DrMohammed M Mubarak Ass Lecturer Of General And Maxillofacial Surgery Embryology The face develops from 5 embryonic processes Hiss concept 1 Fronto nasal process a Forehead ID: 1040279
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1. cleft LIP & PALATEBy Dr/Mohammed M MubarakAss. Lecturer Of General And Maxillofacial Surgery
2. EmbryologyThe face develops from 5 embryonic processes (His’s concept)(1) Fronto-nasal process: a. Forehead b. Nose c. Philtrum (median part of upper lip).d. Premaxilla, {a V-shaped anterior part of upper jaw carrying 4 incisor teeth (1ry palate)}.
3. Embryology(2) Two maxillary processes: One on each side, fuse with fronto-nasal process to form: a. Cheeks b. Upper lip except philtrum. c. Nasal septumd. Two lateral palatine processes which fuse in midline to form 2ry palate The hard palate is formed by fusion of 2ry-palate and lry palate. The incisive foramen marks junction of two components of palate.
4. Embryology(3) Two mandibular processes: One on each side, fuse in middle line to form: a. Part of cheek that covers mandible.b. Mandible. c. Lower lip.*The ear auricle is formed from the 2nd branchial arch by fusion of six auricular tubercles.
5. Embryology
6. Embryology
7. Congenital anomalies
8. Anomalies of fusion(1) Facial clefts: a. Craniofacial clefts: - Cleft on one side of nose due to failure of fusion frontonasal process and maxillary process. - Unilateral or bilateral, complete or incomplete.b. Cleft lip (Harelip) and cleft palate (Commonest anomaly).(2) Preauricular sinus: - It is due to imperfect fusion of the auricular tubercles. - It may be obstructed → infected → abscess → rupture → resistant ulcer(3) Microstoma: Narrow mouth due to excessive fusion between maxillary and mandibular processes(4) Macrostoma: Wide mouth due to failure of fusion between maxillary and mandibular processes(5) Dermoid cyst (Sequestration cyst): It is due to sequestration of epithelium at line of fusion.
9. Miscellaneous1. Microtia: small ear auricle.2. Macrotia (bat ear): large ear auricle protruding laterally.3. Micrognathia: receding mandible4. Macrognathia (prognathism): protruding mandible.5. Macrocheilia: large lip due to cavernous haemangioma or lymphangioma.
10. Craniofacial clefts
11. Preauricular sinus
12. Microtia
13. Macrotia (bat ear)
14. Micrognathia
15. Macrognathia
16. Macrocheilia
17. CLEFT LIP(Harelip)
18. Cleft lip
19. Etiology (congenital disease due to):-a. Familial tendency: +ve family history & more in consanguinity due to chromosomal abnormalities (triosomy 13-15 & 18 and 21 “Down syndrome”). b. Drug teratogenicity (prenatal exposure): anticonvulsant, Salicylates, corticosteroids, and cytotoxic drugs.c. Diseases: German measles.d. Exposure to X-Rays; in the first trimester
20. PathologySite:Cleft lip alone (25%): Upper lip > lower lip. Unilateral > bilateral. Left side > right side. -Male > femaleCleft lip & palate (50%): Male > female.
21. PathologyTypes:A- Upper Lip (Hare lip):(1) Lateral (unilateral, bilateral) or median cleft lip:a) Unilateral: Due to failure of fusion between maxillary process on one side (forming lateral part of lip) and frontonasal process (Philtrum).b) Bilateral: Due to failure of fusion between maxillary process on both sides and frontonasal process (Philtrum).c) Median cleft (Rare): Due to failure of development of median part of lip (from frontnasal process)(2) Incomplete or complete: whether cleft extends in floor of the nostril or not.(3) Simple or alveolar: whether cleft is associated with cleft alveolus or not.B- Lower Hare Lip (Very Rare) Median type, due to failure between the two mandibular processes
22. Complications1. Disfigurement. 2. Psychological upset of parents.3. Suckling: (does not interfere with suckling)A special teat may be required for bottle feeding but, with breast feeding, a mother acquires a technique to feed the baby adequately.4. Speech: interfere with labial letters e.g. M, P.5. Teeth growth may be affected.
23. Investigations1- Chromosomal studies: triosomy 13-15 & 18 and 21 “Down syndrome”.2- Search for other possible congenital anomalies especially heart.3- Routine laboratory investigation.
24. History1- Consanguinity2- Other congenital anomalies3- Family history of similar conditions4- Family history of congenital anomalies5- History of 1st trimester of pregnancy:- a. irradiation b. fever (Rubella, toxoplasma) c. D.M. d. teratogenic drugs ( steroids, diazepam, phenytoin)
25. Diagnosis1- Upper or lower 2- Median or lateral (unilateral or bilateral) (right or left)3- Complete or incomplete4- Simple or alveolar 5- + cleft palate6- + other congential anomalies e.g. congenital heart disease
26. TreatmentAim of treatment: To improve appearance.Timing of repair: Rule of 10:- Age not < 10 weeks (usually at an age of 3 months).- Bodies weight not <10 pounds (infant weight 5-6 kg).- Hb% not < 10 gm%. - Leucocytic count < 10.000/cm3 to exclude infection during surgeryN.B. 1 pounds is equal to 0.45 kilogram
27. Principles1. Release incisions in gingivolabial sulcus, to have lax flaps.2. Paring of edges to create raw surfaces.3. Anatomical repair of cleft in 3 layers: Mucosa to mucosa, muscle to muscle and skin to skin 4. The skin repair is done with interposition of Z plasty to avoid subsequent notching from pull of a linear scar.5. Care to adjust the vermilion and mucous borders.
