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Management of cleft lip and palate in children

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by

James Min

on 8 September 2012

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Transcript of Management of cleft lip and palate in children

By James Min Management of cleft lip and palate in children Challenging Varies with race, geographics, sex, socioeconomic status
Second most common congenital abnormality in newborns
1 in 700 live births in caucasians
Increased rate in males
Left side unilateral left lip common
Highest for Native Americans, Asians
Lowest for Blacks Incidence and prevalence Involves the
Child,
Family,
Specialists Functional Bonding
Finances
Psychological
Schooling Cleft surgeons
ENT surgeons
Plastic surgeons
Oral surgeons
Orthodontists
Speech therapists
Audiometrists
Clinical psychologists
Paediatric dentists
Prosthodontists
Geneticists 70% x 3.6 x 1.5 x 0.4 CL[P]: 60% CP: 40% CL[P]: Cleft lip +/- cleft palate
60%
Higher for males
Higher hereditary role
If unilateral, usually left side 2:1 70% Cleft lip +/- cleft palate Cleft palate (isolated) CP: Cleft palate
40%
Higher for females
Higher environmental role
Ranges from bifid uvula to hard/soft palate Multifactorial aetiology Genetic Environmental Maternal smoking
Alcohol
Corticosteroid use
Phenytoin
Benzodiazepine
Folic acid deficiency
Part of a syndrome (over 400 syndromes associated) such as Gorlin syndrome or Fetal Alcohol Syndrome Aesthetic Lack of suction
Feeding problems
Nasal regurgitation
Poor hearing
Learning to speak
Middle ear infections
Nasal speech
Malocclusion
Bonding with the mother Psychological
Sociological Management sequence 1 2 3 4 5 6 7 0 months:
Neonatal orthopaedics 3-12 months:
Repair of lip and anterior maxilla
by plastic surgeon
Delaire
Millard
Vomer flap (at the same time?) 9-18 months:
Repair of the palate by plastic surgeon

Von Langenbeck
Vomer flap Pros and Cons Popular as it uses minimal repair whilst creating functioning soft palate Delaying repair decreases growth disturbances but speech is affected. However repair is done early for functional reasons 18 months:
Routine assessment looking at
Play skills
Social development
Interaction
Receptive language
Expressive language
Consonant production 5 years:
Revision of lip repair. Often considered before schooling or at the time of ABG 7-10 years:
Orthodontics
ABG: alveolar bone grafting 12-18 years:
Orthodontics
Orthognathic surgery Speech and hearing assessments right through to late teens to early adulthood Many individuals are in their early 20's before being fully discharged from the cleft team Other optional procedures available Optional procedures
Making scars less noticeable
Improve facial appearance
Improving bite
... etc Delaire Millard technique
R is brought inferiorly
A is brought into resulting defect
C creates nasal sill Subperiosteal dissection
Skin boundaries respected
Curvilinear incision along medial cleft margin Von Langenbeck
Use of mucoperiosteal flaps to repair palate
Edges incised and lateral incisions made, then flaps elevated and positioned medially for suturing Vomer Flap
Vomer bone used to reconstruct the palate and cover the cleft
Vomerine mucoperiosteal tissue is versatile
Popular for anterior cleft palate
Disadvantages
Vomer is variable in size (suitablility?)
Vomer mucosa not complete match with oral mucosa ABG Maxilla/premaxilla are 2 separate portions forming alveolar cleft
Considered when canines are over half formed (8.5-10.5years)
Need alveolar molding with orthodontic appliances first
Bone from iliac crest and packed into mucoperiosteal pocket Alveolar Bone Graft Bone for canines to erupt
allows tooth movement into cleft
bony support for alar base
aids closure of oronasal fistula
helps stabilise premaxillary segment (in bilateral cases) Feeding Problem? ? ? ? Anatomical deficiency
Unable to create negative intra oral pressure
Cannot lift the soft palate to seal off nasal airway and create oral seal with nipple or bottle (even with small clefts)
Prolonged feeding times, nasal regurgitation, failure to thrive Some tips include
Patient breastfeeding
Infant in upright position
Small, regular feeding
Burp frequently (due to swallowing air)
Pump breast milk via bottle or specially designed nursing bottles Nasoalveolar molding with palatal obturator
Occludes oronasal fistula
Assists speech and nasal regurgitation
Consists of wires and acrylic nasal stents attached to a denture
Molds nasal cartilages, premaxilla, and alveolar ridges into ideal form prior to surgery The Quad helix
Expands the arch to a favorable form prior to ABG
Cemented to first molars
2 or 4 active helix springs
May correct crossbites if present (common)
Other orthodontic treatments may be required (e.g. for alignment, cosmetics, surgery preparations, palatal lift appliances etc) Specialist Nurse
Full history of pregnancy and delivery
Clinical exam of the child (mechanical and neurological)
Other anomalies Cardiac
Respiratory
Neurological ... Velopharyngeal inadequacy Speech Velopharyngeal inadequacy
The inability to close off the nasal cavity by lifting the soft palate (cleft palate*)
Opening of the roof of the mouth
Decrease in muscle function
Delay in speech/abnormal speech Mild hypernasality?
Speech delay?
Articulation disorder? Speech therapy Functional deficit? Palate Surgery Prosthetic appliances Pharyngeal Flap
Sphincter pharyngoplasty Speech bulb: partially closes off the space between the throat and the soft palate
Palatal lift: lifts the soft palate so that closure is possible Hearing 95-100% of infants born with a cleft palate have fluid present in their middle ear at birth
Hearing loss from 3-90% Sataloss J., Fraser M. If left untreated, middle ear effusion can continue to occur for many years. Fluid build up leads to hearing loss and infection

Recall, in the normal individual, fluid in the middle ear drains via the eustachian tube. Those with a cleft palate have a dysfunction tube. Hearing problems
Audiologist (and speech pathologist) should regularly screen for hearing problems
May indicate
An ear infection
Barrier to speech
Barrier to language
Barrier to socialisation Management
Decongestants
Antibiotics
Placement of grommets
Surgical closure of the palate (eustachian tube improves function over time) Psychological PSYCHOLOGICAL PROBLEMS Low self esteem Self consciousness Frustration Hostility Needle phobia Expectation Bullying Behavioural problems Social withdrawal Social workers Psychologists Psychiatrists Occasionally* Assist these children and families adjust to psychosocial problems Social workers can also provide many families with obtaining community resources Conclusion
Challenging
Multidisciplinary
Psychological
Functional (including feeding, speech and hearing)
Strategic management
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