CLEFTLIPANDPALATE.

LEUKOPLAKIA

1
 EMBRYOLOGY

Facedevelopsfromfiveprocesses

1)Onefrontonasalprocessattheuppercentral
part
2)Twomaxillaryprocessesattheupperlateralpart
3)Twomandibularprocessesatthelowerlateral
part

Duetotheappearanceofolfactorypitsat5thweek
oneoneachsideofthemidlineattheinferiorendof
frontonasalprocess,thefrontonasalprocessis
dividedintoacentralpartcalledmediannasal
process(MNP)andtwolateralprocessescalled
lateralnasalprocesses(LNP).Theolfactorypits
formthenostrils.

2
 EMBRYOLOGY
Continued

MNPdevelopsabulgeoneithersideknownasthe
globularprocess(GP).
MNPandGPformtheseptumofthenose,
philtrumoftheupperlipandthepremaxilla.
LNPformthesidesofthenose.
Maxillaryprocessesformthecheek,wholeof
upperlipexceptthephiltrumandthepremaxilla.
Mandibularprocessesformthelowerjaw.
Thecentralpartofupperlipisthusformedfrom
theMNPwhereasthelateralpartisformedfrom
themaxillaryprocesses.Defectinfusionofthe
MNPwithmaxillaryprocesseswillleadtothe
developmentofcleftlip.

3
 EMBRYOLOGY
Continued
Palatedevelopsfromthreecomponents.

i)PremaxilladevelopsfromtheMNP.

ii) Palatineprocessesofthemaxillary
processes,whicharetwoinnumber,fuse
witheachotherinthemidlineandalso
withthepremaxillaanteriorlytoformthe
palate.Defectsinthefusionofthepalatine
processeswillleadtodevelopmentofcleft
palate.

4
 INCIDENCE

Incidenceisroughlyonein1000livebirthsinWhites.
TwiceascommoninAsians
Cleftlipalone:15%
Cleftpalatealone:40%
Cleftlipandpalate:45%
In75%ofpatients,thecleftisunilateral
Unilateralcleftlipismorecommononleftside
Riskofachildbeingbornwithcleftliporpalateis
moreifoneparentandasiblinghaveCLandCP
(15%)
5
 ETIOLOGY

Bothenvironmentalteratogensandgenetic
factorsareimplicatedinthegenesisofCLand
CP.
Someofthemareexposuretodrugslike
diazepam,steroidsandphenytoin(an
anticonvulsant),smokingduringpregnancy,
alcoholandretinoicacid.Morethan40%of
isolatedCPisassociatedwithothercongenital
malformationsyndromes.

6
 CLASSIFICATION

1) Prealveolarcleft(cleftofthelip
orCL)

(a) Unilateral
(b) Withnotchingofthealveolus
(c)Bilateral

ACLiscalledincompletewhenit
doesnotextenduptothenostril
andcompletewhenthecleft
extendstothefloorofthenose.
Thelatterisassociatedwith
flatteningandwideningofthe
nostriloftheaffectedsideanda
shortcolumella.
7
 CLASSIFICATION
Continued

2) Postalveolarcleft(cleftofthe
palateorCP)

(a)Cleftoftheuvula
(b)Partial(softpalateonly)
(c)Complete(softandhardpalate)
(d)Submucouscleft

D
8
 CLASSIFICATION
Continued

3)Alveolarcleft(cleftof
thelip,alveolusandpalate
orCLP)

(a) Unilateral
(b) Bilateralcleftlipand
palate
9
 PROBLEMSASSOCIATEDWITHCP
Cosmetic
Speech.AchildwithCPisunabletomakethe
consonantsoundsB,D,K,P,andT.Speech
becomesnasal.
Thenose.Upperrespiratorymucousmembrane
getscontaminatedwithoralorganisms.Nostrilis
wide,alaandcolumellaareshort.

10
 PROBLEMSASSOCIATEDWITHCP
Continued

Theteeth.Thecleftinterfereswith Maxillary retrusion

thedentallamina.Theupperlateral
incisormaybesmall,absentoreven
duplicated,withasupernumerary
lateralincisoronthecaninesideof
thecleft.Inbilateralcleft,allthe
incisorsmaybedisplaced.Maxilla
tendstobesmallerandretroposed,
givingarelativemandibular
prognathism.

