Cleft Lip And Palate Management

Cleft Lip And Palate Management

Ismael, Colmenares Joseph de Veyra Al Goytia

Statistics  CL

+Palate 1 in 1000 live births (Aus)  1 in 500 (Asians) 1 in 2000(African)  CP 1 in 2000 all races  CL+P:CL:CP =2:1:1  Left:Right:Bilateral is 6:3:1

What went wrong?

Cleft Lip    

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Oral clefting occurs when the tissues of the lip and/or palate of a fetus don't grow together Children with clefts often don't have enough tissue in their mouths, tissue they do have isn't fused together properly to form the roof of their mouths. A cleft lip appears as a narrow opening or gap in the skin of the upper lip that extends all the way to the base of the nose. A cleft palate is an opening between the roof of the mouth and the nasal cavity. Some kids have clefts that extend through both the front and rear part of the palates, while others have only partial clefting.

The three common kinds of clefts 1. cleft lip without a cleft palate 2. cleft palate without a cleft lip 3. cleft lip and cleft palate together

Why it went wrong!  Unknown  Medications  Smoking  Parental

Age  Family History  Racial  Gender  Syndromic(17.5%CP have Sticklers)

Antenatal Diagnosis

Surgery for Oral Clefting 

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Surgery is usually performed during the first 3 to 6 months to repair cleft lip and between 9 and 14 months to repair the cleft palate. Both types of surgery are performed in the hospital under general anesthesia. Cleft lip often requires only one reconstructive surgery, especially if the cleft is unilateral. The surgeon will make an incision on each side of the cleft from the lip to the nostril. The two sides of the lip are then sutured together. Bilateral cleft lips may be repaired in two surgeries, about a month apart, which usually requires a short hospital stay.

 Cleft

palate surgery involves drawing tissue from either side of the mouth to rebuild the palate.  It requires 2 or 3 nights in the hospital, with the first night spent in the ICU.  The initial surgery is intended to create a functional palate, reduce the chances that fluid will develop in the middle ears, and help the teeth and facial bones develop properly.  In addition, this functional palate will help speech development and feeding abilities.

 Later

surgeries are usually scheduled at least 6 months apart to allow time to heal and to reduce the chances of serious scarring.  It's wise to meet regularly with the plastic surgeon to determine what's most appropriate in your child's case.  Final repairs of the scars left by the initial surgery may not be performed until adolescence, when facial structure is more fully developed.  Surgery is designed to aid in normalizing function and cosmetic appearance so that kids will have as few difficulties as possible.

Fetal Lip Repair

Birth

Lip Repair

Bilateral Lip Repair

Lip:post operative management  Arm

splints for 10 days  Breast feed best  Syringe feed,cup and spoon  Avoid hard teats  Home at 24-48 hours  If required, sutures out at 1 week  Massage scar tds, warn about contraction

Palate repair

Palate:post operative care  Risks

are airway and bleeding  Arm splints  Clear fluids overnight  Syringe, sipper cup,spoon soft diet as tolerated  Home at 48-72 hrs  Secondary bleed at 7-8 days

Hearing

Cleft Palate  97%

have otitis media  Eustachian tube dysfunctionmechanism unknown ?mechanical  Best time for grommet insertion is 3 months (at time of Cleft lip repair or 6 months if palate repaired only)

Touch Ups

New surgical technique promises hope for Cleft Palate Patients 

A Mayo Clinic laboratory study in animals suggest that using distraction osteogenesis, a procedure that uses the mechanical force of an appliance to lengthen soft tissue and bone, may be a feasible and effective method to repair cleft palate in the future

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The distraction osteogenesis method is designed to gradually lengthen the bone of the palate through tension.

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An appliance made of a central body piece, four plates and screws is surgically inserted with the patient under anesthesia.

 After

a rest period of 10 days, a key in the appliance is turned slightly each day for four weeks to slowly lengthen the bone and soft tissue. Finally, the device is surgically removed.  Currently, standard treatment for cleft palate repair involves surgery in which the mucosal flaps of the roof of the mouth are sewn together over the cleft.  The actual missing bone is not repaired.

Problems associated with the current Cleft Palate surgery method

 Leaves

exposed areas of hard palate bone, producing scars that sometimes interfere with the child's later midfacial growth.  Poor cosmetic appearance is usually the result of midfacial growth and can result in poor contact between lower and upper teeth when the child's mouth is closed.  An increased risk of the wound splitting open or the creation of an abnormal passage between the mouth and nose is a possibility.  The current repair method also may shorten and scar the soft palate, which can impair speech.

