Category Archives: Management of Patients with Orafacial Clefts

Prosthetic Speech Aid Appliances

Prosthetic Speech Aid Appliances

Prosthetic care for the cleft patient mav be Il\?ce~\ar~ Ior  wo reasons: first, teeth that are so frequently Illi~sing in the cleft-afflicted patient should be replaced. Second. in patients who have failed to obtain velopharyngeal competence with SUrgical corrections. a speech aid appliance can be made by the dentist to decrease hypernasal speech. A speech aid appliance is an acrylic bulb attached to a toothborne
ap liance in the maxilla (Fig. 27-19). The bulb is fitted to project onto the undersurface of the soft palate and lifts the soft palate superiorly. If this bulb does not give adequate function, another projection ‘of acrylic (i.e., bulb obturator). can be placed’ to extend to the posterior aspect of the palate. This narrows the pharyngeal isthmus, and the size can be adjusted for maximal effectiveness. The posterior pharyngeal wall then will contact this bulb in function: In many instances the size of the bulb can be reduced
as the .pharyngeal m usculature becomes more active. Thi~type of appliance is used in two instances: (1) before a pharyngeal   flap procedure to develop muscle action or (2) if the secondary surgical procedures are not successful in pro ucing velopharyngeal.competence. The speech aid appliance is also useful concomitantly to hold prosthetic dental replacements, to cover hard palate defects, and to support deficie t upper lips by a flange extending into the labial sulcus. Obviously the maintenance of the residual dentition in an optimal state is prerequisite for successful speech aid appliance therapy,

DENTAL NEEDS OF CLEFT AFLFLlCTED INDIVIDUALS

DENTAL NEEDS OF CLEFT AFLFLlCTED INDIVIDUALS

Dentists will have. cleft-afflicted patients in their practice because of the relatively large number of people so affected. These patients should not pose any great problems, because their dental needs do not differ dramatically
from those of other individuals. However, because of the presence of the cleft, either corrected or uncorrected, these individuals have a few special needs of which the dentist should be cognizant.

FIG. 27·15 . CCI1C rl E, Particulate bone graft is placed into the defect F, Closure of the palatal and labial mucosa over the bone graf;. G, Radiographic result is demonstrated 3 days after surgery. H, Three months later the soft tissues have healed. I, Radiograph shows consolidation of the bone graft.FIG. 27·15 . CCI1C rl E, Particulate bone graft is placed into the defect F, Closure of the palatal and labial mucosa over the bone graf;. G, Radiographic result is demonstrated 3 days after surgery. H, Three months later the soft tissues have healed. I, Radiograph shows consolidation of the bone graft.

FIG. 27·15 . CCI1C rl E, Particulate bone graft is placed into the defect F, Closure of the palatal and
labial mucosa over the bone graf;. G, Radiographic result is demonstrated 3 days after surgery.
H, Three months later the soft tissues have healed. I, Radiograph shows consolidation of the bone graft.

I ted patients require, it behooves the dentist to be \ ‘3fl’ of the overall treatment plan formulated by the lert team. for the patient’s management. Awareness of ,i plan precludes the performance of any irreversible
or costly procedures on teeth that may be charted for ~xtraction in the futufe. For instance, placing a bridge to replace a’ congenitally missing lateral incisor before alveolar bone grafting and orthodontic therapy is
unwise. Similarly, extracting supernumerary teeth that may be temporarily retained to maintain alveolar bone support ‘is also disadvantageous. All fixed bridgework should be delayed until after the orthodontic, orthognathic, and alveolar grafting procedures have been completed:
Only then will the dentist be able to determine accurately the exact space and .ndge form .available for  pontics. Furthermore, until the· two halves of. he maxillaryarch have been’ united with bone grafts, the halves will move independently and bridgework spanning the cleft margin may become loose. Therefore the dentist must communicate’ freely with the other professionals who are managing the patient’s other cleft problems,
and coordinat on of services is of paramount  importance.Teeth adjacent to the cleft margins not only may be malformed or absent but also may have poor periodontal . support because of lack of bone and their position in the
cleft’ margin. This situation predisposes them to peripdontitis and early loss-If not kept in an optimal state of health. Because teeth are frequently malaligned and  rotated, oral hygienic measures may be more difficult
these individuals may need more frequent prophylaxis and special oral hygienic instructions with careful reinforcement. Otherwise, rampant caries with premature loss may 4) . This is a special tragedy in the acleftafflicted individual, because he or she may have fewer teeth to serve vital functions (e.g., retaining orthodontic, orthopedic, or speech appliances).

