Cleft Palate & It's Management
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This document discusses the comprehensive management of cleft lip and palate. It covers the embryology, anatomy, classification, rationale and various techniques for cleft palate repair including Von Langenbeck, Bardach, Furlow and Delaire techniques. It also discusses velopharyngeal insufficiency, its assessment and various surgical techniques for correction including palatal lengthening and pharyngeal flaps. The complications of cleft lip and palate surgeries are discussed along with their management. The document provides a detailed overview of cleft palate and its multidisciplinary management.
![Primary Cleft Palate Repair
• Age of Surgery [6-14 months]
• Stages:- a. Lip & Soft palate
b. Lip & Vomerine flap
b. Lip only
c. Palate only
• Technique:- a. Bardach two flap technique
b. Von Langenbeck
c. Furlow’s
d. Delaire's
e. Sommerlads
f. Morphofunctional](https://image.slidesharecdn.com/cleftpalateshortpresentation-200626062156/85/Cleft-Palate-It-s-Management-16-320.jpg)
![Cleft Palate Repair: Furlow
Alternating the reversing Z-plasties of the nasal and
oral flaps and repositioning the levator veli palatini
muscle within the posteriorly mobilized flaps.
Effective for primary closure of a submucous
cleft palate and secondary correction of
marginal velopharyngeal insufficiency.
Advantages:-
No need to raise large mucoperiosteal flaps from
the hard palate.
The soft palate can be lengthened. [Good speech
outcome]
Disadvantages:-
Nonanatomical palatal closure
Ignores musculus uvulae.
Difficult to close wider clefts.
Large raw area - needs to be covered with buccal flap.
Palatoplasty : Evolution and controversies Chang Gung medical journal 31(4):335-45 Nov 2007.](https://image.slidesharecdn.com/cleftpalateshortpresentation-200626062156/85/Cleft-Palate-It-s-Management-20-320.jpg)
![Cleft Palate Repair: Delaire
Stage I Stage II
Two stage Palatoplasty – Lip + Soft
Palate [6 months]
Horizontal incision posterior to greater
palatine vessels.
Advantages
• Encourages normal function of the soft
palate and the tongue.
• Facilitates closure of the hard palate.
• Prevents arch collapse.
• Good palatal lengthening, fewer hearing
problems.
Disadvantages
• Two stage procedure.
Markus AF, Smith WP, Delaire J. Primary Closure of cleft palate: a functional approach. British Journal of
Oral and Maxillofacial Surgery. 31:71-774.1993](https://image.slidesharecdn.com/cleftpalateshortpresentation-200626062156/85/Cleft-Palate-It-s-Management-21-320.jpg)
![VELOPHARYNGEAL INSUFFICIENCY
Inability to achieve complete closure of the velopharyngeal apparatus during
speech.
Velopharyngeal apparatus (Regulation of airflow from the lungs and
larynx)
Soft Palate + Pharyngeal Structures.
Velopharyngeal insufficiency: inability to achieve complete closure of
the velopharyngeal apparatus during speech. [Structural Defect]
Velopharyngeal incompetence: Imperfect closure of velopharyngeal apparatus
that is caused by neuromuscular dysfunction. i;e impaired motor programming
of velopharynx. [Neurogenic Defect]
Velopharyngeal inadequacy: Imperfect closure of the velopharyngeal
apparatus caused by the tissue defect. [Tissue insufficiency]](https://image.slidesharecdn.com/cleftpalateshortpresentation-200626062156/85/Cleft-Palate-It-s-Management-26-320.jpg)
Cleft Palate & It's Management
- 1. Dr Bhavik Miyani CLEFT PALATE & IT’S MANAGEMENT Short Presentation
- 2. Frequently Asked Questions Essay Questions Comprehensive management of Cleft Lip & Palate. Long Answer Questions Complications of Cleft Lip & Palate Surgeries VPI and its management Short Answer Questions Embryology of Palate with neat labelled diagrams. Anatomy of Palate Vs Cleft Palate VonLangenbeck Technique Bardach Technique Management of Palatal Fistula Furlows Technique
- 3. CONTENTS 1. INTRODUCTION 2. ETIOLOGY 3. DEVELOPMENT OF PALATE 4. ANATOMY OF NORMAL AND CLEFT PALATE 5. CLASSIFICATION 6. RATIONALE 7. GENERAL PROTOCOLS FOR MANAGEMENT 8. TECHNIQUES OF CLEFT PALATE REPAIR 9. VELOPHARYNGEAL INSUFFICIENCY 10. COMPLICATIONS & IT’S MANAGEMENT
- 4. 3rd most frequently occurring congenitaldeformity. Unilateral cleft lip and palate – 46% Isolated cleft palate – 33% Cleft palates affect 1:2,000 live births worldwide Isolated cleft palate occurs most commonly in females than in males. INTRODUCTION
- 5. ETIOLOGY • Unknown • Genetics - Familial inheritance • Gestational exposures - Alcohol, cigarette smoking - Steroids, anticonvulsants - Retinoids - Rubella - Hypoxia • Syndromes associated with cleft palate - Velo-Cardiofacial Syndrome - Pierre-Robin Syndrome
- 6. DEVELOPMENT OFPALATE 6th week Primary palate is formed by merging of two median palatine process. 7th – 8th week Formation of secondary palate . Fusion of right and left maxillary process and medial nasal process. Lateral palatine process grows downward and straightens to horizontal position, grows medially and fuses at midline and to nasal septum.
