唇裂腭裂CLEFT LIP AND PALATE.ppt.ppt

cleftlipandcleftpalate normallipwithanatomicalterms vermilion thelowermarginoftheupperlipiscalledthevermilionandischaracterizedbyitsrosycolor cupid sbow thetermcupid sbowisusedtodescribetheconcaveordippedportionofthevermilionborderinthecenteroftheupperliptubercle peakofthecupid sbow philtrum philtraldimple theportionoftheupperlipbetweenthetwophiltralcolumnsisknownasthephiltrumphiltralcolumnsorlines abovethecenteroftheupperlipisadimplecalledthephiltraldimple andtheraisedridgesoneithersideofthisdimplearethephiltralcolumnsorlines normallipwithanatomicalterms typesoffacialclefts cleftlip mediancleft lateralfacialcleft obliquefacialcleft medianfacialcleft lateralfacialcleft hemifacialmacrosomia bilateralobliquefacialcleft cleftlip 1 definitionofcleftpalate cleftlip sometimescalledharelip isacongenitalmalformationofembryonicoriginthataffectsthelip itoccursbyitselfortogetherwithanalveolarorpalatalcleft 2 incidence theincidenceoforalcleftsvariesfrom1to2 21 1000 theincidenceofcleftlipvariesacrossraces approximately1to1000forwhitesand0 41forblacksinunitedstates malepreponderanceismarkedinthemoresevereorcompletecleftlip themale femaleratiobeingapproximately3 2 inmostseriescleftlipwithcleftpalateisreportedas1 5to3timesasfrequentlyasisolatedcleftlip 2 incidence inchina theincidenceisabout1 8 1000 andtheconditionoccursmorefrequentlyinmalesthanfemales 3 etiology thecauseofcleftsisnotunderstoodverywell whilstweknowwhathappens wedonotknowwhy parentalagedruguseinfectionsduringpregnancysmokingor anddrinkingduringpregnancyheredity familyhistoryx ray microwavedeficiencyofvitaminc d benvironmentalfactors 5 typesofcleftlip althoughmanyclassificationshavebeenproposed weprefertousedefinitiveanddescriptivetermsinordertoavoidconfusion 1 accordingtotheposition acleftlipmaybeunilateralorbilateral upperlipcleftandleft sidedoccurrencearemorefrequentthanthelowerandtherightside amediancleftandcleftsofthelowerlipareextremelyrare 5 typesofcleftlip 2 accordingtotheextent thecleftmayvaryinextent beingeitherincompleteorcomplete 1 acompletecleftlip isoneinwhichthecleftextendsthroughthefloorofthenostril thistypeisalmostinvariablyaccompaniedbyanalveolarorpalatalcleft 2 anincompletelipcleft oftenvariesmerelyanothingofthevermilionborder toonethatextendspartwayuptowardthethresholdofthenostril occasionallyshowsascarcelyperceptiblenotchingofthevermilionborderandaslightgroovingoftheskinsurface indicatinganimperfectmuscularunionbeneath unilateralcleftlip unilateralcompletecleftlip unilateralincompletecleftlip unilateralincompletecleftlip unilateralincompletecleftlip unilateralcompletecleftlip lb bilateralcleftlip bilateralincompletecleftlip bilateralcompletecleftlip bilateralmixedcleftlip bilateralcompletecleftlip 17 year oldgirlwithbilateralcleftlipandcleftpalate bilateralcleftlip palate bilateralcleftlip palate bilateralmixedcleftlip 5 presentingfeatures deformityanddysfunctionarisingfromprimaryabnormalitywillleadto separationofthelipabnormalfacialdevelopmentspeechanomalies usuallynotserousairwayabnormalitiesfeedingproblemspsycho socialdifficulties associatedwithaestheticandfunctionaldeficiencies inalmosteverylipcleftthereisanassociatednasaldisfigurement thisusually butnotalways variesinseverityindirectproportiontothewidthofthecleft thusanincompletecleftmayexhibitonlyaslightspreadingandflatnessoftheaffectednostril whileinawidebilateralcleftthenostrilsareextremelyflattenedanddistortedthenasaltipretracted andthenasalcolumellashortened themusclesofthemouthincleftlipfailtomeetinthemidlineandthusseekotherattachments thesesubstituteattachmentspreventthemusclesfrombecomingfullyfunctional andtheirdevelopmentisincomplete 6 treament 1 teamapproach themanagementofcleftsrequirestheparticipationofthefollowingexperiencedspecialists asurgeon suchasaplasticsurgeon anoral maxillofacialsurgeon acraniofacialsurgeon oraneurosurgeon anaudiologist whoassesseshearing apediatricdentistorotherdentalspecialist suchasaprosthodontist whomakesprostheticdevicesforthemouth anorthodontist whostraightenstheteethandalignstheteethandjaws