 

 

 

 

 

 

 

 

Secondary Surgical Procedures

Secondary Surgical Procedures

Secondary surgical procedures are procedures performed after the initial repair of the cleft defects in an effort to improve” speech or correct residual acfects. The most commonly used technique to improve veopharyngeal competence secondarily is the pharyngeal flap procedure

FIG. 27 -1 S Labial (A), palatal, (8) and radiographic (C) views of a patent unilateral alveolar cleft that extends posteriorly along the hard palate. D, ~hotograph shows surgical closure of the nasal mucosa with inversion into the nasal cavity.FIG. 27 -1 S Labial (A), palatal, (8) and radiographic (C) views of a patent unilateral alveolar cleft that extends posteriorly along the hard palate. D, ~hotograph shows surgical closure of the nasal mucosa with inversion into the nasal cavity.

FIG. 27 -1 S Labial (A), palatal, (8) and radiographic (C) views of a patent unilateral alveolar cleft that
extends posteriorly along the hard palate. D, ~hotograph shows surgical closure of the nasal mucosa
with inversion into the nasal cavity.

(Fig. 27-17). In this procedure a wide vertical strip of pharyngeal mucosa and musculature is raised from the pesterior pharyngeal wall and inserted. into the superior aspect of the soft palate. These flaps are most often based
superiorly. The defect left in the posterior pharyngeal wall from elevation of the pharyngeal flap can be closed »rirnanly or left to heal by secondary intention. Once .nserted into the soft palate, the pharynx and the soft
palate are joined, leaving two lateral portsas the opening between the oropharynx and nasopharynx, which reduces the airstream, between the oropharynx and nasopharynx. The velopharyngeal mechanism then con-
. sists of both rai sing the soft palate somewhat and medialconstncnon of the lateral pharyngeal walls. ~ Another technique that has recently had a resurgence uf interest because of new biocompatible material is the placement of an implant behind the posterior pharyngeal

 

Correction of Maxillomandibular Disharmonies

Correction of Maxillomandibular Disharmonies

The individual with a cleft deformity will usually exhibit maxillarv retrusion and’ a transverse maxillary constriction resulting from the cicatricial contraction of previous’ surgeries. In many instances the associated alocclusion is beyond the scope of orthodontic treatment alone.,In
these cases orthognathic surgery similar ·to the procedures outlined in Chapter 25′ are indicated to correct ‘the underlying skeletal  alrelationships.
However, some differences exist in the technical aspects of maxillary surgery because of the other deformities and scarring that are present in the maxillas of cleft-afflicted individuals. ‘In general, total maxillary
osteotomies are necessary to advance and sometimes widen the maxilla. Closure of some of the space in the alveolar cleft area by bringing the alveolus of the cleft side anteriorly is also performed in several instances.
These ‘latter procedures necessitate the segmentation of the maxilla, which, because of the cleft’s nature, usual1y  already has occurred. The differences between the cleftafflicted patient and a non-cleft-afflicted patient, however,
are the scar present across the palate and the decreased blood supply to the maxilla. Scarrrorn previous  surgeries makes widening of the  very difficult.

