Cleft Flashcards
Embryology of cleft lip and palate
Upper lips: Anterior maxillary alveolus: Primary palate —-> Failure of fusion of Medial nasal processes + lateral nasal processes + maxillary processes Happens at 6-7 weeks gestation
Secondary palate:
Failure of Palatal shelves elevation & fusion
8-12weeks gestation
Muscles involved in cleft lip
Orbicularis oris
Muscles involved in cleft palate
Levator veli palatini Tensor veli palatini Palatopharyngeus Palatoglossus Uvular
Whats the blood supply of palate?
- Greater & lesser palatine art (branch of DPA)
- Palatine artery (branch of ascending pharyngeal art)
- Ascending palatine branches of facial art
- Tonsillar br of dorsalis linguae
Diagnosis of cleft
Prenatal diagnosis - transvaginal ultrasound at 12wks gestation (More accurate after 20wks)
- experience of operator
- gestational age at time of study
- indication of the study
- technology used
When is cleft deformity detectable prenatal
Prenatal USG at approx 15 weeks
- lip more easily seen in coronal
- palate at axial view
Name some feeding aids for cleft babies
Mead Johbson compressible bottle
Pigeon Nipple - modified nipple that is longer
Haberman - one way valve
Considerations in their feeding
They swallow more air
Feed upright at 45degree
Burp frequently
Cleft classification
unilateral vs bilateral
complete vs incomplete
cleft of lip, nose, alveolus (primary palate), palate (secondary palate)
LAHSHAL Eg: right complete cleft lip LA——- Left incomplete cleft lip, with right conplete cleft palate - - H S - - L
Issues in cleft patients
- Feeding
- Ear infection
- Speech impairment (VPI)
- Midface growth restriction
Consequences of unrepaired cleft palate
- unable to achieve suction
- nasal regurg
- hypernasal speech
- recurrent ear infection
- breathing problems esp if assoc. with retruded chin like in pierre robin sequence
- malocclusion where teeth angled into cleft
Give the timing of surgical correction of cleft patients
- Cleft lip repair- Rule of 10s (10lbs, 10g/dL, 10 weeks)
- Primary palate repair - 6-9months; 12-18mo in devolepmental delay kids/syndromic kids
- VPI tx - 3-5 yes of age (depending on speech development)
- ABG with cancellous bone and BMP - early secondary grafting to allow eruption of incisors
- ABG with illiac autografts - 9-12yrs of age depending on canine/lat incisor development to allow their eruption
- Cleft orthognathic surgery - 16 - 18 until skeletal development matured
- Cleft rhinoplasty - once skeletal maturation achieved after ogs
- Lip revision - any time
Issues or anatomical defect in cleft lip (UCLP)
Soft tissue:
Discontinuity of the skin, muscle and oral mucosa
Vertical soft tissue deficiency on cleft side
Muscle:
Medial muscle attaches to the base of columella
Lateral muscle attached to the alar base
Nasal:
Rotation of septum, columella and nasal spine away from cleft side
Separation of domes of alar cartilages at nasal tip
Kinking of lateral crus
Displacement and flattening of nasal bone
Issues of BCLP
Central segment contains prolabium and premaxilla and short columella
Alar domes and middle crura are splayed, caudally rotated (bucket handle)
Timing of lip repair
Rule of 10s
10weeks age
10lbs weight
10g/dL Hb
Lip repair
Lip adhesion
Millards rotation advancement flap
Tennison randall triangular flap
Delaire
What are important steps in lip repair
Skin incision design (symmetry, equal lip length, cupids bow, inconspicuous scarring)
Sub periosteal mobilization
Muscle repair
Nasal floor restoration
Alar base positioning and primary nasal dissection
Debate about timing of palate repair
10-12 months vs 18-24months
speech development vs palate growth and occlusion
What are goals of palate repair
- obtain 3 layered closure at soft palate, 2 layered closure at hard palate
- recreate normal anatomy and function of soft palate musculature (esp LVP)
- preserve facial growth
List techniques for palate repair
Vomer flap Langenback palatoplasty Bardach 2 flap palatoplasty Furlow z plasty Intravelar veloplasty ( sommerlad microsurgical recons of LVP) V-Y pushback Wardhill-Killner
Describe the Sommerlad technique used most commonly in the UK
Sommerlad technique - to repair cleft palate
AKA Radical microdissection
1. Incision of cleft margin
2. Mobilization of mucoperiosteum
3. Dissection of oral mucosa from muscle and nasal layer
4. Suturing of the nasal lining
5. Dissection of muscle layer from the nasal layer keeping the nasal layer intact
6. Muscle layer esp the LVP is realigned transversely and sutured
7. Oral mucosa closure
8. Lateral releasing incisions to reduce tension in the midline
9. May use buccal fat pad flap to close any gaps at the sides
Common postop complication for palate repair
Hypernasal speech
Fistula at either ends (anterior or posterior)
Restriction of maxillary growth (late complication)
Describe Langhenback palatoplasty
2 flap palatoplasty where incision is made along the cleft margin and alveolar margin and maintaining the anterior attachment to make it a bipedicled flap - greater palatine vessels and incisive vessels.
Vomer flap
Uses the vomer mucoperiosteum to close the cleft
- mucoperiosteal flap raised and can be used as nasal lining or oral lining
Advantages of vomer flap
Simple surgery
Similar tissue with nasal lining
Disadvantages of vomer flap
It has varying size and visibility (if small and not visible- unable to use vomer flap)
Not aesthetically same with oral mucosa
Affects the midfacial growth
Timing of ABG
Primary - 0-2yrs usually at time of lip repair
Early secondary 2-5 yrs - prior to eruption of incisors and grafted using BMPS only
Late secondary 5-12yrs - when 1/2 or 2/3 of canine root is formed and using autologous bone graft from anterior iliac crest for its abundant marrow
Late - >12yrs after canines erupted
Objectives of ABG
Provide alveolar arch stability Restore arch continuity Allow tooth to erupt Provide bone for orthodontic alignment Close oronasal fistula Recreate piriform rim and provide support to alar base Optimize orthognathic surgery Create platform for prosthetic replacement
Investigations required prior to ABG
OPG, Occlusal, Periapical, CBCT
- to assess presence and position of unerupted teeth at cleft area
- to look at the root formation of unerupted teeth
- to see the size and extent of cleft
Principles of surgery
- Mucoperisoteal flap raised on both buccal and palatal sides of cleft
- Nasal dissection superiorly to pyriform rim and nasal floor
- Recons of nasal floor & nasal seal +/- collagen membrane
- Bone filled between nasal and oral layer, bridging the alveolar segments, extending posteriorly into palatal cleft area, superiorly to nasal floor, laterally to paranasal region
- Overfilling recommended as it will resorb 30%
- Transpositional flap bringing the flap medially to seal orally
- Lateral buccal relieving site will leave exposed bone and allowed to heal secondarily
Parameters to look for success of alveolar bone grafting
- Success of fistula closure
- Eruption of impacted teeth
- Bony support for adjacent teeth
How to assess outcome of ABG
Assess using occlusal/panaromic/cbct to assess bone height and width
Bergland scale: comparing level of interdental septum on graft side to normal side I. Normal height II. >75% of normal height III. 50-75% of normal height IV. <50% of normal height