Laboratory Trials  The

study of this method of cleft palate repair was conducted on 10 adult hounds, due to similarities to the human mouth.

 Two

hounds served as study controls and had a surgically created cleft palate, but no subsequent repair.

 In

the other eight hounds, the distraction osteogenesis device was used to close the cleft palate.

Laboratory Results 

In 7 of the 8 hounds that were treated, researchers observed some degree of bony closure of the cleft; in 5 of them the cleft was closed completely with no side effects.

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The researchers are currently working on perfecting the technique through study of the hounds with incomplete closure.

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The researchers also felt that the distraction osteogenesis device used in this study was too bulky, so they are now testing another more agile apparatus, says Dr. Moore. (Eric Moore, M.D., Mayo Clinic otorhinolaryngologist and one of the study's investigators.)

Help International  Help

International travels with a team coming from Cedars Sinai  The trip is 10 days in total including 5 days of surgery.  Each day the team performs about 130 surgeries and work around 13 hrs.  Their days starts around 6 am and ends at 10pm by the time they get to camp.  They provide their own supplies from or tables to instruments to portabe anesthesia.

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The whole team includes around 110 people from surgeons to cooks. T The program is completely voluntary and each person spends around $1700 out of their own pocket to go. According to one of them, it is really rewarding to the staff to know they help people that otherwise would not have the opportunity to have this kind of surgery.

Speech

Speech  80%

of CP patients have normal speech after repair  15% achieve acceptable speech after therapy

Speech Therapy  Kids

with oral clefting may have trouble speaking — the clefting can make the voice nasal and difficult to understand. Some will find that surgery fixes the problem completely.  Catching speech problems early can be a key part of solving them. A child with a cleft should see a speech therapist between the ages of 18 months and 2 years.  Many speech therapistslike to talk with parents at least once during the child's first 6 months to provide an overview

 After

the initial surgery is completed, the speech pathologist will see the child for a complete assessment.  The therapist will evaluate developing communication skills by assessing the number of sounds the child makes and the actual words he or she tries to use, and by observing interaction and play behavior.  This analysis helps determine what, if any, speech exercises a child needs and if further surgery is needed. The speech pathologist often will continue to work with the child through additional surgeries.  Many kids will work with a speech

Summary  Birth 3

months-------------LIP  6-9 months-----------PALATE  4-8 Years-------------SPEECH  8-10 Years-----------BONE GRAFT  14-18 Years----------JAW , NOSE,SCAR

Emotional and Social Issues  Society

often focuses on appearances, and this can make childhood — and, especially, the teen years — they might experience painful teasing that can damage self-esteem.  Part of the cleft palate and lip treatment team includes psychiatric and

Ways to support:  

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• Try not to focus on the cleft and don't allow it to define who your child is. • Create a warm, supportive, ands accepting home environment, where each person's individual worth is openly celebrated. • Encourage your child to develop friendships with people from diverse backgrounds. The best way to do this is to lead by example and to be open to all people yourself. • Point out positive attributes in others that do not involve physical appearance.

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Having opportunities to make decisions early on — like picking out what clothes to wear — lets kids gain confidence and the ability to make bigger decisions down the road.

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Consider encouraging your child to present information about clefting to his or her class with a special presentation that you arrange with the teacher.

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Or perhaps your child would like you to talk to the class. This can be especially effective with young children.

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If your child does experience teasing, encourage discussions about it and be a patient listener.

 Encourage

autonomy by giving your child the freedom to make decisions and take appropriate risks, letting his or her accomplishments lead to a sense of value.  Provide tools to confront the teasers by asking what your child would like to say and then practicing those statements.  If your child seems to have ongoing selfesteem problems, contact a child psychologist or social worker for support and information. Together with the members of the treatment team,you can help your child through tough times.

Web Sites  

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Wide Smiles Web Site       Cleft Lip and Palate Resource The Cleft Lip and Palate Association - United Kingdom       This site answers some of the most commonly asked questions about cleft lip and palate and provides information on the services and advice offered by CLAPA - The Cleft Lip and Palate Association. Cleft Lip and Palate Association of Ireland       A voluntary group formed to provide support and information for parents of children affected by cleft lip and palate and those directly affected by the condition. Prescription Parents       Parents helping Parents of children with cleft lip & palate

 Smiles

      "SMILES" is a group of dedicated families who have developed a first-hand understanding of the needs of children with cleft lip, cleft palate and craniofacial deformities.  Cleft Palate Foundation       A non-profit organization dedicated to optimizing the quality of life for individuals affected by facial birth defects.

THANK YOU

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