Intraoperative technique

Patient supine under GA/neck hyperextended

Asepsis, antisepsis/ sterile drapes placed Dingman mouth gag applied Noted complete cleft of the primary and

secondary palate Marks of incision placed/LA injected Vomer flap developed Lateral incision on both sides up to the level of the hamular process

Intraoperative technique
Incision done along the cleft margin
Oral mucoperiosteal flaps developed Right oral mucoperiosteal flap brought to the

midline to cover the alveolar cleft Closure by layers: nasal mucoperiosteum/muscle/oral mucoperiosteum Hemostasis End of procedure Patient tolerated

CLEFT LIP & PALATE

Grand Rounds

Joseph Arneil J. Limbag, MD

HISTORY
Cleft lip & palate were 1st described in writings

of ancient Egypt 1st recorded attempts to repair was reported in 1000 AD French dentist, Le Monnier, performed one of the 1st surgical repairs in 1746

ETIOLOGY
Clefts of the lip, alveolus and palate are the

most common congenital malformations of the head and neck CLaP are considered intrinsic disorders of morphogenesis Heterogenous 30- 65% are assoc. w/ a syndrome

ETIOLOGY
Environmental factors acted in concert w/

somogenetic aberration to produce the cleft phenotype - steroids - anticonvulsants - retinoic acid (vit A) derivatives - folic acid antagonists - smoking - alcohol

Risk Factors for Cleft Recurrence

Predicted recurrence (%) Cleft lip Cleft & palate palate 0.1 0.04 4.4 2.5 3.2 6.8 15.8 14.9 9.0 1.00

Affected relatives Gen. population 1 sibling 1 parent 1 sibling, 1 parent 2 siblings

EPIDEMIOLOGY
Incidence Whites 1:1000 American Indians 3.6:1000 Japanese 2.1:1000 Chinese 1.7:1000 Blacks 0.3:1000 The more severe the defect, the more males affected CLaP 2:1 CL 1.5:1 Bilateral > Unilateral

EPIDEMIOLOGY
80% unilateral; 20% bilateral An assoc. CP is present in 85% of bilateral &

70% of unilateral clefts Incomplete 10% CP alone - half the incidence of CLaP - higher in females 4:1 - 20- 30% are syndromic Submucous clefts - 1:1200 to 1:2000 - > 50% in males

CLASSIFICATION
No universally accepted classification
Veau classification- most commonly used

Class Class Class Class

I- soft palate II- hard & soft palate III- unilateral cleft lip & palate IV- bilateral CLaP

CLASSIFICATION
I. Cleft lip A. Unilateral or bilateral B. Complete or incomplete II. Cleft palate A. Location in reference to incisive foramen 1. Primary- anterior 2. Secondary- posterior B. Unilateral or bilateral c. Complete or incomplete III. Submucous cleft palate

Thallwitz Classification
Thallwitz nomenclature (also known as the

LAHSHAL) is a descriptive classification of each individual case of cleft lip and palate. It is simple, concise, flexible, exact but graphic. It describe the site, size, extent as well as type of cleft.

Thallwitz Classification
It provides an objective documentation of the

cleft deformity The recorded findings can also be easily stored into a computer for data analysis.

Thallwitz Classification
Each area is divided into thirds, and cleft

defects are graded as to how much of each are affected. Grading is done for both sides as shown: (right side) (midline) (left side) L-lip A-alveolus H-hard palate S-soft palate H-hard palate A-alveolus L-lip

Thallwitz Classification
L = Lip - 1/3 or 2/3 or 3/3

A = Alveolar cleft - 1/3 or 2/3 or 3/3

H = Hard palate cleft - 1/3 or 2/3 or 3/3

S = Soft palate cleft - 1/3 or 2/3 or 3/3

ANATOMIC DEFECTS
UNILATERAL CLEFT
Lateral displacement of the premaxilla on the

non-cleft side; frequent upward tilting of the premaxilla into the cleft defect Underdevelopment of the maxilla on the side of the cleft Marked malalignment of the alveolar arches Shortened columella, attenuated lower lat. cartilage w/ a flared alar base on cleft side Vertical shortness of lip on cleft side

ANATOMIC DEFECTS
BILATERAL CLEFT LIP & PALATE
Pre-maxilla is freq. protruding & often deficient

in bone Overlying mid-portion of the lip commonly attaches directly to the nasal tip w/ a nearly total absence of the columella Variably-sized prolabium containing no muscular elements; no Cupids bow or philtrum Maxillary alveolar arches are often underdeveloped & are freq. collapsed in an upward inward direction