 

 

 

 

•• r- .'; ; ': Triple-layered soft palate closure. A, Excision of mucosa at cleft margin. B, Dissection of nasal mucosa from soh palate to facilitate closure. Nasal muc.osa is sutured together with knots tied . on nasal (i.e., superior) surface. Note small incision made to insert instrument for hamular process fracture. ,This maneuver releases tensor vell palatini and facilitates approximation in midline. C, Muscle is dissected from insertion into hard palate, and sutures are placed to approximate muscle in midline. 0, Closure of oral mucosa is accomplished last. E, Layered closure of soft palate. (From Hayward JR: Oral surgery, Springfield, III, 7976, Charles C Thomas.)•• r- .'; ; ': Triple-layered soft palate closure. A, Excision of mucosa at cleft margin. B, Dissection of nasal mucosa from soh palate to facilitate closure. Nasal muc.osa is sutured together with knots tied . on nasal (i.e., superior) surface. Note small incision made to insert instrument for hamular process fracture. ,This maneuver releases tensor vell palatini and facilitates approximation in midline. C, Muscle is dissected from insertion into hard palate, and sutures are placed to approximate muscle in midline. 0, Closure of oral mucosa is accomplished last. E, Layered closure of soft palate. (From Hayward JR: Oral surgery, Springfield, III, 7976, Charles C Thomas.)

•• r- .’; ; ‘: Triple-layered soft palate closure. A, Excision of mucosa at cleft margin. B, Dissection of
nasal mucosa from soh palate to facilitate closure. Nasal muc.osa is sutured together with knots tied
. on nasal (i.e., superior) surface. Note small incision made to insert instrument for hamular process fracture.
,This maneuver releases tensor vell palatini and facilitates approximation in midline. C, Muscle is
dissected from insertion into hard palate, and sutures are placed to approximate muscle in midline.
0, Closure of oral mucosa is accomplished last. E, Layered closure of soft palate. (From Hayward JR: Oral
surgery, Springfield, III, 7976, Charles C Thomas.)

11

The Wardill operations for palatal lengthening on closure. A and B, Pour-flap operation for extensive cleft. C and D, Three-flap operation for shorter cleft. Note amount of denuded palatal bone left after these operations

The Wardill operations for palatal lengthening on closure. A and B, Pour-flap operation
for extensive cleft. C and D, Three-flap operation for shorter cleft. Note amount of denuded palatal
bone left after these operations

frequently excision of some of this tissue is necessary, The clinician should try to be diligent and to maintain as much mucoperiosteum to the maxilla as possible because of the poor blood supply that the cleft maxilla receives.
Care must also be taken not to create another oronasal fistula. If the alveolar cleft ha-d not been grafted -previously, this can be do e in the same operation. In bilateral clefts, however, the blood supply to the prolabia I segment is very poor. It may be more prudent in these instances to perform the alveolar cleft grafts first and then perform a one-piece maxillary osteotomy after sufficient time has passed for rcvascularization of t he prolabia! segment. O!lC problem.faced by the patient with a cleft palate
when rnaxillarv advancement procedures are planned is the effect this -may have on -the velopharyngeal mechanism. When the maxilla is brought forward, the soft palate is also drawn .forward.  A patient’s preoperative
marginal competence of the velopharyngeal mechanism may become incompetent in the postoperative period. It is very difficult to determine which patients will have this problem. Because of the possibility of this incompetence, however, secondary palatal or pharyngeal surgical rocedures “to increase velopharyngeal competence are discussed with the patient. These procedures can be performed later if necessar

 

 

Alveolar Cleft Grafts

Alveolar Cleft Grafts

The alveolar cleft defect is usually not corrected in the original surgical correction of either the cleft lip or the cleft palate (Fig. 27-15 on pages 6..U-6-12). As a result, the cleft-afflicted individual may have residual oronasal fistulae in this area, and the maxillary alveolus will not be continuous because of the cleft. Because of this, five problems commonly occur: (1) oral fluids escape into the nasal cavity, (2) nasal secretion drains into the oral cavity, (3) teeth erupt into the alveolar cleft, (-1) the alveolar segments collapse, and (5) if the cleft is large, speech is adverselv affected . . Alveo’lar cleft bone grafts provide se~’eral advantages: First, tl1f~yunite the alveolar segments and help prevent collapse and constriction of the dental arch, which is especially important if the maxilla has been orthodontically
expanded, Second, alveolar cleft bone grafts provide bone support for teeth adjacent to the cleft and for those that will erupt into the area of the cleft, Frequently, the bone support on the distal aspect of the central incisor is
thin, and the height of the bone support varies, These teeth may show slight mobility because of this lack of bone support. Increasing the amount of alveolar bone for this tooth will help ensure its periodontal maintenance.
The canine tends to erupt into the cleft site and, with healthy bone placed into the cleft, will maintatn good periodontal support during eruption and thereajter. That third ‘benefit of alveolar cleft grafts is closure of the oronasal fistula, which will partition, the oral and nasal

