Lip and Palat Flashcards
The critical period for cleft lip and palate embryologic development is 4 to 7 weeks
T
The critique of the Veau classification system is that it lacks terminology to describe isolated clefts of palate?
The critique of the Veau classification system is that it lacks terminology to describe isolated clefts of the lip.
Complete orbicularis oris muscle disruption is the hallmark of a true cleft lip
-
T
Cleft lip results from failure of fusion
of the medial nasal process and the maxillary prominence
T
The medial nasal prominence serves as the precursor to the nasal
tip, columella, philtrum, and premaxilla and the nasal ala
F The medial nasal prominence serves as the precursor to the nasal
tip, columella, philtrum, and premaxilla. The lateral nasal prominence is
the precursor to the nasal ala
Thelower lipand jaw derive from the bilateral mandibular prominences,
which fuse across the midline
T
Palatogenesis initiates during the sixth week of development
T
the medial nasal prominences fuse to form the intermaxillary segment
T
In the eight week of development, the palatine shelves assume a horizontal orientation,
F In the seventh week of development, the palatine shelves assume a horizontal orientation, right before left
fusion of the hard palate complete by the 10th week and soft palate
fusion achieved by the 12th week
T
Male has more risk to develope isolated cleft palate
F I :2 male-to-female gender
predominance for isolated cleft palate
2:1 male-to-female gender predominance for CLIP
T
Isolated CLIP remains more common than isolated
cleft palate which is more common than isolated cleft lip with a
5:3:2 ratio
T
For patients with syndromic
etiologies for CLIP, such as van der Woude syndrome, the risk
to subsequent children will be 10%
F 50%
Veau classification
Class I: cleft of the soft palate
Class II: cleft ofthe hard and soft palate up to the incisive foramen
Class III: clefts of the soft and hard palate extending unilaterally
through the alveolus
Class IV: clefts of the soft and hard palate extending bilaterally
through the alveolus
The critique of the Veau classification system is that it lacks terminology to describe isolated clefts of the lip
T
Kernahan and Stark suggested that characterization should be based on the
embryologic origins of the primary and secondary palate
T
Kernahan
and Stark classified clefts
- Clefts of structures anterior to the incisive foramen
- Clefts of structures posterior to the incisive foramen
- Clefts affecting structures anterior and posterior to the incisive
foramen
The striped-Y simplified record keeping and allowed classification of
clefts to become a visual rather than cognitive exercise
T
lowercase
letters (I, a, h, s) for incomplete clefts of a region
T
The nasal
deformity associated with microform cleft lip
s variable but typically demonstrates some degree of lower lateral alar slumping, the horizontal orientation of the nostril, depression of the nostril sill, and cephalo-retrodisplacement of the alar base.
straight-line surgery can be used in microform cleft lip
T
Separation that is greater than 3 mm in height
compared with the Cupid’s bow on the uninvolved side defines a true
incomplete cleft lip from a microform cleft
T
Complete orbicularis oris
muscle disruption is the hallmark of a true cleft lip
T
if the
cleft extends to less than two-thirds the height of the lip, there may be
intact orbicularis oris muscle fibers traversing the superior aspect of
an incomplete cleft
T
A complete cleft with a Sirnonart band can be
differentiated from an incomplete cleft by the presence of an underlying complete alveolar cleft
T
In incomplete unilateral cleft vertical lip height is diminished on the noncleft side with an increasing paucity of vermillion as it tracks into the cleft margin.
T
The cleft nasal deformity associated with unilateral cleft lip
lower lateral cartilage hypoplasia,
flattening of the cleft side alar dome,
lack of upper lateral and lower lateral cartilage overlap,
subluxation of the lower lateral cartilage,
a horizontal orientation of the nostril,
and alar base displacement posteriorly and superiorly due to the underlying maxillary hypoplasia
caudal septum
and anterior nasal spine are typically deviated toward the noncleft side
T
incomplete forms and microform clefts can be seen with asymmetry in cleft severity from side to side in bilateral cleft lip
T
Causes of fattening of the alar domes in bilateral cleft lip
secondary to subluxation of the
lower lateral cartilages from their normal anatomic position overlying
the upper lateral cartilages
Underdevelopment or absence of the
anterior nasal spine causes posterolateral displacement of the medial
crural footplates and contributes to a lack ofnasal projection a broad
nasal tip, and significant foreshortening of the columella
t
Tympanostomy and placement of pressure equalization tubes are typically performed at the
time of primary palatoplasty.
T
50% of all isolated clefts occur
in the setting of an associated syndrome or anomaly.
