1. Congenital anomalies of the facial region of the head. Cleft lip. Cleft palate.

Question 1

Intro: Embryology of the Lip and Palate

Answer 1

The “primary palate,” which includes the nostril sill, upper lip, alveolus, and hard palate anterior to the incisive foramen, forms from fusion between the medial nasal and maxillary prominences during weeks 4 through 7 of gestation

Question 2

Intro: Embryology of the Lip and Palate - Development of the Hard Palate

Answer 2

Development of the hard palate posterior to the incisive foramen and the soft palate, which are collectively known as the “secondary palate,” occurs during weeks 6 through 12 of gestation.

Question 3

Intro: Function of Palate (1)

Answer 3

The normal palate functions primarily as a speech organ, but it is also intimately involved in feeding, swallowing, and breathing

Question 4

Intro: Function of Palate (2)

Answer 4

The soft palate, or velum, together with lateral and posterior pharyngeal walls, can be conceptualized as a valve that regulates the passage of air through the nasopharynx.

Question 5

Intro: Classification of Craniofacial Anomalies.

Classification 1

Answer 5

1. Clefts

Question 6

Intro: Classification of Craniofacial Anomalies.

Classification 2

Answer 6

2. Synostoses: The term “craniosynostosis” refers to premature fusion of one or more calvarial sutures.

Question 7

Intro: Classification of Craniofacial Anomalies.

Classification 3

Answer 7

3. Atrophy–hypoplasia

Question 8

Intro: Classification of Craniofacial Anomalies.

Classification 4

Answer 8

4. Hypertrophy–hyperplasia–neoplasia

Question 9

Development of Face

Answer 9

Face develops from median nasal process, lateral nasal process, maxillary process, mandibular arch, globular arch, olfactory pit and eye.

Any change in the development or
fusion of these arches leads to formation of different types of cleft lip or cleft palate.

Question 10

Etiology of Cleft Lip and Cleft Palate.

Etiology (1)

Answer 10

Familial—more common in cleft lip or combined cleft lip and palate (Risk is 1:25
live births).

Question 11

Etiology of Cleft Lip and Cleft Palate.

Etiology (2)

Answer 11

Protein and vitamin deficiency.

Question 12

Etiology of Cleft Lip and Cleft Palate.

Etiology (3)

Answer 12

Rubella infection.

Question 13

Etiology of Cleft Lip and Cleft Palate.

Etiology (4)

Answer 13

Radiation.

Question 14

Etiology of Cleft Lip and Cleft Palate.

Etiology (5)

Answer 14

Chromosomal abnormalities.

Question 15

Etiology of Cleft Lip and Cleft Palate.

Etiology (6)

Answer 15

Maternal epilepsy and drug intake during pregnancy (steroids/ eptoin/diazepam).

Question 16

Classifications of Clefts

Classification 1

Answer 16

I. Cleft lip alone: Unilateral, Bilateral, Median.

II. Cleft of primary palate (in front of incisive foramen) only:

a. Complete—means absence of pre-maxilla.
b. Incomplete—means rudimentary pre-maxilla: Unilateral, Bilateral, Median.

III. Cleft of secondary palate (behind the incisive foramen) only:
a. Complete—nasal septum and vomer are separated from palatine process.
b. Incomplete.
c. Submucous: It can be - Cleft with soft palate involvement. - Cleft without soft palate
involvement.

IV. Cleft of both primary and secondary palates.

V. Cleft lip and cleft palate together.

Question 17

Classifications of Clefts

Classification 2

Answer 17

Veau classification - The most clinically useful system to describe cleft palate morphology

A Veau I cleft is midline and limited to the soft palate alone.

A Veau II cleft may extend further anteriorly to involve the midline of the posterior hard palate (the “secondary palate”).

A Veau III cleft is a complete unilateral cleft of primary and secondary palates, in which the cleft extends through the lip, the alveolus, the entire length of the nasal floor on the cleft side, and the midline of the soft palate.

Veau IV clefts are bilateral complete clefts of the primary palate that converge at the incisive foramen and continue posteriorly through the entire secondary palate.

Not included in the Veau classification is the submucous cleft palate, which occurs when there is clefting of the soft palate musculature beneath intact mucosa.

Submucous cleft palate classically presents as the triad of a bifid uvula, a midline translucency called the “zona pellucida” and a palpable notch of the posterior hard palate.

Question 18

Classifications of Clefts

Classification 3

Answer 18

Cleft Lip
Central—rare. In upper lip. Between two median nasal processes. (Hare lip)

Lateral—maxillary and median nasal process, commonest; can be unilateral or
bilateral

Incomplete cleft lip does not extend into nose

Complete cleft lip extends into nasal floor

Simple cleft lip is only cleft in the lip

Compound cleft lip is cleft lip with cleft of alveolus.

Question 19

Classifications of Clefts

Classification 4

Answer 19

LAHS classification of cleft disorders

‘L’ for lip, ‘A’ for alveolus, ‘H’ for hard palate, ‘S’ for soft palate

Capital ‘LAHS’ for ‘complete type’

Small letters ‘lahs’ for ‘incomplete type’

Asterisks ‘lahs’ for microclefts

‘LAHSHAL’ for bilateral clefts

Question 20

Complications of Clefts

Answer 20

Difficulty in sucking and swallowing. This is more commonly observed in cleft palate than in cleft lip.

Speech is defective especially in cleft palate, mainly to phonate B, D, K, P, T and G.

Altered dentition or supernumerary teeth.

Recurrent upper respiratory tract infection.

