Week 2 - Part 2 Flashcards
Cleft lip / Palate Surgery
Cleft lip / palate epidemiology facts
- Unilateral:Bilateral - 9:1
- L side:R side - 2:1
- Most common in Asians (1:500) then whites (1:1000) then African Americans (1:2000)
chance of other kids having a cleft
CLP (one parent/child) - 4%
CLP (2 children) - 9%
CLP (1 parent & 1 child) - 17%
CP (1 kid) - 2%
CP (2 kids) - 1%
CP (1 parent) - 6%
CP (1 parent & 1 kid) - 15%
Multidisciplinary cleft care team includes…
-Plastic surgeon, dentist/oral surgeon, AuD, geneticist, nutritionist/dietitian, ENT, pediatrician, psychologist/social worker, SLP
Development of the primary palate
Forms from an internal swelling of the inter maxillary process (fusion of medial processes)
-Fusion of the medial nasal processes & the frontonasal process gives rise to the primary palate
Development of the secondary palate
Forms from the two lateral palatine shelves or processes - develop as internal projections of the maxillary prominences
-Fusion of the lateral palatine processes in the midline form the secondary palate
Oronasal development
Oronasal cavity is bounded ant. by primary palate & occupied by developing tongue - after development of secondary palate, the oral and nasal cavities can be distinguished - hardening of the palate involves withdrawal of tongue
Microform Cleft lip
Furrow / scar transgressing the vertical length of the lip - vermillion notch - imperfections in the white roll - variable distortion of the ala
Incomplete cleft lip
-Spares the superior aspect of the lip - orbit does not cross cleft unless cutaneous bridge at least 1/3 normal
Complete cleft lip
Lip, alveolus, and nose are all affected
Bilateral cleft lip
Over-projection of the pre maxilla and prolabium - broad, flat nasal tip, absent columella
Timing of lip closure: rule of 10’s
> 10lbs
10 weeks
Hgb > 10
*usually around 3 months
Pre-surgical NAM
Naso-alveolar molding - reduces the # of secondary surgeries required on nose - better results - neonatal cartilage is + plasticity & - elasticity - high levels of hyaluronic acid - high levels of circulating maternal estrogen
*Started ~1-2 weeks after birth
Advantages to post-natal lip repair
-baby carries mother’s immunity to infection, good healing mech, protection of maxillary segments from further distortion, improved feeding conditions, psychological benefit, reduction of cost from additional hospital stay
Contraindications to early surgery
- More at risk for general anesthetic complications, preterm infants, severe anemia, jaundice, technically challenging
- Proportion of blood loss is more significant for an infant
Cleft lip anatomy
-Premaxilla outwardly rotates/projected, lateral segment posterior, nasal spine in floor of the normal nostril, disruption of the orbicularis
Cleft side nasal deformity
Lower lateral cartilage attenuated, medial crus lower in columella, dome lower than normal side, lateral segment flat, spread across cleft at obtuse angle, alar base rotated outward in flare
Goals of lip repair (5)
Reconstruct orbicularis musculature Establish nasal base symmetry Creata symmetrical cupid's bow Reconstruct vermillion & mucosal projection Minimize scaring
What are the two main cleft lip repairs?
- Millard Rotation-Advancement
- Tennison Triangular Flap
Describe the Millard Rotation-Advance surgery
Medial lip element is rotated inferiorly and the lateral lip is rotates superiorly - columnar flap is used to create the nasal sil/base
Where do you want the scar from a cleft lip surgery?
Along the philturn column so it blends
Describe the Tennison (Triangular) Lip Repair
Medial lip is lengthened by incorporating a triangular flat from the inferior portion of the lateral lip - which leads into the philtrum
Why are non-absorbable sutures used for lip repairs?
They are stronger & less reactive –> less scarring
Timeline of treatment for cleft lip & palate - newborn
Diagnostic exam, general counseling of parents, feeding instruction, palatal obturator, genetic evaluation, prevention?
Timeline of treatment for cleft lip & palate - 3 months
Repair of cleft lip - placement of myringotomy tubes
Timeline of treatment for cleft lip & palate - 6 months
Pre-surgical orthodontics, first speech evaluation
Timeline of treatment for cleft lip & palate - 9 months
Speech therapy begins
Timeline of treatment for cleft lip & palate - 9-12 months
Repair of cleft palate
Timeline of treatment for cleft lip & palate - 1-7 years
Orthodontic treatment
Timeline of treatment for cleft lip & palate - 7-8 years
Alveolar bone grafting
Timeline of treatment for cleft lip & palate - 8+ years
Continued orthodontic treatment, secondary surgery (columellar lengthening, cleft lip rhinoplastly & septoplasty, lip scar revision, LeFort I maxillary osteotomy)
What are the main cleft palate repairs?
von Langenbeck Repair
Wardill-Kilner (V-Y Pushback)
Furlow
Describe the von Langebeck Repair
Putting flaps along the cleft side & the lateral side and then advancing them together. Lateral side might get a gap, but the body will heal that gap
Describe the Wardill-Kilner (V-Y Pushback) repair
It lengthens the palate - didn’t take good enough notes - check book
Describe the Furlow repair
Mainly a soft palate repair - Double opposing ‘C’ palate surgery
Alveolar Bone Grafting
Alveolar cleft HAS to remain in place until ~8-9 y/o due to mixed dentition period - spongey bone cells from the iliac crest are taken an dusted for the bone grafting at the alveolar ridge
What is Distraction Osteogenesis?
Application of gradual & incremental traction to surgically separated bony segments to produce additional bone
Describe distraction osteogenesis
1- bone separation (distraction zone)
2- Reparative callus formation in the distraction zone over 5-7 days (latency period)
3- Distraction forces applied to separate callus edges & elongate segment (activation period)
4-Consolidation period - stable over 8weeks
Orthognathic Surgery
Surgical movement of the tooth-bearing segments involving the maxilla and the mandible
What is Class I Occlusion?
Normal dentition
What is Class II Malocclusion?
An overbite
What is Class III Malocclusion?
Underbite
What are other types of malocclusion (other than Class II and CLass III) (2)
Crossbite & Open bite
What is LeFort Osteotomy?
LeFort spots are weak spots of the bone where you want to cut (due to least resistance)
Rigid External Distraction (R.E.D)
Used for patients who need a cm+ of advancement of their upper jaw - once they make the cut, they put this device on and advance it 1mm at a time - soft tissue gets stretched gradually - wear for ~3 months - good results - less infection