FIG. 27-11 Variation of von Langenbeck operation for concomitant hard and soft palate closure. It uses three-layer closure for soft palate (i.e., nasal mucosa, muscle, ora! mucosa) and two-la ..-er closure for hard palate (i.e., flaps from vomer and nasal floor to produce nasal closure, palatal flaps for UI ,Ii closure). A, Removing mucosa from margin of cleft. B, Mucoperiosteal flaps on hard palate are developed; note lateral releasing incisions. C, Sutures placed into nasal mucosa after development of nasal Ilaps from vomer and nasai floor. Sutures are placed so that knots will be on nasal side. D, Nasal mUCO~Jhas been closed. E, Frontal section showing repair of nasal mucosa. F, Closure of oral mucoperiosteumFIG. 27-11 Variation of von Langenbeck operation for concomitant hard and soft palate closure. It uses three-layer closure for soft palate (i.e., nasal mucosa, muscle, ora! mucosa) and two-la ..-er closure for hard palate (i.e., flaps from vomer and nasal floor to produce nasal closure, palatal flaps for UI ,Ii closure). A, Removing mucosa from margin of cleft. B, Mucoperiosteal flaps on hard palate are developed; note lateral releasing incisions. C, Sutures placed into nasal mucosa after development of nasal Ilaps from vomer and nasai floor. Sutures are placed so that knots will be on nasal side. D, Nasal mUCO~Jhas been closed. E, Frontal section showing repair of nasal mucosa. F, Closure of oral mucoperiosteum

FIG. 27-11 Variation of von Langenbeck operation for concomitant hard and soft palate closure. It
uses three-layer closure for soft palate (i.e., nasal mucosa, muscle, ora! mucosa) and two-la ..-er closure
for hard palate (i.e., flaps from vomer and nasal floor to produce nasal closure, palatal flaps for UI ,Ii closure).
A, Removing mucosa from margin of cleft. B, Mucoperiosteal flaps on hard palate are developed;
note lateral releasing incisions. C, Sutures placed into nasal mucosa after development of nasal Ilaps
from vomer and nasai floor. Sutures are placed so that knots will be on nasal side. D, Nasal mUCO~Jhas
been closed. E, Frontal section showing repair of nasal mucosa. F, Closure of oral mucoperiosteum

FIG. 27-12 VornerIlap technique for closure of hard palate cleft (bilateral in this case). A;lncisions through nasal mucosa on underside of nasal septum (i.e., vomer) and mucosa of cleft marqlns. B, Mucosa of nasal septum is dissected off nasal septum and inserted under palatal mucosa at margins of cleft. This is one-layer nasal closure orily. Connective tissue undersurface of nasal mucosa will epithelialize. This technique, because it does not require.extensfve elevation of palatal mucoperiosteum, produces less scarrtriq with attendant FIG. 27-12 VornerIlap technique for closure of hard palate cleft (bilateral in this case). A;lncisions through nasal mucosa on underside of nasal septum (i.e., vomer) and mucosa of cleft marqlns. B, Mucosa of nasal septum is dissected off nasal septum and inserted under palatal mucosa at margins of cleft. This is one-layer nasal closure orily. Connective tissue undersurface of nasal mucosa will epithelialize. This technique, because it does not require.extensfve elevation of palatal mucoperiosteum, produces less scarrtriq with attendant growth restriction.growth restriction.