Respiratory obstruction (in Pierre-Robin syndrome)

Chronic otitis media, middle ear problems.

Cosmetic problems.

Hypoplasia of the maxilla.

Problems due to other associated disorders.

Question 21

Treatment of Cleft Lip

Prior to Cleft Lip treatment, observe the:

Answer 21

Millard criteria

Question 22

Millard Criteria

Answer 22

AKA Millard citeria (rule of 10)

10 pound in weight

10 weeks old

10 gm % haemoglobin

Question 23

Treatment of Cleft Lip :

Answer 23

Millard cleft lip repair by rotating the local nasolabial flaps.

Management of associated primary or secondary cleft palate deformity.

Proper postoperative management like control of infection, training for sucking,
swallowing and speech.

Tenninson’s ‘Z’ plasty (Tenninson-Randall triangular flap).

Delaire timing of the cleft surgery – Unilateral/bilateral
cleft lip alone, in one stage operation done in 4–6
months.
For cleft palate alone involving only soft palate, in one stage, surgery is done in 6 months.

For cleft palate alone but involving both soft and hard palates—soft palate in 6 months; hard palate in 18 months.
In combined cleft lip and palate, unilateral or bilateral, in two stages—cleft lip and soft palate in 6 months; hard palate in 18 months

Question 24

Cleft Palate: Etiology

Answer 24

It is due to failure of fusion of the two palatine processes.

Defect in fusion of lines between premaxilla (developed from median nasal process) and palatine processes of maxilla one on each side.

When premaxilla and both palatine processes do not fuse, it leads into complete cleft palate (Type I cleft palate).

Question 25

Cleft Palate:

Incomplete Fusion causes

Answer 25

Incomplete fusion of these three components can cause incomplete cleft palate beginning from uvula towards posteriorly at various lengths.

So it could be Type II a–bifid uvula, Type II b–bifid soft palate (entire length) or Type II c –bifid soft palate and posterior part of hard palate (but anterior part of hard palate is normal).

Question 26

Cleft Palate: Physical features

Answer 26

Small maxilla with crowded teeth, absent/poorly developed upper lateral incisors.

Question 27

Cleft Palate: Complications

Answer 27

Bacterial contamination of upper respiratory tract with recurrent infection is
common.

Chronic otitis media with deafness may occur.

Swallowing difficulties to certain extent and speech problems can occur.

Cosmetic problems can occur.

Question 28

Principles of Cleft Lip repair:

Principle 1

Answer 28

1. “Rule of 10’ should be fulfilled

Question 29

Principles of Cleft Lip repair:

Principle 2

Answer 29

2. Before 6 months, it should be operated

Question 30

Principles of Cleft Lip repair:

Principle 3

Answer 30

3. Infection should not be present

Question 31

Principles of Cleft Lip repair:

Principle 4

Answer 31

4. Millard advancement flap is commonly used for unilateral cleft lip repair

Question 32

Principles of Cleft Lip repair:

Principle 5

Answer 32

5. Bilateral cleft lip repair can be done either in a single or two stages (with 6 months
   gap between each stage)

Question 33

Principles of Cleft Lip repair:

Principle 6

Answer 33

6. One stage bilateral cleft lip repair is done using Veau III method/ Millard’s single
   stage/Black method

Question 34

Principles of Cleft Lip repair:

Principle 7

Answer 34

7. Proper markings are made prior to surgery and incision should be over full
   thickness lip

Question 35

Principles of Cleft Lip repair:

Principle 8

Answer 35

8. Often 1:2,00,000 adrenaline injection is used to achieve haemostasis

Question 36

Principles of Cleft Lip repair:

Principle 9

Answer 36

9. Three-layer lip repair should be done (mucosa, muscle and skin)

Question 37

Principles of Cleft Lip repair:

Principle 10

Answer 37

10. Cupid’s bow should be horizontal

Question 38

Treatment for Cleft Palate

Answer 38

Cleft palate is usually repaired in 12–18 months. Early repair causes retarded maxillary growth (probably due to trauma to growth center and periosteum of the maxilla during surgery if done early). Late repair causes speech defect.

Both soft and hard palates are repaired.

Abnormal insertion of tensor palati is released. Mucoperiosteal flaps are raised in
the palate which is sewed together. If maxillary hypoplasia is present, then
osteotomy of the maxilla is done. With orthodontic help teeth extraction and
alignment of dentition is done.

Regular examination of ear, nose and throat during follow up period.

Postoperative speech therapy.

Whenever complicated problems are present, staged surgical procedure is done.

Wardill- Kilner push back operation—by raising mucoperiosteum flaps based on greater palatine vessels.

Question 39

Treatment for Cleft Palate - Secondary Management

Answer 39

Hearing support is given using hearing aids if defect is present; control of otitis media.

Speech problems occur due to velopharyngeal incompetence; articulation problems also can occur – speech therapy is given. It is corrected by pharyngoplasty, veloplasty, speech devices.

Dental problems like uneruption, unalignments are common. They should be corrected by proper dentist opinion, and reconstructive surgery.

Orthodontic management with alveolar bone graft, maxillary osteotomy—done in 8–11 years of age.

Veloplasty, dental implants, rhinoplasty, orthognathic surgeries, etc.

Question 40

Principles of palatoplasty

Answer 40

Timing is between 10–18 months

Mucoperiosteum flap is raised

Palatal defect is closed using 3 layers—nasal, muscle and oral layers

Hook of pterygoid hamulus is fractured to relax tensor palate muscle to relieve tension on suture line.