33、ft of the soft palate onlyv2.incomplete cleft of palate : extending no further than the incisive foramen.1342v3.complete unilateral cleft : extending from 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 fu

34、ture lateral incisor tooth.v4.complete bilateral cleft : resembling type 3 with two clefts extending forward from the incisive foramen through the alveolus.1342cleft of the soft palate onlycomplete unilateral cleftcomplete bilateral cleftcomplete bilateral cleftunilateralcomplete cleft lip and palat

35、ebilateral complete cleft palate and lipbilateral cleft lip and palate bilateral cleft lip and palate velopharyngeal closurevduring speech and swallowing the palate moves both superiorly and posteriorly against the posterior pharyngeal wall to separate the oral pharynx and nasal pharynx.this is call

36、ed velopharyngeal closure.vwhen palate is cleft ,however, not only is there inadequate velopharyngeal closure but, in addition , the opening in the palate permits the air stream to pass partly through the nose. thus ,the air stream ,passing through both nasal and oral cavities, can not be altered pr

37、operly to produce the normal sounds.5.symptoms vseparation of the palate vspeech and/or language problem: nasal voicevrecurrent ear infections vnasal regurgitations during bottle feeding vpsychological problems : of the adolescent or adult patients and patients families.feeding bottles and teats for

38、 babies born with cleft lip and/or palatevan infant with a cleft will have problems sucking as communication with the nasal cavity will allow air to pass into the oral cavity instead of drawing milk from a feeding bottle or the breast. thus, squeezable bottles with a directional teat, or a variable-

39、flow teat and pump-action valve, are required vthe cleft lip and palate association recommends that normal feeding methods should be encouraged. 6.treament 1.team approach2.timing of operation vin china , surgeons most commonly carry out the surgical repair of cleft palate when the patient is 3 year

40、s old ,whatever incomplete or complete, unilateral or bilateral.3.aim of operationvthe ultimate aim of cleft palate surgery is to produce a palate that is able to fulfill the two main functions of the normal hard and soft palate.v1.the first is to maintain a mechanical partition between the oral and

41、 nasal cavities, thereby preventing the introduction of foreign bodies into the nasal cavity, with the consequent possibility of infection of nose and middle ear.v2.the second function of palate is its participation in speech production , or we can say to gain adequate velopharyngeal closure.3.metho

42、d of operation(taking incomplete cleft as an evample)vv-y retroposition (“push-back”) procedurevgeneral anesthesia is used and the palate is injected with 0.25% lidocaine with 1:200,000 epinephrine solution to reduce blood loss.va .outline of incision.b .the flaps are raised.c .suture of the mucous

43、membrane.d .position of the flaps at the completion of the operation. 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.before and after surgeryspeech therapy vthe effect of a cleft lip and palate on s

44、peech is very variable and not always related to the type or extent of the original problem. generally however, a cleft lip without a cleft palate rarely has any effect on speech. sometimes if the cleft lip involves both sides, or if the gum is also affected, there may be some minor speech difficult

45、ies. speech therapyvchildren with cleft lip and palate commonly need speech therapy. speech production requires coordination of the tongue, hard and soft palate. this coordination is achieved by the movement of the muscles within the tongue and soft palate. children with cleft palate have an abnorma

46、l insertion and movement of the muscles within the soft palate. they may also have poor coordination of the tongue movements and its placement. this results in an abnormal speech requiring speech therapy.treatment goal of speech therapyvthe goal of speech therapy is to elimination of the patients pa

47、rticular speech disorders by the time the child enters kindergarten. methodvactivities for therapy should be done in a natural and fun way where possible and parents should not place the child under pressure. here are some guidelines recommended to parents:v1.talk to your child from a very early age

48、. do not just do an activity; talk your child through it, e.g. at bathtime, “heres the soap/water/towel etc.”, “mammy is washing”, “washing hands/face/toes etc.”. v2. name everyday items such as cup, spoon, plate, car, door, dog, bricks etc. for your child to help him/her to understand and use vocabulary. v3. going through simple picture books and naming