ageneticist whoscreenspatientsforcraniofacialsyndromesandhelpsparentsandadultpatientsunderstandthechancesofhavingmorechildrenwiththeseconditions teamapproach anurse whohelpswithfeedingproblemsandprovidesongoingsupervisionofthechild shealth anotolaryngologist an earnoseandthroat doctor or ent apediatrician tomonitoroverallhealthanddevelopment teamapproach teamapproach apsychologistorothermentalhealthspecialist tosupportthefamilyandassessanyadjustmentproblems aspeech languagepathologist whoassessesnotonlyspeechbutalsofeedingproblems andothernecessaryspecialists whotreatspecificaspectsofcomplexcraniofacialanomalies teammembers 2 surgicalrepairofcleftlip timingofoperation selectingasuitabletimetooperateonthecleftlipvariesfromsurgeontosurgeon someclinicspreferoperatingontheinfantsimmediatelyfollowingbirth preferablywithin48hours even24hours othersconsistthatthesurgeryshouldbedelayedforaminimumof8to10weeksfollowingthebirth ruleoftens althoughtherearestillmanydifferentopinions themostacceptedstandpointisthatliprepairshouldbecarriedoutwhenthechild sgeneralhealthandweightpermitthesafeinductionofgeneralanesthesia anesthesia thetime honored ruleoftens isausefulguidetothetimingofsurgery accordingtothisrule liprepairshouldbecarriedoutwhenthechildhasattainedaweightof10pounds is10weeksold andhasahemoglobinconcentrationhigherthan10milligram dl timingofoperationinchina 1 unilateralcleftlip 3 6monthsold2 bilateralcleftlip 6 12monthsold thepurposeofrepair a restorationofnormal nearnormalanatomyb restorationofnormal nearnormalfunctionc promotionofnormal nearnormaldevelopmentresultinginsatisfactory 2 surgicalrepairofcleftlip thepurposeis ofcourse torestoretheanatomicpartstotheirproperpositionstopromotenormalgrowthanddevelopment aneffectiverepairmustrealignthevermillionandcupid sbowofthelip reconstructtheupperlipandphiltrum andreapproximatetheorbicularisorismusclewithintherepair 2 surgicalrepairofcleftlip criteriaforliprepairaccurateskin muscle andmucousmembraneunionsymmetricalnostrils symmetricalnostrilfloorssymmetricalvermillionborderpreservationofthecupid sbowaminimalscar 2 surgicalrepairofcleftlip anesthesia generalanesthesiaisused 2 surgicalrepairofcleftlip takingunilateralliprepairasanexample methodsofunilateralliprepair tennision randallmethod triangularflapmethod millardmethod rotation advancementmethod itisthemostpopulartechniqueforunilateralcleftlipdescribedbymillard millardmethodthefirststep markings midlinenadir2peaksofcupid sbow1 3newcupid sbowpeakoncleftside4theextentofrotationcurve5commissures6 7alarbaseoncleftside8theincisionismadealongline6 3 3 5and8 7 4 millardmethodthesecondstep makingtheincision theincisionismadealongline6 3 3 5and8 7 4arotationincisiononthemedialsidepermitstheentirecupid sbowcomponenttodropdownintothenormalposition theflapbhelpstopullthecolumellaandmembranousseptumintoposition thedefectbetweenaandbisthenfilledbytheadvancementflapcfromthelateralside advancementofthelateralflapcrotatesthealaintopositionandcorrectsthedeformityofthenostril millardmethodthesecondstep suture thelongitudinalincision5 3followsandimitatesthenaturallineofaphiltralcolumn thez plastyintheupperportionofthelipishiddenintheshallowandinthecreaselinesofthenostrilfloor themuscleandsubcutaneoussuturesshouldbecarefullyapplied unilateralcleftlipontheleftside torepairacleftlip thesurgeonwillfirstmakeanincisiononeachsideofthecleftfromtheliptothenostril thecleftlipisthendrawntogetherandstitchedtocreateanormal cupid sbow shapetotheupperlip thescarleftaftersurgerywillgraduallyfadewithtime thescarleftaftersurgery thescarleftaftersurgery cleftpalate 1 definitionofcleftpalate cleftpalateisacongenitalmalformationofembryonicoriginthataffectthepalate itoccursbyitselfortogetherwithanalveolarorlipcleft 2 incidenceofcleftpalate theincidenceofcleftlipandpalatevarieswithdifferentraces theincidenceofcleftpalatealoneis1outof2 500peopleaccordingtoreportsfromada breakdownoffacialclefts 3 etiology aswithcleftlip theetiologyofcleftpalateismultifactorial animalmodelshavedemonstratedthatvitamina corticosteroids andphenytoinproducecleftpalatewhengiveninpregnancy 