T
wide U-shaped cleft palate occures n the case of Pierre Robin
sequence
T
Submucous Cleft Palate is defined by a classic triad offindings including a bifid uvula, notching of the posterior hard palate, and midline
mucosa! attenuation known as the zona pellucida
T
Anatomically,
there is anterior displacement ofthe levator veli palatini muscles onto
the notched hard palate leading to variable degrees of velopharyngeal dysfunction (VPD) despite the lack of an overt cleft
T
patients may still benefit from palatoplasty beyond the age of critical
language development
T
Passive methods include
lip taping, nasoalveolar molding, and lip adhesion
Active methods such as the Latham device exert a progressive and tunable force across tissues to create the desired effect
T
Lip taping applies as early as the first week of life
T
significantly reduce alveolar gaps with taping
T
Lip
adhesions have been demonstrated to significantly reduce alveolar
gaps and normalize preoperative cleft severity but at the cost of an
additional operation prior to definitive repair
T
Nonalveolar molding (NAM) benefits
aligning the alveolar segments and helping to correct the preoperative cleft
nasal deformity by supporting the alar domes, lengthening the columella and improving nasal tip projection and symmetry
Latham pin-retained device that is surgically implanted into the alveolar segments
T
In bilateral cases the device was used to rein in the premaxilla while
simultaneously expanding the palatal arch
T
secondary growth disturbance can occurs with NAM
F with LATHAM
Rose and Thompson via curvilinear incisions, now known as the Rose-Thompson effect
T
Introduction of the Z-plasty to cleft
lip repair to further correct vertical lip height deficiency is credited
to LeMesurier
Introduction of the Z-plasty to cleft
lip repair to further correct vertical lip height deficiency is credited
to LeMesurier
The main critique of Tennison technique
is the low placement of the Z-plasty limbs, which inevitably cross
both the cleft side philtral column and central philtrum
F The main critique of LeMesurier technique
Randall modified the LeMesurier repair and reoriented the
Z-plasty so that one limb would coincide with the peak of the cleft
side Cupid’s bow, there by preserving the natural curvature of the cupid bow
F Tennison modified the LeMesurier repair
Tennison preserves the natural curvature of the
central Cupid’s bow
T
Tennison’s use of a malleable wire to mark the Z-plasty limbs
T
Randall, who
introduced standardized measurements of the cleft and noncleft
side philtral heights.
T
he difference between the normal and cleft
side philtral columns was used to determine the base width of the
triangular flap used to augment the vertical lip height on the cleft
side
T
Drawpack of Randal
the drawback of creating a long lip with the laterally based triangular flap which also results in a visible scar on the lower philtrum
RandallTennison repair can be used for wide clefts
T
In Millard the back-cut which is made across the
midline of the columellar labial junction back toward, but not violating, the noncleft side philtral column
T
he superiorly based
triangular C-jlap then can be rotated medially to lengthen the columella or rotated laterally into the nose to assist with nasal floor
T
Mohler modifications on millard include……
including the use of a vertical back-cut
onto the columella to obviate the need for
a horizontal scar across the philtrum and leverage the columellar skin
to lengthen the lip
Fisher repair employs a geometric design with triangular flaps
akin to the Randall-Tennison technique
T
Fisher repair result in a Rose-Thompson
effect with the final straight-line closur
T
The critique of the
Fisher method is that it can be more time-consuming,
T
preservation of anatomic landmarks, and
favorable scar positioning with Fisher
T
Relying on the prolabium to reconstitute the entirety of central lip is ill advised given
its lack of orbicularis muscle, inadequate vermillion and cutaneous height, and lack of a well-defined white roll
T
relatively recent paradigm shift in bilateral cleft lip repair that primary correction of the nasal
deformity with alar repositioning could create columellar length
T
primary goals
of palatoplasty are to separate the oral and nasal cavities and create a competent velopharyngeal port.
T
Secondary goals include the
avoidance of a palatal fistula and the prevention of maxillary growth
disturbance
T
von Langenbeck technique creating two bipedicled flaps based off the greater palatine vessels posteriorly and the
sphenopalatine arteries emanating from the incisive foramen anteriorly
T
the lateral relaxing incisions in von Langenbeck technique
are left to heal by secondary intention in
T
The Veau-WillardKilner repair offers the added benefit of increasing palatal length to assist
with velopharyngeal competency
T
critique of Veau-WillardKilner repair
A large area of denude palate centrally
leading to potential maxillary growth disturbance and secondary scar contracture with foreshortening of the initial palatal
pushback
The lateral relaxing incision lines can
usually be closed loosely in baradach
T
Bardach technique, it does not increase palatal length following flap elevation and
inset and therefore is usually paired with a lengthening soft palate
repair technique
t
mucoperiosteal flaps elevated from the vomer
provide additional tissue that can be recruited into the nasal side
closure in bilateral palatal cleft
T
The original vomer flaps were inferiorly based with incisions high up on the nasal septum with subsequent downward
reflection of the mucoperichondrium
T
the primary critique of the intravelar veloplasty is
that it does not significantly increase palatal length
T
The primary drawback to the Furlow technique is the sacrifice of width to achieve length resulting in tension transversely across
the palatal closure.
T
undergoing
Furlow palatoplasty have improved speech outcomes in comparison
with other techniques
T
The buccal fat pad line the open lateral relaxing incision
defects in hard palate repairs to protect the exposed palatine vessels
as well as prevent secondary scarring and contracture thought to lead
to restriction of transverse growth over time
T
The buccal fat used as a middle lamella in the space just behind
the posteriorly transposed muscles of an intravelar veloplasty and a
Furlow repair
T
Benefits of Buccal fat pad
decrease the incidence of fistula formation
prevent secondary contracture and retropositioning of the transposed
muscles
VPI is an anatomic
problem and will not improve with speech therapy and therefore
requires surgical intervention.