FIG. 27-12 VornerIlap technique for closure of hard palate cleft (bilateral in this case). A;lncisions
through nasal mucosa on underside of nasal septum (i.e., vomer) and mucosa of cleft marqlns.
B, Mucosa of nasal septum is dissected off nasal septum and inserted under palatal mucosa at margins
of cleft. This is one-layer nasal closure orily. Connective tissue undersurface of nasal mucosa will epithelialize.
This technique, because it does not require.extensfve elevation of palatal mucoperiosteum, produces
less scarrtriq with attendant growth restriction.

cavities and prevent escape of fluids between them. Augmentation  of the alveolar ridge in the area of the cleft is . a fourth advantage, because it facilitates the use of dental prostheses bycreating a more suitable supporting base. A fifth benefit is the creation of a solid foundation for the
lip and alar base of the nose. It has become evident that the alveolar cleft-grafting procedure itself creates a favorable change in the nasal structure, because the tissue at the base of the nose become supported after alveolar
grafting, whereas before the graft they had no solid osseous foundation. Therefore the alveolar graft should be performed before nasal revisions.
Tinting of graft procedure. The alveolar cleft graft is usually performed when the pati .nt is between ages 7  and 10. By this time a major portion of maxillary growth has occurred, and the alveolar cleft surgery should, not
adversely affect the future growth of the maxilla. It is important to have the graft in place before the eruption of the permanent canines into the cleft, thus ensuring -their peri:odontal support. Ideally the grafting procedure
is performed when one half to tWQthirds ofthe unerupted canine root has formed.Orthodontic expansion of the arch fore or after the procedure is equally effective; how “~r, some’ surgeons prefer to expand before bone graft: _OJ so that access into the cleft area is facilitated at surgle Intact  each side must cover bone grafts placed into the alveolar cleft. This means that naps’ nasal mucosa, palatal mucosa, and labial mucos a all be  eveloped and sutured in a tension-free, watertight mariner to prevent infection of the gl aft. The soft tissue incisions for alveolar cleft grafts vary but in’ each procedure these conditions are met (Fig. 27-16 on p.lge 643). – The bone placed into the alveolar cleft is usually obtained from the patient’s ilium or cranium however some surgeons are using allogeneic bone (i.e.,  omologous bone from another individual). The grafts are made into a particulate consistency and are packed’ into the defect once the nasal and-palatal mucosa’ have been closed. The labial mucosa is then closed over the bone graft. In time these grafts are replaced by new bone that is indistinguishable f-om the surrounding alveolar process (see Fig. 27-1” )rthodontic movement of teeth into the graft sites is possible, and eruption of teeth into them usually proceeds unimpeded.

 

 

 

 

Palatorrhaphy

Palatorrhaphy

Palatorrhaphy Is usually performed in ope operation, but occasionally it is performed in two. In two operations the  oft palate closure (i.e., staphylorrhaphy) is usually performed first and the hard palate closure (i.e., uranorrhaphy) is performed second. ()/Jjntin’s. The primary purpose. of the cleft palate repair is to create a mechanism capable of speech and deglutition without significantly Interfering with subsequent maxillary growth. Thus creation of a competent velopharyngeal mechanism and partitioning of the nasal and oral cavities are prerequisites to achieving these goals. The aim is to obtain a long ana mobile soft palate capable
of producing normal speech. Extensive stripping of soft tissues from bone will create more scar formation, which will adversely affect maxillary growth. The precarious nature of the problem indicates the complexity of the surgical procedures designed and the.ages at which they are instituted.
Surgical techniques. Opeative procedures for palatorrhaphy are as varied as techniques for Cleft lip repair. Each cleft of the palate is unique. They vary in Width, completeness, amount of hard .and soft tissue available, and
palatal length. Thus the surgical techniques used to close cleft palate deformities are extremely varied, not just from’ one surgeon to another but from one patient to the next. Hard palate closure. The hard palate is closed with soft tissues only. Usually no effort is made to create an osseous partition between the nasal and oral cavities. The soft tissues extending ‘around the cleft margin vary in quality. Some are atrophic and not particularly useful. Others appear healthy and readily lend themselves to dissection ,and suture integrity. In the most basic sense the soft tissues
are incised along the cleft margin and dissected .from the. palatal shelves until approximation over the cleft defect is possible. This procedure frequently necessitates the use of lateral relaxing incisions close to. the dentition (Fig. 27-ld). The soft tissues are then sutured in a watertight manner over the cleft defect and allowed to heal. The areas of bone
exposed  by lateral relaxing incisions are allowed to heal by secondary intention. The superior aspect of the palatal flaps will also reepithelialize with respiratory epithelium, because this surface is now the lining of the nasal floor. When possible, it is advisable to obtain a two-layer closure
of the hard palatal cleft (Fig. 27-11 on page 637), which necessitates that-the nasal mucosa from the floor, latetal wall, and septal areas of the nose be mobilized and sutured’ together before the oral closure. When the vomer is long and. attached to the palatal shelf opposite the cleft, a mucosal flap can be raised from it and sutured to the palatal tissues on the cleft side (Fig.  27-12 on page 638). This procedure (i.e., vomer flap technique) requires little stripping of palatal mucoperiosteum and produces minimal scar contraction. The denuded areas of vomer and the opposite sides of the flap where  no epithelium is present will reepithelialize. The ‘vomer flap technique is useful in clefts that are notwide and where the vomer is readily available for use. It is a onelayer closure. The closure of the soft palate is technically the most difficult of the operations yet discussed in the cleft-afflicted individual. Access is the

