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NYU Review > Cleft Lip and Palate > Flashcards

Cleft Lip and Palate Flashcards

Miloro 2015

1
Q

In the USA the incidence of CLE or CLP is:

a. equal among all races
b. increased in whites
c. increased in blacks
d. increased in asian americans

A

d. More prevalent in Asian countries

Ring of Fire geographic distribution

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2
Q

Which is true of CLP?

a. overall prevalence of 1:4000 live births
b. Orofacial clefting lowest in native americans
c. isolated CP more common than CL
d. syndromic diagnosis is more common with isolated CP

A

D. syndromic patients more commonly have isolated CP.

Baseline incidence of 1:1000 in US.

M:F = 3:2
Whites = 1:1000
Blacks 1:2000
Asians 2:1000
Native americans = 3.6/1000
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3
Q 
Isolated CP occurs most commonly:
a. in males
b. on right side
c. in females
d on left side
A

C. CP more common in Females

Left:Right:Bilateral = 6:3:1

CL is more common in Males!!
Hard palate 75% soft palate 25%
75% unilateral:25% bialteral

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4
Q

Which physical finding should alert the surgeon to the possibility of a submucous cleft palate?

a. Alveolar notch
b. Naolabial fistula
c. enlarged adenoid pad
d. bifid uvula

A

d. bifid uvula

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5
Q

The repair of a submucous cleft palate is indicated when?

a. after 3 or more episodes of otitis media within 6 months
b. at time of dx
c. in presence of VPI
d. in presence of OSA

A

c. only in presence of VPI

requires functional deficit to mandate repair

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6
Q

What antaomic feature determines primary vs secondary cleft palate?

A

Based on incisive foramen

Primary = lip and alveolus
Secondary = includes hard and/or soft palate
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7
Q

Cleft of the palate typically occur at what point in utero?

a. 1-3 weeks
b 7-10 weeks
c 12-16 weeks
d 4-6 months

A

b. 7-10 weeks

Face develops form weeks 4-12.

Palate has maxillary, median and lateral swellings. These fuse during weeks 7-10 to create primary (median) and secondary palates (lateral) and nasal septum

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8
Q

In which direction does palatal fusion occur?

A

from anterior to posterior like a zipper from weeks 6-11 .

During this time the tongue must descend to prevent cleft palate. If syndromic (pierre robin = small mandible, no room for tongue to descend= cleft palate)

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9
Q

Primary cleft = failure to fusion of what?

secondary cleft = failure of fusion of?

A

Primary cleft = failure of fusion of median, lateral and maxillary processes/swellings

Secondary cleft= failure of fusion of palatine shelve (maxillary processes) due to tongue not descending.

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10
Q

Etiology CLP?

A

General rule:

CL=environment
- amniotic band theory - causes clefting in areas without bony fusion

CP=genetics -DIX gene, Sonic hedgehog, IRF6

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11
Q

Sibling or parent or both with cleft?

A

4, 7, 14% chance next child will have cleft, respectively

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12
Q

Are most cleft syndromic?

A

60-85% are nonsyndromic

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13
Q 
Which tooth is most commonly absent in a patient with cleft lip and palate?
A. CI
b. LI
c. k9
d mesiodens
A

b. lateral incisor

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14
Q

What malocclusion is most common in CLP patients?

A

Class III pseudoprognathism due to maxillary deficiency.

Major segment and minor segment - minor segment is missing teeth in cross bite. due to scarring of prior procedures

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15
Q

Cleft Classification

A

Kernahan Y

Tessier

LAHSHAL
- bilateral CLP = LAHSHAL
- LEFT CLP= SHAL
- Right CLP=LAHS
l= lip, a= alveolus, h= hard palate, s= soft palate

International:
Group 1 lip and alveolus only
Group 2 lip alveolus and palate
Group3 : hard and soft palates only

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16
Q

In the unrepaired CP, the levator veli palatini muscle inserts abnormally into:

a. Medial pterygoid plate
b. Lateral pterygoid plate
c. Posterior hard palate
d. passavant’s ridge

A

c. posterior hard palate

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17
Q

Which of the following is the most appropriate in the feeding of an infant with an unrepaired cleft?

a. Squeezable bottle with one-way valve
b. reclined position
c. burping of infant
d. fabrication of custom feeding appliance.

A

a. Squeezable bottle with oneway valve

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18
Q

CLP patient tend to have what speech pattern?