11
 PROBLEMSASSOCIATEDWITH
CP

Continued
Suckingandeating.InfantswithCPveryoftenhavedifficultyinsucking.
Theyhavetobefedwithaspoon.Theremayberegurgitationwhile
eating,leadingtobronchopneumonia.Thiscanbeovercometemporarily
byfixingadenturewithspecialextensionplatetooccludethecleft.This
willalsohelptomoldthepalatepriortosurgicalrepair.

Hearing.Acuteandchronicotitismediaandhearingproblemsare
common,sometimesevenafterrepair.Thisisduetoinflammatory
oedemaofpharyngealmucosaanddefectivemuscularactivityinterfering
withefficientventilationanddrainageofthemiddleearviatheEustachian
tubeleadingtoretentionofinflammatoryexudatesanddeafness.
Airwayobstruction.Somebabiesarepronetodevelopacutehypoxic
attacksduringsleeporwheneating.

12
 MANAGEMENTOFPRE
ALVEOLARCLEFT
ManagementofCLandCPisbyamultidisciplinary
teamconsistingofplasticsurgeon,audiologist,
dentist,oralsurgeon,orthodontist,ENTsurgeon,
psychologist,geneticist,pediatrician,socialworker,
nutritionistandspeechpathologist.
Preliminarymoldingplatesmayhavetobeusedin
widealveolardefectsandCP.
Surgerymayhavetobecarriedoutinstages,final
correctionsbeingdoneafterfullskeletalmaturity.

13
 MANAGEMENTOFPRE
ALVEOLARCLEFT Continued
Repairofunilateralcleftlip

Manyprocedureshavebeendescribedfor
repair.Goodresultdependsonproper
understandingofthealteredanatomyandthe
basicprinciplesunderlyingeachprocedure.

14
 MANAGEMENTOFPREALVEOLAR
CLEFT Continued

Principlesofrepair
1. Exciseaslittleaspossible
2. Naturallandmarksmustbepreservedand
correctlypositioned
3. Thelipmustbesuturedinthreelayers,i.e.
mucosa,muscleandskin,withouttension

15
 MANAGEMENTOFPRE
ALVEOLARCLEFT Continued
Operationsforrepairof
unilateralCLfallintothree
categories

Rose procedure
1) Simpleparingofthemargins
andsuture(e.g.Rose
operation)
2) Interpositionoflocaltriangular
flaps(e.g.Tennison,Randall)
3) Rotationandadvancement
flaps(Millard)

16
 MANAGEMENTOFPRE
ALVEOLARCLEFT Continued
Ofthese,Millardsoperationisthemost
popularbecauseitissimple,doesnotrequire
complicatedmeasurements.Correctionis
visualizedastheoperationproceeds.
MILLARDS PROCEDURE

17
 MANAGEMENTOFPRE
ALVEOLARCLEFT (MILLARDSop.)
Continued

ThisoperationpreservestheCupidsbowandthe
integrityofthephiltrumandachievesunilateral
lengtheningofthecolumella.
Thescarisinconspicuousasitliesalongone
pillarofthephiltrumandalongthefloorofthe
nostril.Besides,itcanberevisedeasily.

18
Millards procedure
 MANAGEMENTOFPRE
ALVEOLARCLEFT (Millardsop.)
Continued

Millardsrepairforunilateralprealveolarcleft
Landmarkpointsaremarkedwithskinmarkingpen.
Incisionsaremadethroughfullthicknessofthelip,i.e.
mucosa,muscleandskin.
FlapsAandBareseparatedfromtheperiosteumofthe
maxillaoneithersideforashortdistanceandfromthe
floorofthenostril.FlapCconsistsofskinonly.Theflaps
areinterposedandsuturedinthreelayers.FlapCmaybe
usedtoelongatethecolumellaonthecleftsideortoline
thefloorofthenostril.

Millards 19
procedure
 MANAGEMENTOFPRE
ALVEOLARCLEFT (Millardsop.)
Continued

Repairofbilateralcleftlipisessentiallythe
same,exceptthatthepremaxillawhichis
projectinghastobepushedback.
Millards procedure

20
 MANAGEMENTOFCLEFT
PALATE
Idealageforcorrectionis12to15months,
beforethechildacquiresthebadhabitof
nasalspeech.Closureofthehardpalate
defectcanbedeferredtillthetimeof
secondarydentition.