~----------------------------------------------------.------------.------, ~--:--. FIG. 27·8 Several cheilorrhaphy techniques. A and B, Le Mesurier technique for incomplete unilateral cleft. C and 0, Tennison operatior .. Eami F,Wynn operation. G and H, Millard operation (i.e., rota. tion advancement technique).

~—————————————————-.————.——, ~–:–.
FIG. 27·8 Several cheilorrhaphy techniques. A and B, Le Mesurier technique for incomplete unilateral
cleft. C and 0, Tennison operatior .. Eami F,Wynn operation. G and H, Millard operation (i.e., rota.
tion advancement technique).

riG. )7 Y The Millard cheilorrhaphy technique. A, Inm:ons o-ittined. B, Flaps rotated and advanced into position. C, Closure. c •

riG. )7 Y The Millard cheilorrhaphy technique. A, Inm:ons o-ittined. B, Flaps rotated
and advanced into position. C, Closure.

FIG. 27-10 Von Langenbeck operation for closure-of hard palate using lateral releasing incisions. This technique is one-layer closure-nasal (i.e., superior) aspect of palatal flaps will epithelialize, as will denuded areas of palatal bone.

FIG. 27-10 Von Langenbeck operation for closure-of hard palate using lateral releasing incisions. This
technique is one-layer closure-nasal (i.e., superior) aspect of palatal flaps will epithelialize, as will
denuded areas of palatal bone.

largest problem, because the soft palate is toward the back of the oral cavity. The combination of difficulty with light, retraction, and the fact that the clinician can work only from the oral side yet must correct both the oral and nasal sides of the soft. palate lead to difficulties. In addition, the clinician may have to work with extremely thin, atrophic tissues yet produce a closure that will hold together under function while healing is progressing. To help accomplish this goal, the soft palate is always closed
in three layers and in the same order: (1) nasal mucosa, (2) muscle, and (3) oral mucosa (Fig. 27-13). The margins of the cleft are incised from the posterior end of the hard palate to at least the distal end of the uvula (some surgeons carry the incision and closure down the palatopharyngeal
fold to elongate -the soft palate). The nasal mucosa is then dissected free from the underlying musculature and sutured to the nasal mucosa of the opposite side, The muscular layer requires special care. The musculature
of the cleft soft palate is not inserted across to the opposite side but instead is inserted posteriorly and laterally along the margins of the hard palate. These muscular insertions must be released from their bony insertions
and reapproxlrnated to those of the other sides. Only then will the velopharyngeal mechanism have a , chance to perform properly. ‘If the quantity of muscular I tissue Is inadequate for approximation of the musculature  in the midline, the pterygoid hamular processes can
be in fractured, thus releasing the tensor palatini muscles toward the midline. This maneuver is frequently necessary, especially in wide clefts.
Occasionally, the soft palate is found to be short, and articulation with the pharyngeal wall is impossrcle. this situation is especially prevalent in incomplete palatal clefts-those of the soft palate only. In these cases the
palate can be closed in a mariner that not only brings the two lateral halves together in the midline but also gains palatal length (Fig. 27-14 on page 6-tO).The so-called W-Y push-back procedure (Wardill) and V-shaped push-back procedure (Dorrance and Brown) are commonly used. The mucoperiosteum of the hard palate is incised and elevated in a Planner that allows the entire soft tissue elements of the hard and soft palate to extend posteriorly, thus gaining palatal length.