A

hypernasal speech

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19
Q

Treatment sequence of CLP?

A

Birth: consults/team planning, NAM, tape clefts, maxillary appliance for feeding

Cheiloplasty ( lip repair) at 10 weeks

Palatoplasty at 12-24 months (prior to speech)

Pharyngeal flap at 5-9 years for VPI if needed

Alveolar bone graft 6-12 years (prior to canine eruption) - late mixed dentition 9-12

Orthognathic sx 14-18 years

Lip revision/rhinoplasty/implants at 18 years

20
Q

IN CLP patient which of these treatment modalities may cause growth restrinction in maxilla?

a. lip adhesion
b. lip taping
c. NAM device
d. Pin retained orthopedic device (latham)

A

d. Latham device disturbs facial growth

21
Q

Primary CL repair should occur when the child is?

a. 1 week of age and 5 lbs
b. 10 weeks of age and 10 lbs
c. 10 weeks of age and 10 kg
d. 10 months of age and 22 lbs

A

b. 10 week and 10 lb

Rule of tens for cheilorrhaphy (lip repair)

10 weeks old, 10 lbs, > 10 gm/dl Hgb, <10,000 WBC

22
Q

Best repair of cleft lip?

  1. straight line repair
  2. Tennison Randall lip repair
  3. Millard rotation advancement
A
  1. Millard rotation advancement - uses landmarks to reapproximate ( cupid bow, commissure, columella, ala base)
    - rotation 6 - advancement 4

Straightline repair often lead to whistle deformity

23
Q

What is the difficulty in bilateral maxilla cleft lip repair?

A

repositioning the premaxilla ( it is projected subnasale in bilateral CL. Proper closure of musculature allows for orthopedic traction of the premaxilla to retract it. Columella lengthening may be necessary secondary procedure

24
Q 
The age of initial repair of a cleft palate is based primarily on:
a. anticipate development of speech
b childs ability to eat
c. concerns for airway patency
d. anticipated need for bone grafting
A

a. speech development

25
Q

one stage repair of a cleft of the secondary palate is generally done at what age?

a. prior to 3 months
b. 3-6 months
c 10-18 months
d 3-5 years

A

c. 10-18 months

Palatoplasty - 2-3 layer closure (nasal mcuosa, oral mucosa, muscle)

26
Q

Which of the following cleft palate repair techniques retains an anterior soft tissue pedicle for improved flap perfusion?

a. von langenback
b furlow z plasty
c. bardach (2-flap) technique
d. v-y pushback procedure

A

a. von langenbeck repair
- 2 releasing incisions - 2 relaxing incisions, closure of cleft, secondary ehalign of relaxing.
- may not correct VPI.

  • V-Y pushback with increase length of palate and improve VPI.
  • Furlow Double reversing z plasty also increases palate length but is less popular

-

27
Q

during primary repair of a cleft palate using two flap technique the palatal flaps are based upon which vessel ?

a. ascending pharyngeal artery
b. facial artery
c. greater palatine artery
d. sphenopalatien artery

A

c. Greater palatine

28
Q

During primary repair of a CP using a two flap technique the greater palatine neurovascular bundle is transected, what is the next step?

a. Abort procedure and reposition flap.
b. Proceed with palatoplasty
c. Proceed but without further flap elevation
d. attempt reanatomosis

A

b. proceed with palatoplasty due to collateral blood supply

29
Q

What treatments can be utilized for secondary fistula repair?

A

tongue flap, buccal fat pad, temporalis flap

tongue flap take down at 14-21 days

30
Q

Secondary bone graft reconstruction of the cleft alveolus occurs:

a. at time of palate repair in infancy
b. when the maxillary central incisor is 2/3 formed
c. when max canine is 1/2 to 2/3s formed
d. after partial eruption of maxillary canine

A

c. after 1/2 to 2/3 of max k9 is formed
- delayed to prevent further growth restriction
- can be done with 2 piece lefort

31
Q

If an alveolar cleft bone graft begins to extrude during the postop period you should:

a. manage it expectantly with local debridement and supportive measures
b immediately return to OR to remove failed graft
c. immediately augment the graft with additional bone
d. place additional sutures in mucosa at sites of bone extrusion to prevent further bone loss

A

a manage it expectantly with local debridement and supportive measures

32
Q

An 8 year old with unilateral CLP has an unrepaired residual ONF. The plan may include:

a. incisor rotation prior to grafting
b. maxillary expansion
c. maintaining primary teeth in cleft site
d using alloplastic bone substitute

A

b. maxillary expansion

“because the other ones are less desirable”

Its better to expand prior to grafting - this is more common ,easier expansion, improves access to soft tissue, better hygiene, less chance of ONF.