28. Operation1. Unilateral Hare lip A- Incomplete type:- (straight line repair) * Small defect → straight incision+ straight repair * Large defect → Rose Thomson straight line repair (Curved incision + Straight line repair) B- Complete type:- (Z- plasty operations) * Millard rotation advancement repair (Best).* Le Mesurier & Mirault quadrilateral flap repair* Tennison- Randall flap repair
29. Operation2. Bilateral Hare lip:* Manchester repair: - Each side is repaired separately. - 2nd operation is done after 3 months as we do moulding of the maxilla to avoid tension on suture line.* Rose operation: V-Y operation.
30. Operation3. Cleft alveolus: Corrected at 11-12 years old (to not interrupt canine eruption) Small defect: 1ry repair. Large defect: bone graft from iliac crest
31. CLEFT PALATE
32. Embryology of The Palate
33. CLEFT PALATE
34. CLEFT PALATE
35. EtiologyThe same as cleft lip;(congenital disease due to):-.1234
36. Pathology* Site: Cleft palate alone (35%): females > males.* Types:1) Cleft of 1ry palate: a) Unilateral: Due to failure of fusion between maxillary process on one side and frontonasal process.b) Bilateral: Due to failure of fusion between maxillary process on both sides and frontonasal process.
37. Pathology2) Cleft of 2ry palate: Bifid uvulacleft soft palatecleft soft and hard palate (intermaxillary cleft either complete or incomplete as not reaching incisive foramen).3) Cleft of 1ry and 2ry palates: Bipartite & tripartite clefts.
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39. Complications1) Disfigurement (distortion of facial growth). 2) Psychological upset of parents.3) Suckling:- It interferes markedly with suckling due to failure to create a negative intra-oral pressure because of oronasal communications. - In this case feeding may be assisted with special bottles and teats, or spoon-feeding may be employed. 4) Speech defects: * Development of nasal tone → irreversible (not in submucous type) * Inability to produce consonants letters (e.g., K, T, P, D). * To make them, air must not escape the nose via nasopharyngeal sphincter (levator sling pulls soft palate backwards and into contact with the posterior wall of pharynx).
40. Complications5) Teeth growth: is affected.6) Regurgitation of food into nasal cavity leading to:- Acute sinusitis - Acute otitis media → Hearing is affected- Aspiration pneumonia7) Airway obstruction: Pierre-Robin syndrome ** Cleft palate + receding mandible (Micrognathia) + posterior displacement of tongue (glossoptosis) obstructing oropharyngeal airway ** So we advice the mother to place the child in a prone position to prevent prolapse of the tongue
41. TreatmentInvestigations: as before.Treatment: * Aim: to correct oronasal communication and its complications.* Timing of repair: - Soft palate → 6 month - Hard palate → 1-1.5 years * Not before 1 year → to avoid interference to ossification center of the palate → asymmetry of the face * Not after 1.5 years → the patient start to talk & once he developed nasal tonation it cannot be corrected
42. Principles1) Release incisions of mucoperiosteum creating lax flaps with preservation of neurovascular pedicle (greater palatine artery & nerve).2) Fracture head of the pterygoid hamulus to relax the tensor palati.3) Paring of the edges.4) Repair in 3 layers, an inner nasal mucosa, muscle layer and outer oral mucosa.The relaxing incisions fill by granulation tissue and then creeping by epithelium.
43. OperationI- Closure of defect:- A- Von Langenbeck technique:- - bipedicle mucoperiosteal flaps of both hard and soft palate are raised and closed in the midline B- Three flap (Wardill- Kilner – Veau) technique:- (V-Y repair) 1- Mucoperiosteal flaps are raised and peeled back off the bony surface of the hard palate → this allows the surgeon to identify the posterior palatine arteries (branch from 3rd part of maxillary artery)2- Freeing the muscle attachment from the pterygoid plates and if need be fracturing the hamular process to release tension. 3- Detach the soft palate muscles from their abnormal attachment to the posterior border of the hard palate and bring the muscle ends across the midline where they can be sutured together 4- The nasal lining is then closed with interrupted sutures
44. OperationC- Furlow Z-plasty:- A. Design of Z flaps. B. Elevation of mucosal flaps. C. Repair of nasal lining and musculus levator veli palatine sling. D. Transposition and lengthening of flaps with closure.D- Schweckendiek technique:-The soft palate is first repaired (3-4 m) then hard palate repair 18 months 1. The initial repair is accomplished by making incisions in the soft palate along the margins of the cleft.2. The levator muscle, which is abnormally attached to the posterior free edge of the bony palate, is dissected free and reoriented. 3. 3-layer closure of the nasal mucosa, the levator muscles, and the oral mucosa is then performed. 4. The resultant hard palate fistula is closed at a later date.
45. OperationII- Treatment of pharyngeal incompetence:- Pharyngoplasty = Repair of nasopharyrangeal sphincter at 17 years old.- Indicated for nasopharyngeal sphincter incompetence, the soft palate being short, it does not touch post wall of pharynx on swallowing or phonation. - It is done by either:1) Purse string around the pharyngeal wall & soft palate.2) Cutting the pharyngeal wall transversely and suturing it longitudinally.3) Submucosal muscle graft in the posterior wall of the pharynx.4) Mucosal flap from posterior wall of pharynx & sutured to soft palate.
46. OperationN.B. * If cleft lip is associated with a cleft palate, lip is repaired first due to:-1. Psychologically for parents.2. To retract premaxilla if there is prognanthism.3. Avoid interference with ossification centre of palate if cleft palate corrected before 1 year. So avoid facial asymmetry
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