 

 

 

 

 

 

 

 

 

 

 

Chellorrhaphy

Chellorrhaphy

Clieilorrhuphv is the surgical correction of the cleft lip deformity; this term is derived from   junction by a seam or suture. It is usually the earliest
operative procedure used to correct cleft deformities and is undertaken as soon as medically possible. The cleft of the upper lip disrupts the important circumoral orbicularis oris musculature. The lack of continuity  of this muscle allows the developing parts of the maxilla to grow in an uncoordinated manner so that the cleft in the alveolus is accentuated. At birth the alveolar process on the unaffected side may appear to protrude from the mouth. The lack of sphincteric muscle control from the orbicularis oris will cause a bilateral cleft lip to exhibit a premaxilla that protrudes from the base of the nose and produces an unsightly appearance. Thus restoration of this muscular sphincter with lip repair has a favorable
effect on the developing alveolar segments. Ohicctivcs. The objectives of cheilorrhaphy are twofold: (1) functional and (2) esthetic. The cheilorrhaphy should  restore the functional arrangement of the orbicularis oris musculature to reestablish the normal- function of the upper lip. If muscle continuity is not restored across the area of the cleft, an esthetically unpleasing depression will result when the lip is brought into function. The second objective of cheilorrhaphy is to produce a lip that displays
normal anatomic structures, such as a vermilion tubercle, cupid’s bow, and philtrum. The lip must be symmetric, well contoured, soft, and supple, and the scars must be  Another esthetic necessity is to correct (at least
partially) the nasal deformity resulting from the cleft lip. Despite the skill of the’ surgeon, these ideal objectives are rarely achieved. H indrances are the poor quality of tissues in. the cleft margins and the distortion of structures
before surgical intervention. Several’ surgical techniques reproduce normal appearance immediately but do not maintain this appearance with growth. However, with care~l selection of surgical technique, satisfactory results
are obtainable.  appearence. As each :cleft is unique, so must be the surgical procedure. Countless techniques can be used for cheilorrhaphy, each designed to elongate the cleft margins to facilitate closure (Figs. 27-8 and 27-9). In , unilateral cases the unaffected side serves as a guide for
lip length and symmetry. A key point in design is to break up lines of the scar so to at with fibrosis and contracture, deformity of the lip will be minimized. In lips closed in a . linear fashion, scar contracture causes a characteristic notching of the upper lip. Attention to reorienting and
reuniting the musculature of the lip is of paramount importance if normal function is to be established. Cheilorrhaphy procedures serve to restore symmetry not only to the lip but also to, the nasal tip. With the cleft extending through the floor of the nose, the continuity of the nasal apparatus is disrupted: Without the bony . foundation for the alar cartilage, a collapse of the lateral aspect of the nose occurs, When the lip is closed, itis necessary to a(1’v’ar:ce.this laterally displaced tissue toward the midline. Thus cheiJorrhaphy is the first and one of the IPO~t important steps in correcting the nasal  comman  cleft patients.

