MAJ SERAT RAHMAN
PG Trainee (Oral & Maxillofacial Surgery)
FREQUENCY & DISTRIBUTION
TREATMENT ALGORITHM & OBJECTIVES
SURGERY FOR CLEFT LIP, PALATE, VPI, ALVEOLAR GRAFTING
ORTHOGNATHIC SURGERY, DISTRACTION & ORTHODONTICS
Orofacial clefts (ie, cleft lip [CL], cleft lip and palate [CLP], cleft palate [CP] alone, as well as median, lateral [transversal], oblique facial clefts) are among the most common congenital anomalies. Cleft lip and / or palate may be associated with syndromes that include anomalies involving multiple organs. Patients may have impaired facial growth, dental anomalies, and speech disorders (if a cleft palate is present), and they may experience late psychosocial difficulties. The surgeon’s understanding of craniofacial growth has an important impact on clinical treatment decisions to alter craniofacial morphology. Optimal timing and stability of craniofacial surgery are dependent on a thorough appreciation of the sequence, timing, magnitude, and differential expression of craniofacial growth. The interdisciplinary approach to the management of patients with a cleft lip and/or palate and other craniofacial anomalies requires careful coordination and communication; a cleft palate team establishes a patient-centered approach that follows critical pathways. Care for an infant born with an orofacial cleft begins with primary surgical repair of the lip followed by the palate and continues in defined and appropriate stages to late adolescence. The timing and sequencing of care is critical because of the interaction of facial growth with the development of the speech, psychology and dentition. EMBRYOLOGY
In facial morphogenesis, neural crest cells migrate into the facial region, where they form the skeletal and connective tissue and all dental tissues except the enamel. Vascular endothelium and muscle are of mesodermal origin Development of the upper lip is characterized by mesenchymal migration and fusion of the primitive somite-derived facial elements - the maxillary prominences with central frontonasal, two lateral maxillary, mandibular processes. This process starts during the fourth week of gestation and is completed by the seventh week. When migration and fusion are interrupted for any reason, a facial cleft develops along embryonic fusion lines. The embryonic development of the primary palate (lip and palate anterior to the incisive foramen) differs from the secondary palate (palate posterior to the incisive foramen). Failure of mesenchymal migration to unite one or both of the maxillary prominences with the medial nasal prominences results in a unilateral or bilateral cleft of the lip, respectively. Cleft lip usually occurs at the junction between the central and lateral parts of the upper lip on either side. The cleft may affect only the upper lip, or it may extend more deeply into the maxilla and the primary palate. (Cleft of the primary palate includes CL and cleft of the alveolus.) If the fusion of palatal shelves is impaired also, the CL is accompanied by CP, forming the CLP abnormality. The developing processes of the medial nasal prominence, lateral nasal prominence, and maxillary prominences form the primary palate. Fusion occurs, followed by "streaming" of mesodermal elements derived from the neural crest. In contrast, the secondary palate is formed by the fusion of palatal processes of the maxillary prominence alone. The difference in embryonic development suggests the possibility of differing degrees of susceptibility to genetic and environmental influences and accounts for the observed variation in incidence .The secondary palate develops from the right and left palatal processes. Fusion of palatal shelves begins at the 8th week of the fetal period and continues usually until the 12th week. One hypothesis is that a...