Ortho may move tooth into cleft and loos tooth though and a wider cleft requries more bone graft.

33
Q

5 goals of alveolar bone grafting

A
  1. closure of ONF
  2. establish alveolar bone continuity
  3. bone support for erupting adult teeth and orthodontics
  4. bone support for lip and alar base
  5. bone support for future implants
34
Q

Common bone grafts?

A

anterior iliac, cranium, tibia, anterior mandible, rib, Alloplast, rhBMP

35
Q

What must be known before doing anterior iliac in peds patients?

A

the status of the cartialge cap of the iliac crest (usually at kids <12)

  • do a lateral approach to avoid this
36
Q

Phase I orthodontics in the bilateral CLP patient prior to alveolar bone graft surgery is primarily intended to:

a. collapse the cleft segments in order to obtain a class I molar relationship
b. correct transverse maxillary discrepancy and align premaxilla
c expedite the exfoliation of primary teeth
d. expand the cleft segments in order to obtain class I molar relationships

A

b. correct transverse maxillary discrepancy and align premaxilla

37
Q

Which indication for bone graft reconstruction of the cleft maxilla is unique to bilateral clefts?

a. bone support for erupting canine
b. establish alveolar continuity
c. closure of ONF
d. stabilization of premaxilla

A

d. stabilization of premaxilla

38
Q

Which is correct regarding passavant’s pad?

a. only seen as part of cleft palate malformation
b. it does not facilitate velopharyngeal closure
c. it forms along the palatophyaryngeus muscle
d. it forms along the superior pharyngeal constrictor muscle

A

d. it forms along the superior pharyngeal constrictor muscle

Passavants pad = area where soft palate contacts pharyngeal wall

Superiorly based pharyngeal flap is most popular or an implant at passavants pad

39
Q

When raising a superiorly based pharyngeal flap, dissection is carried to but not through which structure?
a. superior pharyngeal constrictor muscle
b. palatopharyngeous
c. prevertebral fascia
pretracheal fascia

A

c. prevertebral fascia

40
Q

The successful creation of velopharyngeal competence after superiorly based pharyngeal flap surgery requires:

a. adequate lateral wall mobility
b. Palatal elongation at sx time
c presence of passavants ridge
d. glottic closure

A

a. adequate lateral wall mobility

41
Q

How is VPI diagnosed?

a. Perceptual evaluation by speech pathologist
b. fiberoptic nasopharyngoscopy
d. videofluroscopy
d. nasometry

A

a. Perceptual evaluation by speech pathologist

Could be insufficiency or incompetence diagnoses

insufficiency is anatomic limit, incompetence is a function deficit.

42
Q

The most common speech alteration complication of LeFort advancement of repair CP patient is:

a. Denasality
b. Frontal Distortion
c. Lateral distortion
d. hypernasality

A

d. hypernasality

pulls soft palate from pharyngeal wall - must compensate with tongue

43
Q

complications of orthognathics in CLP pts

A

scarring with decreased blood supply, VPI, increased relapse, shortend lip.

GOAL is to keep pedicle in front or consider DO

44
Q

Which is correct regarding DO of the cleft maxilla?

a. Long-term stability is greater than standard Lefort sx
b. There is less likelihood of post op VPI than standard Lefort sx
c. Less post op ortho is required than standard lefort sx
d. appliances must be retained for several months

A

d. appliances must be retained for several months

45
Q

a 17 yo M with repaired left unilateral CLP has a large class II malocclusion with plans for LeFort I advancement. The incidence of postop VPI at 6 months is:

a. 1%
b. 15%
c. 50%
d. 75%

A

b. 15%

DO has no advantage over LeFort I in preventing VPI or speech disturbance in moderate cleft advancement

46
Q

initial management of the patient who develops VPI and hypernasality after Lefort I advancement should be:

a. Pharyngeal flap surgery at 4-6 weeks postop
b. z-plasty to lengthen soft palate at 4-6 weeks postop
c. Repeat LeFort I to reposition maxilla
d. Reevalaution at 6 months

A

d. Reevalaution at 6 months

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