21
 MANAGEMENTOFCLEFTPALATE
Continued

1)LANGENBECKSOPERATION

Inthisoperation,themarginsofthecleftarepared,thenasalseptumisdefined
andseparatedofftheuppersurfaceofthecleftpalate.Themucoperiostealflaps
areliftedupfromthehardpalate.Tworeleaseincisionsaremadeoneoneach
sidejustmedialtothealveolarmargins.Themucoperiostealflapsaremobilized
tillthereleaseincisionsarereached.Thecleftisthenrepairedinthemidlineby
bringinginthemucoperiostealflapsandthenasalmucosamedially.Repairis
doneinthreelayers nasalmucosaandsoftpalatemuscleswithinterrupted
catgutsuturesandthemucoperiostealflapswithinterruptedsilk.

Langenbecks
operation 22
 MANAGEMENTOFCLEFTPALATE
Continued

2)WARDILLSOPERATION (Fourflapoperation)

Thisoperationdiffersfromthepreviousoneinthreeaspects.

i)Thetwoflapsofthecleftpalatearedividedobliquelyuptothereleasing
incisions.So,nowfourflapsareavailable.Theanteriortwoflapsare
broughttothemidlineandsutured.Theposteriorflapsarenotonly
broughttothemidline,butalsopulledposteriorlytolengthenthepalate.
Thisoperationlengthensthepalate,sothatthespacebetweenthe
oropharynxandthenasopharynxisdiminished.

ii)Tensionatthesuturelineisreducedfurtherbybreakingthehamulus
processofthepterygoidboneoneachside,thusrelaxingthetensorpalati
muscle.

iii)Pharyngoplastyisadded.Thisprocedureisaimedatreductionofthe
diameterofthenasopharynxandalsomakestheridgeofPassavant
prominent.
23
 MANAGEMENTOFCLEFT
PALATE

Continued

WARDILLSOPERATION (Fourflapoperation)

24
 SUBMUCOUSCLEFT
Submucouscleftpresentswithdefectivespeech.
Examinationwillshowashortpalate,bifiduvulaanda
bluestreakrunninginthemidline.Transillumination
throughthenosewillbepositiveastheunderlying
musclesaredeficient.Palpationwillrevealanotchinthe
posteriorborderofthehardpalate.Submucouscleft
withdefectivespeechhastobecorrectedbysurgeryin
thesameway.
Submucous cleft

25
 Followup

Maxillaryosteotomymayberequiredfor
correctionofmaxillaryretrusion.
Patientsneedregularfollowupforrevision
surgeryofresidualdefects,speechtherapy,
andorthodontictreatment.

26
 LEUKOPLAKIA
Definition :Leukoplakiaisawhitepatchof
thickeningoverthemucousmembranewhich
cannotbeeasilyrubbedoff.
Itisapremalignantcondition.

Leukoplakia

27
 LEUKOPLAKIA
Continued

Thepatchisrough,granularandthesurfacemayshow
fissuringandhardening.Commonplaceswhereleukoplakia
occursaretheoralcavity,vocalcords,vulvaanduterine
cervix.Orallesionsaremorecommoninoldermen.Inthe
oralcavity,thelips,floorofthemouth,tongueandgumsare
affected.About4%oftheselesionsturnmalignant.Ofallthe
lesionsoccurringintheoralcavity,leukoplakiaofthetongue
ismorelikelytobecomemalignant.

28
 LEUKOPLAKIA
Continued

Causes :Excessivesmoking,betelnut
chewing,alcoholoranyotherchronic
irritationcangiverisetoleukoplakia.Hairy
leukoplakiaisassociatedwithHIVinfection.

29
 LEUKOPLAKIA
Continued

Histopathology:Keratinisation ofthe
epithelium.Changesmayrangefrommild
dysplasiatocarcinomainsitu.Ithastobe
differentiatedfromCandidiasis.

KERATIN

30
 LEUKOPLAKIA
Continued

Management :

Abstinencefromsmoking,betelchewingand
alcohol,attentiontooralhygiene.
Biopsyisdonefirst.Ifdysplasiaorcarcinomainsituis
found,thelesionisexcised.
Excisionisdonebyscalpel,electrocautery,orlaser.
Cryoablationisalsoused.
Followupofthelesionisessentialasrecurrenceis
common.

31