4 classification 1 cleftofthesoftpalateonly2 incompletecleftofpalate extendingnofurtherthantheincisiveforamen 3 completeunilateralcleft extendingfromtheuvulatotheincisiveforameninthemidline thendeviatingtoonesideandusuallyextendingthroughthealveolusatthepositionofthefuturelateralincisortooth 4 completebilateralcleft resemblingtype3withtwocleftsextendingforwardfromtheincisiveforamenthroughthealveolus cleftofthesoftpalateonly completeunilateralcleft completebilateralcleft completebilateralcleft unilateralcompletecleftlipandpalate bilateralcompletecleftpalateandlip bilateralcleftlipandpalate bilateralcleftlipandpalate velopharyngealclosure duringspeechandswallowingthepalatemovesbothsuperiorlyandposteriorlyagainsttheposteriorpharyngealwalltoseparatetheoralpharynxandnasalpharynx thisiscalledvelopharyngealclosure whenpalateiscleft however notonlyisthereinadequatevelopharyngealclosurebut inaddition theopeninginthepalatepermitstheairstreamtopasspartlythroughthenose thus theairstream passingthroughbothnasalandoralcavities cannotbealteredproperlytoproducethenormalsounds 5 symptoms separationofthepalatespeechand orlanguageproblem nasalvoicerecurrentearinfectionsnasalregurgitationsduringbottlefeedingpsychologicalproblems oftheadolescentoradultpatientsandpatients families feedingbottlesandteatsforbabiesbornwithcleftlipand orpalate aninfantwithacleftwillhaveproblemssuckingascommunicationwiththenasalcavitywillallowairtopassintotheoralcavityinsteadofdrawingmilkfromafeedingbottleorthebreast thus squeezablebottleswithadirectionalteat oravariable flowteatandpump actionvalve arerequiredthecleftlipandpalateassociationrecommendsthatnormalfeedingmethodsshouldbeencouraged 6 treament 1 teamapproach 2 timingofoperation inchina surgeonsmostcommonlycarryoutthesurgicalrepairofcleftpalatewhenthepatientis3yearsold whateverincompleteorcomplete unilateralorbilateral 3 aimofoperation theultimateaimofcleftpalatesurgeryistoproduceapalatethatisabletofulfillthetwomainfunctionsofthenormalhardandsoftpalate 1 thefirstistomaintainamechanicalpartitionbetweentheoralandnasalcavities therebypreventingtheintroductionofforeignbodiesintothenasalcavity withtheconsequentpossibilityofinfectionofnoseandmiddleear 2 thesecondfunctionofpalateisitsparticipationinspeechproduction orwecansaytogainadequatevelopharyngealclosure 3 methodofoperation takingincompletecleftasanevample v yretroposition push back proceduregeneralanesthesiaisusedandthepalateisinjectedwith0 25 lidocainewith1 200 000epinephrinesolutiontoreducebloodloss a outlineofincision b theflapsareraised c sutureofthemucousmembrane d positionoftheflapsatthecompletionoftheoperation thesurgeonmakesanincisionalongbothsidesofthecleft tissueisdrawntogetherfrombothsidesoftheclefttorebuildtheroofofthemouth beforeandaftersurgery speechtherapy theeffectofacleftlipandpalateonspeechisveryvariableandnotalwaysrelatedtothetypeorextentoftheoriginalproblem generallyhowever acleftlipwithoutacleftpalaterarelyhasanyeffectonspeech sometimesifthecleftlipinvolvesbothsides orifthegumisalsoaffected theremaybesomeminorspeechdifficulties speechtherapy childrenwithcleftlipandpalatecommonlyneedspeechtherapy speechproductionrequirescoordinationofthetongue hardandsoftpalate thiscoordinationisachievedbythemovementofthemuscleswithinthetongueandsoftpalate childrenwithcleftpalatehaveanabnormalinsertionandmovementofthemuscleswithinthesoftpalate theymayalsohavepoorcoordinationofthetonguemovementsanditsplacement thisresultsinanabnormalspeechrequiringspeechtherapy treatmentgoalofspeechtherapy thegoalofspeechtherapyistoeliminationofthepatient sparticularspeechdisordersbythetimethechildenterskindergarten method activitiesfortherapyshouldbedoneinanaturalandfunwaywherepossibleandparentsshouldnotplacethechildunderpressure herearesomeguidelinesrecommendedtoparents 1 talktoyourchildfromaveryearlyage donotjustdoanactivity talkyourchildthroughit e g atbathtime here sthesoap water toweletc mammyiswashing washinghands face toesetc 2 nameeverydayitemssuchascup spoon plate car door dog bricksetc foryourchildtohelphim hertounde