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OMFS > Cleft > Flashcards

Cleft Flashcards

1
Q

Embryology of cleft lip and palate

A 
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

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2
Q

Muscles involved in cleft lip

A

Orbicularis oris

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3
Q

Muscles involved in cleft palate

A 
Levator veli palatini
Tensor veli palatini
Palatopharyngeus
Palatoglossus
Uvular
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4
Q

Whats the blood supply of palate?

A
  1. Greater & lesser palatine art (branch of DPA)
  2. Palatine artery (branch of ascending pharyngeal art)
  3. Ascending palatine branches of facial art
  4. Tonsillar br of dorsalis linguae
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5
Q

Diagnosis of cleft

A

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
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6
Q

When is cleft deformity detectable prenatal

A

Prenatal USG at approx 15 weeks

  • lip more easily seen in coronal
  • palate at axial view
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7
Q

Name some feeding aids for cleft babies

A

Mead Johbson compressible bottle
Pigeon Nipple - modified nipple that is longer
Haberman - one way valve

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8
Q

Considerations in their feeding

A

They swallow more air
Feed upright at 45degree
Burp frequently

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9
Q

Cleft classification

A

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
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10
Q

Issues in cleft patients

A
  1. Feeding
  2. Ear infection
  3. Speech impairment (VPI)
  4. Midface growth restriction
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11
Q

Consequences of unrepaired cleft palate

A
  1. unable to achieve suction
  2. nasal regurg
  3. hypernasal speech
  4. recurrent ear infection
  5. breathing problems esp if assoc. with retruded chin like in pierre robin sequence
  6. malocclusion where teeth angled into cleft
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12
Q

Give the timing of surgical correction of cleft patients

A
  1. Cleft lip repair- Rule of 10s (10lbs, 10g/dL, 10 weeks)
  2. Primary palate repair - 6-9months; 12-18mo in devolepmental delay kids/syndromic kids
  3. VPI tx - 3-5 yes of age (depending on speech development)
  4. ABG with cancellous bone and BMP - early secondary grafting to allow eruption of incisors
  5. ABG with illiac autografts - 9-12yrs of age depending on canine/lat incisor development to allow their eruption
  6. Cleft orthognathic surgery - 16 - 18 until skeletal development matured
  7. Cleft rhinoplasty - once skeletal maturation achieved after ogs
  8. Lip revision - any time
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13
Q

Issues or anatomical defect in cleft lip (UCLP)

A

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

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14
Q

Issues of BCLP

A

Central segment contains prolabium and premaxilla and short columella
Alar domes and middle crura are splayed, caudally rotated (bucket handle)

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15
Q

Timing of lip repair

A

Rule of 10s
10weeks age
10lbs weight
10g/dL Hb

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16
Q

Lip repair

A

Lip adhesion
Millards rotation advancement flap
Tennison randall triangular flap
Delaire

17
Q

What are important steps in lip repair

A

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

18
Q

Debate about timing of palate repair

A

10-12 months vs 18-24months

speech development vs palate growth and occlusion

19
Q

What are goals of palate repair

A
  1. obtain 3 layered closure at soft palate, 2 layered closure at hard palate
  2. recreate normal anatomy and function of soft palate musculature (esp LVP)
  3. preserve facial growth
20
Q

List techniques for palate repair

A 
Vomer flap 
Langenback palatoplasty
Bardach 2 flap palatoplasty
Furlow z plasty
Intravelar veloplasty ( sommerlad microsurgical recons of LVP)
V-Y pushback Wardhill-Killner
21
Q

Describe the Sommerlad technique used most commonly in the UK

A

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

22
Q

Common postop complication for palate repair

A

Hypernasal speech
Fistula at either ends (anterior or posterior)
Restriction of maxillary growth (late complication)

23
Q

Describe Langhenback palatoplasty

A

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.

24
Q

Vomer flap

A

Uses the vomer mucoperiosteum to close the cleft

- mucoperiosteal flap raised and can be used as nasal lining or oral lining

25
Q

Advantages of vomer flap

A

Simple surgery

Similar tissue with nasal lining

25
Q

Disadvantages of vomer flap

A

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

26
Q

Timing of ABG

A

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

27
Q

Objectives of ABG

A 
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
28
Q

Investigations required prior to ABG

A

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
29
Q

Principles of surgery

A
  1. Mucoperisoteal flap raised on both buccal and palatal sides of cleft
  2. Nasal dissection superiorly to pyriform rim and nasal floor
  3. Recons of nasal floor & nasal seal +/- collagen membrane
  4. 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
  5. Overfilling recommended as it will resorb 30%
  6. Transpositional flap bringing the flap medially to seal orally
  7. Lateral buccal relieving site will leave exposed bone and allowed to heal secondarily
30
Q

Parameters to look for success of alveolar bone grafting

A
  1. Success of fistula closure
  2. Eruption of impacted teeth
  3. Bony support for adjacent teeth
31
Q

How to assess outcome of ABG

A

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

OMFS (54 decks)

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