Timing of Surgical Repair

Timing of Surgical Repair

The.timklg of the Surgical repair has been and remains one Of the most debated issues among surgeons, speech pathologists, audiologists, and orthodontists. It is tempting to correct all of the defcct-, as ~OOJ1 as the baby is able to withstand the surgical procedure. The parents of a child born with a facial cleft would certainlv desire this mode of treatment, eliminating all of the baby’s clefts as early in life as possible. Indeed the cleft lip is usually corrected as early as possible. xrost surgeons adhere to the proven “rule of 10” as determining when an otherwise healthy baby is fit for surgery (i.e., 10 weeks of age, 10 lb in body weight,’ and at least 10 g of hemoglobin per  deciliter of blood). However, because surgical correctionof the cleft is an elective procedure, if any other medical condition jeopardizes the health of the baby, the cleft surgery s postponed until medical risks are minimal.
Unfortunately each possible  advantage for closing a palatal cleft early in life has several possible disadvantages for the individual later in life. The six advantages for early closure of palatal defects are (1) better palatal and pharyn- . geal muscle development once repaired, (2) ease of feeding,
(3) bette r development of phonation skills, (4) betterauditory tube function, (5) better hygiene when the oral and nasal partition is competent, and (6) improved psychologic state for parents and baby. The disadvantages of  closing palatal clefts early in life are also several: The twomost important are (1) surgical correction is more difficult in younger children with small structures, and (2) scar formation res ulting from the surgery causes maxillary growthrestriction. Althougp different cleft teams time the surgical repair differently, a widely accepted principle is compromise. The lip iscorrected as early as is medically possible. The
soft palatal cleft is closed between 8 and 18 months of age, depending upon a host of factors. Closure of the lip as early as possible is advantageous, because it performs a favorable “molding” action on the distorted alveolus. It  also assists the -child in feeding and is of psychologic benefit.The palatal cleft is closed next, to produce a functional  velopharyngeal mechanism when or before speech skills are developing. The hard palatal cleft is occasionally not repaired at the time of soft palate repair, especially
if the cleft is wide. In such cases, the hard palate cleft is left open as long as possible so that maxillary growth will proceed as unimp ded as possible. Closure of the hard palatal cleft can be postponed at least until all of the
deciduous dentition’ has erupted. This postponement facilitates the use of orthodontic appliances and allows more maxillary growth to’ occur before scarring from the surgery is induced. Because a significant portion of maxillary growth has already occurred by ages 4 to 5, closure of the hard palate at this time is usually performed before the child’s enrollment in school. Removable palatal obturators can be fitted and worn in the meantime to partition  the oral and nasal cavities.The largest problem in evaluation of treatment regimens is the fact that the final results of surgical repair of clefts can only be judged conclusively when the individual’s
growth is complete. A surgical method used today cannot be put to careful scrutiny for 10 to 20 years. which, unfortunately, may allow many individuals with cleft deformities to be treated with procedures that  later be discarded, when follow-up examinations studies show unsatisfactory or poor effects

 

TREATMENT OF CLEFT LIP AND PLATE

TREATMENT OF CLEFT LIP AND PLATE

The aim of treatment of cleft lip and palate is to correct the cleft and associated problems surgically and thus hide the anomaly so that patients can lead normal lives. This correction involves surgically producing a face that does not attract attention, a vocal apparatus that permits intelligible. – speech, and a dentition that allows optimal function and esthetics. Operations begin early in life and may continue for several years. In view of the gross distortion of tissues surrounding the cleft, it is amazing that success is ever achieved. _However, with modern anesthetic techniques, excellent pediatric care centers, and surgeons who have had a wealth of experience because of the frequency of the cleft deformity, acceptable results are commonplace.

 

Associated Anomalies

Associated Anomalies

Although the child with an oral cleft is 20 times more likely to have another congenital anomaly than a normal child, no correlation is evident with specific anatomic zones of additional anomaly in volvernent  Of those children who have associated anomalies, 38% have isolated cleft palate and 21% have cleft lip, with or without cleft palate. In the overall cleft-afflicted population, approximately 30% have other anomalies in addition to the facial cleft, ranging’ from clubfoot to neurologic disturbances. Of the overall cleft-afflicted population, 10% have congenital heart disease, and 10% have some degree of mental retardation. Thus the child with a facial cleft may require addition.
al care beyond the scope of the cleft team.