Management of Patients with Orafacial Clefts Medical Assignment Help

CHAPTER OUTLINE

EMBRYOLOGY ,
tAUSATIVE fACTORS
PROBLEMS OF CLEFT-AFFLICTED INDIVIDUALS
Dental Problems
Malocclusion
Nasal Deformity
Feeding
Ear Problems
Speech Difficulties
Assoclated Anomalies
TREATMENT OF CLEFT LIP AND PALATE
Timing of Surgical Repair
Cheilorrhaphy
Objectives’
Surgical Techniques
Palatorrhaphy
Objectives
Surgical Techniques
Hard Palate Closure
Soft Palate Closure
Alveolar Cleft Grafts
Timing of Graft’ Procedure
Surgical Procedure
Correction of .Maxillomandibular Disharmonies
Secondary Surgical Procedures
DENTAL NEEDS OF CLEFT-AFFLICTED INDIVIDUALS
. Prosthetic Speech Aid Appliances

 Acleft is a congenital abnormal space or gap in , the upper lip, alveolus, or palate, The colloquial’ term for this condition is harelip. The use of this
term should be discouraged, because it carries demeaning connotations of lnferlority, The more appropriate terms are cleft lip, cleft palate, or cleft ‘lip and palate. ‘ Clefts of the lip and palate are the most common serious
congenital anomalies to affect the orofacial region. Their initial appearance may be grotesque. Because they are deformities that can be seen, felt, and heard, they constitute a serious affliction to those who have them. Because of their location, they’ are deformities that involve the dental specialties throughout their protracted course of treatment. The general dentist will become involved in managing these patients’ special ‘dental needs, because they may’ have partial anodontia and supernumerary teeth. Malocclusion is usually present orthodontic therapy with or without corrective jaw
surgery is freque ntly indicated.The occurrence of a cleft deformity is a source of  slderable ,shock to the parents of an afflicted ‘baby, and the, most appropriate approach to the parents is one of  informed explanation and reassurance. They should be told that the defects are correctable and need not adversely affect the child’s future. However, they shouldbe pre-‘ . pared for a protracted course of therapy to correct the deft deformities and to allow the individual to function with them.

FIG. 27-' Ventral view of palate,.Iip, and nose showing variability of cleft lip and palate deformity. A, Normal. B, Unilateral cleft lip extending into nose. C, Unilateral cleft involving lip and alveolus, extending to incisive foramen. 0, Bilateral cleft involving lip and alveolus. E, Isolated cleft palate. F, Cleft palate combined with unilateral cleft of alveolus and lip. G, Bilateral complete cleft of lip and palate. (From Langman J: Medical embryology, ed 3, Baltimore, 1975, Williams & Wilkins.)FIG. 27-' Ventral view of palate,.Iip, and nose showing variability of cleft lip and palate deformity. A, Normal. B, Unilateral cleft lip extending into nose. C, Unilateral cleft involving lip and alveolus, extending to incisive foramen. 0, Bilateral cleft involving lip and alveolus. E, Isolated cleft palate. F, Cleft palate combined with unilateral cleft of alveolus and lip. G, Bilateral complete cleft of lip and palate. (From Langman J: Medical embryology, ed 3, Baltimore, 1975, Williams & Wilkins.)

FIG. 27-‘ Ventral view of palate,.Iip, and nose showing variability of cleft lip and palate deformity.
A, Normal. B, Unilateral cleft lip extending into nose. C, Unilateral cleft involving lip and alveolus,
extending to incisive foramen. 0, Bilateral cleft involving lip and alveolus. E, Isolated cleft palate.
F, Cleft palate combined with unilateral cleft of alveolus and lip. G, Bilateral complete cleft of lip and
palate. (From Langman J: Medical embryology, ed 3, Baltimore, 1975, Williams & Wilkins.)

The problems encountered in rehabilitation of patients – with cleft deformities are unique. Treatment must address patient appearance, speech, hearing, mastication, and deglutition. A team manages most children currently affected with orofacial clefts. Cleft teams are found in most cities of at least moderate size. These teams commonly comprise a general or pediatric dentist, ‘an orthodontist, a prosthodontist, an oral and maxillofacial surgeon or a plastic surgeon, an audiologist, .an otorhinolaryngologist, a pediatrician, a speech pathologist, a psychologist or psychiatrist, and a social worker. The number of specialists required reflects the number and “complexity of the problems faced by individu als with orofacial clefts.The occurrence of oral clefts in the United States has been estimated as 1 in 700 births. I Clefts exhibit interesting racial predilections, occurring less frequently in bl-acks but more so in Asians. Boys are affected by orofacia I clefts more often than girls, by a ratio of 3:2. Cleft lip and palate (together) occurs about twice as often in boys as in girls, whereas isolated clefts of the palate (without cleft lip) occur slightly more often in girls. Oral clefts commonly affect the lip, alveolar ridge) and . hard and soft palates. Three fourths are unilateral defermities; one fourth are bilateral. The left side is involved more frequently than the right when the defect is unilateral. The cleft may be incomplete, that is, it may not extend the entire distance from lip to soft palate. Cleft lip may occur without clefting of the palate, and isolated cleft palate may occur without clefttngof the lip (Fig. 27 -1). A useful classification divides the anatomy into primary
and secondary palates. The primary palate involves

FIG. 27-2 Photographs of various types of cleft deformities. Nasal deformities are also apparent. A, Unilateral complete cleft of lip and palate. B, Bilateral complete cleft lip and palate. C, Palatal view of bilateral complete cleft lip and palate. The nasal septum is unattached to either palatal shelf. 0, Isolated cleft of soft palate.

FIG. 27-2 Photographs of various types of cleft deformities. Nasal deformities are also apparent.
A, Unilateral complete cleft of lip and palate. B, Bilateral complete cleft lip and palate. C, Palatal view
of bilateral complete cleft lip and palate. The nasal septum is unattached to either palatal shelf. 0, Isolated
cleft of soft palate.

those structures anterior to the incisive foramen-the lip and alveolus; the secondary palate consists of those structures posterior to the incisive foramen-the hard and soft yalates 2 Thus an individual may have clefting of the primary palate, the secondary palate, or both (Fig. 27-2). Clefts of the lip may range from a minute notch on the edge ‘of the vermilion border to a wide cleft that extends into the nasal cavity and thus divides the nasal floor. Clefts of the soft palate may also show wide-variations from a bifid uvula to a wide inoperable cleft. The bifid uvula is. the most minor form of ‘cleft palate, in which only the uvula is clefted. Submucosal clefts of the soft palate are occasionally seen. These clefts are also called occult clefts, because they arc not readily seen on cursory examination. The defect ill such a cleft is a lack of continuity in the musculature of the soft palate. However,  the nasal and oral mucosa is continuous and coversthe muscular defect. To diagnose such a defect, the dentinspects the soft palate while the patient says This ~on lifts the soft palate, and in individuals  it submucosal palatal clefts, a furrow in the midline is seen can also palpate the posterior aspect of the hard palate to detect the absence’of the posterior nasal spine, which is characteristically absent in submucosal clefts. If a patient shows hypernasal speech without an obvious soft palatal cleft, the dentist should suspect a submucosal cleft of the soft-palate.

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