ANATOMIC DEFECTS
CLEFT PALATE DEFORMITY
Clefts of the secondary palate have varying

deficiencies of bone & muscle Mucosal deficiency is always present except in a submucus cleft palate Palatal muscles are directed anteriorly & have an abnormal insertion into posterior margin of the bony palate and are usually hypoplastic

ANATOMIC DEFECTS
SUBMUCOUS CLEFT
characterized by midline mesodermal deficiency

between the oral & nasal mucus membranes inv. the soft palate & posterior edge of the hard palate there is notching of the posterior edge of the hard palate Loss of posterior nasal spine muscular deficiency of the soft palate w/ a bifid uvula zona pellucida

CLEFT PALATE DEFECT

PROBLEMS
1. Basic anatomic deformity
2. Dental problems - missing, malformed & supernumerary teeth - malocclusion

PROBLEMS
3. Feeding - cleft palate - breastfeeding is often impossible - communication bet. oral & nasal chamber > impairs normal sucking & swallowing mechanism > this channel also predisposes the infants to reflux food particles into nasal chamber

PROBLEMS
4. Otologic problems a. ET dysfunction Abnormal insertion of tensor veli palatiniprevents satisfactory emptying of the middle ear Horizontal positioning of the ET leads to nasopharyngeal reflux Abnormal skull base b. chronic ear discharge c. hearing loss

PROBLEMS
5. Speech problem a. primary precipitating componentvelopharyngeal incompetence - hypernasality - nasal escape - can be corrected b. secondary compensatory componentglottal & pharyngeal articulation - once acquired, extremely difficult to correct even if competent velopharyngeal mech. is successfully constructed

MANAGEMENT
The multidisciplinary cleft team approach
Basis: 1. No discipline possesses all the necessary expertise for the many problems faced by the cleft patient 2. The best approach is patient- rather than specialty- oriented

MANAGEMENT
Minimal requirement

1. Surgeon 2. Dentist 3. Speech pathologist 4. Audiologist Long & short- term management plans & outcome results are important responsibilities of the team

MANAGEMENT
TIMING A. Cleft lip rule of 10s - 10 weeks old - weighs 10 lbs. - Hgb level of 10

MANAGEMENT
Advantages of immediate repair: 1. possibility of maximal healing potential exists 2. prevents a separate hospitalization, thus less traumatic 3. parents leave the hosp. w/ a relatively normal- looking child

MANAGEMENT
Advantages of the delayed repair: 1. larger tissue for the repair 2. ample time to allow complete pediatric evaluation of the Px 3. increased understanding of the congenital defects by the parents

MANAGEMENT
TIMING B. Cleft palate- controversial 1. Speech- early 2. Dental- late

Usual Age of Cleft Patient for Various Therapeutic Procedures

Procedure
Lip adhesion Lip repair Primary Secondary Palate repair Correction of velopharyngeal incompetence Orthodontic therapy Lip revision Premaxillary recession Nasal reconstruction Tip Dorsum & septum

Initial Procedure
2- 4 wk 2- 3 mo 5- 7 mo 12- 30 mo 4 yr & older 4 yr & older 4 yr & older 5 yr & older 6- 10 yr 15- 17 yr

Second Procedure
3 mo 4- 5 mo 7- 10 mo

Cummings 3rd edition, Vol. 5, Chapter 10, p139

UNILATERAL CLEFT LIP REPAIR

1 .Straight line closure
2.Lower Lip Z-plasty 3.Upper Lip Z-plasty 4.Upper & lower Lip Z-plasty

Rotation- advancement: Millard

ADVANTAGES Adaptable to all unilateral clefts Minimal discard of tissue Preservation of cupids bow & philtral column & groove Tension shifted to upper 3rd of lip Scars concealed in natural lines Improved nasal correction DISADVANTAGES Requires artistic judgment

Triangular flap: Tennison- Randall

ADVANTAGES Mathematical construction Preservation of Cupids bow For wide complete clefts DISADVANTAGES Distortion of phitral column & groove w/ tension in lower portion of lip Scar may be prominent Some nasal distortion persists

BILATERAL CLEFT LIP REPAIR

1 .Straight line repair
2.Lower Lip Z-plasty 3.Upper Lip Z-plasties 4. Upper & Lower lip Z-plasties

CLEFT PALATE REPAIR

Goals: 1. Separation of the nasal & oral cavities 2. Construction of a watertight & airtight velopharyngeal valve 3. Preservation of facial growth 4. Development of aesthetic dentition & functional occlusion

CLEFT PALATE REPAIR

VON LANGENBECK FLAP
WARDILL VY FLAP ISSHIKI KOYMO FLAP

Thank You