Summary of Congenital Craniofacial Clefts: Etiology and Treatment

## Introduction Tessier craniofacial clefts describe uncommon but important patterns of soft-tissue and bony disruption of the face and skull. This material focuses on the clinical features, skeletal and soft-tissue involvement, and practical considerations for specific Tessier cleft numbers discussed in the provided content (numbers 2, 3, 4, 7, and 8). It is written for a Not attending student and emphasizes recognition, complications, and clinical implications. > Definition: Tessier clefts are numbered craniofacial clefts that map along lines from the mouth to the skull; each number corresponds to a reproducible anatomical track of soft-tissue and bony disruption. ## How to approach each Tessier cleft Break down assessment into three parts for each cleft: 1. Soft-tissue findings (lip, cheek, eyelid, canthus, globe) 2. Skeletal involvement (where the osseous defect runs, which sinuses/orbit/oral cavities communicate) 3. Functional consequences and clinical priorities (lacrimal injury, globe exposure, feeding, occlusion) ### Practical exam checklist for any suspected Tessier cleft - Inspect lip and philtrum, note relationship to cupid’s bow and oral commissure - Check lower and upper eyelids, medial and lateral canthi - Test lacrimal drainage and look for displaced puncta or cutaneous drainage - Assess globe position and corneal exposure - Palpate zygoma, maxilla, infraorbital rim; note asymmetry - Request CT to map bony defects and sinus/orbital communications ## Tessier number 3 (oronaso-ocular cleft) ### Soft-tissue features - Begins through the philtral column and floor of the nose, between patterns similar to numbers 1 and 2 - Tissue deficiency between the alar base and lower eyelid; nasal ala may be displaced - Medial canthus often inferiorly displaced and may be hypoplastic - Colobomas of the lower eyelid are medial to the inferior punctum - Globe often malpositioned inferiorly and laterally; microphthalmia is possible ### Lacrimal and ocular consequences - The nasolacrimal system, especially the lower canaliculus and inferior punctum, is commonly disrupted - Drainage may exit onto the cheek instead of the nasal cavity, predisposing to recurrent dacryocystitis - Corneal exposure and erosions can occur; protect the globe early to prevent desiccation and vision loss ### Skeletal involvement - Osseous defect begins between the lateral incisor and canine and extends through the lacrimal groove - Direct communication may exist among oral, nasal, maxillary sinus, and orbital cavities - Anterior maxillary arch may be flattened (contrast to numbers 1 and 2) - Severe cases may be bilateral and can continue cephalad as a cranial number 11 or 12 cleft ### Clinical priorities and management implications - Early imaging (CT) to evaluate bony involvement and plan reconstruction - Lacrimal system evaluation and surgical planning because of high risk for obstruction and infection - Protect the globe (lubrication, temporary tarsorrhaphy if needed) Fun fact: The number 3 cleft is the most common Tessier craniofacial cleft and shows roughly equal sex distribution and an even split among right, left, and bilateral presentations. ## Tessier number 2 ### Key features - Begins between the lateral incisor and canine (similar bony start as number 3) but follows a distinct track - Extends into the pyriform aperture lateral to the septum and medial to the maxillary sinus - May involve hard and soft palate; nasal septum deviation away from the cleft is common - Distorts nasal bones as it passes between them and the frontal process of the maxilla - Ethmoidal sinus involvement can be associated with orbital hypertelorism ### Skeletal consequences - Asymmetry of greater and lesser sphenoid wings and the anterior cranial base may be present ### Clinical implications - Look for palatal clefts and evaluate airway and feeding - Imaging to assess sphenoid and cranial base asymmetry for surgical planning ## Tessier number 4 (meloschisis / oro-o