10. Cleft Lip and Palate Flashcards
Cleft lip with or without cleft palate occurs in how many live births?
1/940
Highest and lowest incidence of cleft?
Native Americans 1/500
African Americans 1/2500
Cleft lip more often in M/F?
Which side?
Cleft palate more often in M/F
Cleft Lip M
Left side
Cleft Palate F
Median nasal process fuses with maxillary process at ___ weeks gestation
6 weeks
Palatine shelves of maxillary processes merge in midline at ____ weeks gestation
8-12 weeks
Factors associated with cleft
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)
Classification system for palatal cleft
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
Kernahan and Stark Classification
“Striped Y” as a symbolic representation of untreated cleft lip and palatal deformity with incisive foramen as the dividing point.
When can clefting be identified via ultrasound
13-14 weeks (sensitivity prior to 18-20 weeks is lower)
Cleft management birth to 6 months
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)
Rule of 10s
10 weeks old
10 lbs in weight
10 mg/dL of hemoglobin
Primary lip repair at this time (3-4 months)
Cleft management 6+ months
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
Primary lip repair technique
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).
Similar to Millard technique, this technique is often used for bilateral cleft lips
Delaire technique
Tensor veli palatini
Innervation
Function
Tensor veli palatini
Trigeminal nerve (V)
tenses and depresses soft palate
Levator veli palatini
Innervation
Function
Levator veli palatini
Pharyngeal nerve (branch of vagus X)
Elevates the palate
Musculus uvulae
Innervation
Function
Musculus uvulae
Pharyngeal nerve (branch of vagus X)
Draws uvula up and forward
Palatoglossal
Innervation
Function
Palatoglossus
Pharyngeal nerve (branch of vagus X)
Draws palate down and narrows pharynx
Palatopharyngeal
Innervation
Function
Palatopharyngeal
Pharyngeal nerve (branch of vagus X)
Draws palate down and narrows pharynx
Palatal repair techniques
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)
Velopharyngeal insufficiency
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
Timing of surgical management of VPI
Ideally around age 5, but can be done later
Evaluation age 3-5 (can’t be reliably done before this)
Superiorly based pharyngeal flap
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.
This procedure is indicated for management of VPI for those with markedly impaired or absent lateral pharyngeal wall motion
Sphincter pharyngoplasty (in comparison to superiorly based pharyngeal flap which is done when there is adequate lateral pharyngeal wall movement).
Goals of alveolar bone grafting
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
How is alveolar bone grafting timed/divided
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