T
Velopharyngeal incompetence can
be improved with speech therapy if normal palatal motion can be
learned by the patient
T
Video nasendoscopy is essential for surgical candidates with velopharyngeal incompetence to characterize the closure pattern of the vetopharyngeal port
T
Furlow palatoplasty can be applied to mild to moderate velopharyngeal gaps
T
PPFG can
also be utilized as an adjunctive procedure for modest (>2 cm’) gaps
F PPFG can
also be utilized as an adjunctive procedure for modest (<2 cm’) gaps
The volume of autologous fat required and regions for augmentation
are determined from preoperative nasendoscopy
T
The PPF is utilized in cases with large velopharyngeal gaps
T
The technique makes two longitudinal incisions through the mucosa
and muscle of the posterior pharyngeal wall to the level of the prevertebral fascia
T
with PPFG
increases in postoperative obstructive sleep apnea can occure
without significant
increases in postoperative obstructive sleep apnea.
The resultant posterior pharyngeal wall donor site is closed primarily
T
PPF flaps the superiorly based
flap is most commonly practiced today
t
The DSP flaps are then raised to the height of the anticipated level of
the velopharyngeal port is just inferior to the adenoid pad.
T
pre- and postoperative polysomnographic evaluation is warranted for patients requiring PPF and DSP.
T
The DSP technique elevates superiorly based musculomucosal flaps from the posterior tonsillar pillars and include the underlying palatoglosus muscle
F underlying palatopharyngeus muscle
Method of Alveolar Cleft Closure
primary bone grafting,
gingivoperiosteoplasty (GPP),
and secondary bone grafting during mixed dentition
The rationale for early primary bone grafting ( <2 years old) is that bony reconstruction of maxillary arch will
prevent collapse of the greater and lesser segments
T
Split rib corticocancellous grafts were typically
used in primary bone grafting
T
concern for disruption of maxillary growth with early
primary bone grafting has caused this approach to largely fall out of
favor
T
GPP is typically performed
at the time of the primary lip repair and theoretically obviates the
need for a secondary surgery and additional donor site morbidity
T
significantly higher failure rates
of both primary and secondary GPP compared with secondary bone
grafting alone
T
up to 40% of patients treated with GPP still
require secondary bone grafting a
T
Secondary bone grafting is typically performed just prior to
eruption of the permanent maxillary canine into the cleft margin (8-9 years of age)
T
Cancellous bone is harvested from the iliac
crest and utilized to definitively close the anterior oral-nasal fistula
T
success rates for secondary alveolar cleft bone grafting in
the literature approach 80% to 90%
T
CLIP
patients often develop maxillary hypoplasia and resultant Angle
Class II malocclusion
F
Class III malocclusion
Cleft patients can also exhibit transverse
maxillary hypoplasia
T
the typical orthognathic correction for
cleft patients is a LeFort I maxillary advancement with variable
need for palatal osteotomies
T
48% for unilateral
clefts and 65% for bilateral clefts need orthognathic surgery
T
In the noncleft population, the standard prerequisites
for undertaking orthognathic surgery
include full eruption of the
permanent dentition, completion of presurgical orthodontia to level
and align the dental arches and completion of maxillomandibular
growth
orthognathic correction prior to achieving skeletal maturity som time need to finish before the cleft population
T
In case of early orthognathic surgery distraction osteogenesis (DO) or a finalizing osteotomy
after completion of facial growth may be required.
T
DO is indicated for correction of a negative overjet of greater than 10 mm in cleft
patients
F DO is indicated for correction of a negative overjet of greater than 6 mm in cleft
patients and greater than 10 mm in noncleft patients
postoperative VPI following midface advancement can occures
T
Patients with borderline
preoperative velopharyngeal function or who require large advancements (> 10 mm) are at higher risk for VPI
T
Finally,
the surgical plan for cleft orthognathic cases should factor in a modest degree of overcorrection to account for surgical relapse
T
Unfortunately, these inferiorly based vomer flaps resulted in a high incidence of maxillary
growth disturbance and fistula, leading to their abandonment.
The technique was modified with a midline incision on the caudal
margin of the vomer with superior reflection of the two septa!
mucosa flaps in opposite directions. These superiorly based vomer
flaps can then be inset to the lateral nasal mucosa to reconstitute
the nasal side closure in bilateral clefts
T
The frontonasal prominence is the precursor to the
medial and lateral nasal prominences
T
The frontonasal prominence is the precursor to the
medial and lateral nasal prominences
T
If one child or one parent
has CLP then there is a 4% chance of a subsequent child being
born with a cleft. If two children have CLP then there is a 9%
chance ofasubsequent child being born with a cleft. If one child
and one parent both have CLP then there is a 17% chance a subsequent child being born with a cleft.
T
speech disturbance is not
a primary indication for bone grafting
T
