10. Cleft Lip and Palate

Question 1

Cleft lip with or without cleft palate occurs in how many live births?

Answer 1

1/940

Question 2

Highest and lowest incidence of cleft?

Answer 2

Native Americans 1/500
African Americans 1/2500

Question 3

Cleft lip more often in M/F?
Which side?
Cleft palate more often in M/F

Answer 3

Cleft Lip M
Left side
Cleft Palate F

Question 4

Median nasal process fuses with maxillary process at ___ weeks gestation

Answer 4

6 weeks

Question 5

Palatine shelves of maxillary processes merge in midline at ____ weeks gestation

Answer 5

8-12 weeks

Question 6

Factors associated with cleft

Answer 6

Family history
Maternal smoking and alcohol use
Maternal zinc deficiency
Advanced paternal age
Folate deficiency in periconception period
Certain medications (retinoids, corticosteroids, anticonvulsants including phenytoin and valproic acid)

Question 7

Classification system for palatal cleft

Answer 7

Veau system
- Group 1: soft palate only
- Group 2: soft and hard palate
- Group 3: complete unilateral cleft lip and palate
- Group 4: complete bilateral cleft lip and palate

Question 8

Kernahan and Stark Classification

Answer 8

“Striped Y” as a symbolic representation of untreated cleft lip and palatal deformity with incisive foramen as the dividing point.

Question 9

When can clefting be identified via ultrasound

Answer 9

13-14 weeks (sensitivity prior to 18-20 weeks is lower)

Question 10

Cleft management birth to 6 months

Answer 10

Lactation consultation/speech therapy: Haberman bottle
Pre-operative orthopedics (lip/nasal taping) - approximate within 5mm
Lip adhesion at 3-4 months
Primary lip repair at 10 weeks (“rule of 10s”)
Audiology screening/ENT eval before 6 months (myringotomy tubes, difficulty controlling middle ear pressure due to eustachian tube dysfunction as a result of abnormal insertion of levator veli palatini and tensor veli palatini)

Question 11

Rule of 10s

Answer 11

10 weeks old
10 lbs in weight
10 mg/dL of hemoglobin

Primary lip repair at this time (3-4 months)

Question 12

Cleft management 6+ months

Answer 12

Primary cleft palate repair (palatoplasty in one or multiple stages) 9-18 months (timed with speech development to avoid compensatory misarticulations.

Correction of velopharyngeal insufficiency at 3-5 years

Nasolabial revision delayed until completion of nasal growth.

Alveolar grafting at 6-9 years (canine 1/2 to 2/3 formed)

Early orthodontics for maintaining transverse dimension

Orthognathic surgery 14-16 in females, 16-18 in males

Rhinoplasty 6-12 months after orthognathic surgery

Question 13

Primary lip repair technique

Answer 13

Millard rotational-advancement flap
- 3-layered closure following excision of hypoplastic tissue at the cleft margins.
- Orbicularis oris continuity is re-established
- Incision lines fall within natural philtral ridges of the lip
- Columellar lengthening

• Non-cleft side is cut in a way that the tissue rotates to create a longer vertical width and the cleft side advances horizontally (scar hidden in philtral line).

Question 14

Similar to Millard technique, this technique is often used for bilateral cleft lips

Answer 14

Delaire technique

Question 15

Tensor veli palatini
Innervation
Function

Answer 15

Tensor veli palatini
Trigeminal nerve (V)
tenses and depresses soft palate

Question 16

Levator veli palatini
Innervation
Function

Answer 16

Levator veli palatini
Pharyngeal nerve (branch of vagus X)
Elevates the palate

Question 17

Musculus uvulae
Innervation
Function

Answer 17

Musculus uvulae
Pharyngeal nerve (branch of vagus X)
Draws uvula up and forward

Question 18

Palatoglossal
Innervation
Function

Answer 18

Palatoglossus
Pharyngeal nerve (branch of vagus X)
Draws palate down and narrows pharynx

Question 19

Palatopharyngeal
Innervation
Function

Answer 19

Palatopharyngeal
Pharyngeal nerve (branch of vagus X)
Draws palate down and narrows pharynx

Question 20

Palatal repair techniques

Answer 20

Bardach two-flap technique (most common, 2 flaps based off greater palatine artery)

Furlow Z-Plasty (allow for lengthening of the hard palate by reorienting muscles in more physiologic reapproximation; more technically difficult)

Question 21

Velopharyngeal insufficiency

Answer 21

Incomplete closure of the velopharyngeal sphincter, thus incomplete separation of oral and nasal cavities during speech.

1/4 of patients after cleft palate repair

Hypernasal speech
Nasal emission
Nasal substitution
Compensatory misarticulations

Question 22

Timing of surgical management of VPI

Answer 22

Ideally around age 5, but can be done later
Evaluation age 3-5 (can’t be reliably done before this)

Question 23

Superiorly based pharyngeal flap

Answer 23

When there is adequate lateral pharyngeal wall movement
Tissue form posterior pharyngeal wall and attached to soft palate, creating midline subtotal obstruction of the oral and nasal cavities with two small lateral openings that ideally remain open during respiration and nasal consonant production and close for consonants.

Question 24

This procedure is indicated for management of VPI for those with markedly impaired or absent lateral pharyngeal wall motion

Answer 24

Sphincter pharyngoplasty (in comparison to superiorly based pharyngeal flap which is done when there is adequate lateral pharyngeal wall movement).

Question 25

Goals of alveolar bone grafting

Answer 25

Allow eruption of dentition
Provide support to adjacent periodontium
Stabilize maxillary segments
Close oronasal fistulae
Improve speech and language development
Provide adequate tissue for dental health
Provide adequate bone for future dental implant therapy
Reconstruct nasal floor and lift the alar base
Allow greater lip support
Cosmesis
Greater self esteem

Question 26

How is alveolar bone grafting timed/divided

Answer 26

Primary (at time of cleft lip or palate repair)
Secondary (later in life)
- Early 3-5yrs
- Early mixed dentition 6-8 yrs
- Late mixed dentition 9-12 yrs
- Late 13+ yrs