Published on March 23, 2013
CLEFT LIP & CLEFT PALATE Dr. Ali Yaldrum B.D.S, M.Sc (London) Faculty of Dentistry, SEGi University get in touch
Learning Objectives At the end of this lecture, students should be able to:• Develop an understanding terms Cleft lip & Palate• Develop an understanding of incidence of the condition• Describe the etiology and pathogenesis• Describe classiﬁcation and dental implications
Contents1. Cleft Lip & Palate2. Incidence3. Causes 8. Dental Implications4. Method of Transmission 9. References5. Pathogenesis6. Normal Process7. Classiﬁcation
Cleft Lip & PalateThe term cleft lip & palate is commonlyused to represent two types ofmalformation • cleft lip with or without cleft palate (CL/P)(ﬁg.1) • cleft palate (CP) (ﬁg.2)
sult in clefting.NCE Extraoral Characteristics: Not applicable Perioral and Intraoral Characteristics: Refer to Figure 6.24 for examples of cleft lip, cleft palate, and cleftonsidered to Bilateral cleft of lip & palate (ﬁg.1)
ount for about 70% ofDCR, 2006). he method of transmis- cause of the clefting.dence of autosomal dom-x-linked inheritance pat- cleft of the hard & soft palatesspontaneous mutation orWhile genetic factors ap- (ﬁg.2)r clefting, environmentalelopment of the cleft.ng of some type occurs in
at account for about 70% ofme (NIDCR, 2006).on: The method of transmis-ecific cause of the clefting.bit evidence of autosomal dom-and sex-linked inheritance pat- lt of a spontaneous mutation orenes. While genetic factors ap-dual for clefting, environmental se development of the cleft.l clefting of some type occurs in to 550 live births in the United use of oral clefting is highly re-vidual and the type of cleft in- bilateral cleft have the greatests and the lowest number of en- les with a unilateral cleft have tic influences and the highestctors (Tolarova, July 2005). /palate occurs when there is the palate, premaxilla, and re- e 6th to 8th week of embry- Figure 6.24. Oral clefting. A. Bilateral cleft of the lip and palate. (From Rubin E, Farber JL. Pathology. 3rd ed.ifactorial inheritance impliesn the environment will either Unilateral cleft of lip Philadelphia: Lippincott Williams & Wilkins, 1999.) B. Cleft of the hard and soft palates. (Courtesy of R Chase.) C.ment of a cleft or enhance the Unilateral cleft of the upper lip. (Courtesy of R Chase.) (ﬁg.3)
cleft of lip & palate (ﬁg.4)
Biﬁd uvula (ﬁg.5)
Cleft lip, cleft palate, and the combinationof cleft lip and palate are considered tohave a multifactorial cause, including bothenvironmental and genetic elements.
incidence• common congenital malformation• reported incidence varies from 1 in 500 to 1 in 2500 live births• male:female 2:1• Asian population have higher incidence compared to the caucasian population
Causes• Oral clefts have been linked to genes located on more than several chromosomes including 1, 2, 4, 6, and 19, among others
Causes• maternal smoking (especially more than 20/day) and exposure to passive smoke• Drugs: Accutane, phenytoin, warfarin ethanol• maternal folic acid deﬁciency• ingest large quantities of Vit A
Method of Transmission• Depends on the speciﬁc cause of the clefting.• Multifactorial clefts can exhibit evidence of autosomal dominant, autosomal recessive, and sex-linked inheritance patterns• spontaneous mutation or mutations in one or more genes.
Method of Transmission• If one of the parent has a cleft lip, his/her child face a risk of 20%• If their is one child with cleft lip, the following child faces risk of 14%• A non cleft parent with a cleft lip faces a risk of 4% for the following child
Pathogenesis• The face and facial structures are formed out of three plates, each migrating toward a meeting point in the middle area of the face.
• The facial structures of the orbicularis muscle form the lip. They are joined at the philitrum lines.• join by 4th week of pregnancy
• The palate is then formed out of the structure that begins as the tongue and palate.• Between the fourth and the eighth weeks of gestation, the tongue drops down and the palatal segments then move from the sides and toward the middle, fusing in the center.
• A cleft, therefore, is not something that is formed, so much as it is something that does not form.
Normal Process6 Weeks • Maxillary process • Lateral nasal process • Median nasal processThese three processes join and fuse to form theprimary palate
Normal Process7 WeeksMedian nasal process and maxillary process havefused creating upper lip and anterior maxillaryalveolus
Normal Process8 WeeksComplex totally fused and mesodermal migrationcompleted Tongue, which has been posturedsuperiorly between lateral palatal shelves of maxilla,moves inferiorly allowing palatal processes to growtoward midline and fuse, form nasopalatine foramento uvula
Normal Process11 WeeksTotal palatal closure
Classification• The Veau Classiﬁcation system (table.1)• The Striped-Y Classiﬁcation system (ﬁg.6)
The Veau Classification systemClass Description I Soft palate only II Hard & soft palate to the incisive foramen Complete unilateral of soft, hard, lip, & III alveolar ridge Complete bilateral of soft, hard, and/or lip and IV alveolar ridgeThese descriptions can be modiﬁed with the wordsincomplete, right, left, one/third, and so on. (Table.1)
* 18/9/03 09:14 Página 25 The Striped-Y Classification First East Indian International Cleft Surgery Workshop system R L I Lip Alveolusion in clefts is considerable. Primary palate N y to record a cleft lip is by Foramen hy. A better way to record a incisivum t is to fill in the followingh stripes and dots. Vomer T Spinae Soft pa late R R L (ﬁg.6) O
figure with stripes and dots. Vo Soft pa lat R L Fig. 2 Cleft palate R L Cleft palate (ﬁg.7) Fig. 3
Fig. 2 Cleft palate R L Fig. 3 Left-sided unilate cleft lip and palat R LLeft-sided unilateral complete cleft lip and palate (ﬁg.8) Fig. 4 Bilateral complete
Fig. 3 Left-sided unila cleft lip and pal R L Fig. 4 Bilateral comple and palate R LBilateral complete cleft lip and palate Fig. 5 (ﬁg.9) Bilateral-right i complete-cleft li
Fig. 4 Bilateral compl and palate R L Fig. 5 Bilateral-right complete-cleft l palateBilateral-right incomplete, left complete- cleft lip and primary palate 25 (ﬁg.10)
Dental Implications• The dental implications of cleft lip and/or palate depend on the number of dental abnormalities present and the stage of treatment.• The dentist play an important role in managing the care of the individual with a cleft lip and/or palate through education and preventive dental hygiene therapy.
• Numerous surgical and other medical and dental treatments are necessary to correct cleft lip/palate. The surgeries are scheduled starting at about 3 months of age & ending at about 1 year to correct simple clefts.
References• Dr. B. Sudarshan & Dr. Bhanu Murthy, “Plástikos - Cleft Surgeons & Doctors - Smile Train Partners” in First East Indian International Cleft Surgery Workshop, 2003. http://medpro.smiletrain.org.uk/library/images/WS-India-Manual.pdf• Leslie DeLong, Nancy W. Burkhart, “Developmental, Hereditary and Congenital Disorders” in General Oral Pathology for Hygienists, 1st Edition, Lippincott Williams and Wilkins, 2008 pp 110-146.• Development of Face, Interactive guide: http://www.indiana.edu/~anat550/ hnanim/face/face.html
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