- 7. Anatomy of Cleft Palate & Normal Palate Veau 1934 Skoog 1969 NormalAnatomy The tensor palati and superficial portion of the palatopharyngeus muscles are fixed to the posterior border of the palate so that their orientation is longitudinal rather than transverse which is the normal anatomy.
- 8. Davis & Ritchie Pre-alveolar cleft (cleft lip only) Unilateral Median Bilateral Post-alveolar clefts (cleft palate only) Soft palate Hard palate Alveolar clefts (cleft lip, alveolus & palate) Unilateral Median Bilateral CLASSIFICATION
- 9. Kernhan’s Or Striped Y • Elsahy – Modified by adding triangular peak • Millard – Modified by inverted triangle
- 10. LAHSHAL or Kriens • R - Right Complete cleft of lip • L -Left Complete cleft of lip • Capital letters – Complete cleft • Lowercase – Partial clefts
- 11. Unilateral complete cleft palate associated with cleft lip with palatal shelves at the same level anteriorly Unilateral complete cleft palate associated with cleft lip with palatal shelves at the different levels anteriorly Cleft of hard and soft palate associated with cleft lip Bilateral complete cleft palate associated with cleft lip with palatal shelves at the different levels of the premaxilla anteriorly Cleft palate variations Bilateral complete cleft palate associated with cleft lip with palatal shelves at the same level of the premaxilla anteriorly
- 12. Cleft of hard and soft palate Isolated Cleft Palate Submucous cleft palate Bifid uvula Cleft palate variations Cleft of soft palate
- 13. RATIONALE 1. Growth 2. Feeding & Swallowing 3. Speech 4. Eustachian tube
- 14. General protocol for the management of a cleft patient • 0-3 days - counselling - advice regarding feeding • 3-6 months - repair of the cleft lip • 1 – 1-1/2 years - repair of the cleft palate • 3-6 years - speech assessment - speech therapy - pharyngoplasty for velo- - pharyngeal incompetence
- 15. • 9-11 years - Alveolar bone grafting - Pre & post grafting - Orthodontic therapy • 15-18 years - Orthognathic surgery - Rhinoplasty - Lip revision ( if necessary )
- 16. Primary Cleft Palate Repair • Age of Surgery [6-14 months] • Stages:- a. Lip & Soft palate b. Lip & Vomerine flap b. Lip only c. Palate only • Technique:- a. Bardach two flap technique b. Von Langenbeck c. Furlow’s d. Delaire's e. Sommerlads f. Morphofunctional
- 17. Cleft Palate Repair: Bardach The design of this flap is entirely dependent on the greater palatine neurovascular pedicle and it provides greater versatility to cover the cleft. Advantages:- Complete closure of the entire palate in one stage. Creation of more physiologic soft palate muscle sling and a layered closure technique. Disadvantages:- Does not provide additional length to the repaired palate to allow normal speech production. Bardach J. Two flap palatoplasty Bardach Technique. Operative Techniques in Plastic and Reconstructive Surgery. 2(4):211-214.1995
- 18. Cleft Palate Repair: Von Langenbeck The VonLangenbeck technique is similar to Bardach palatoplasty but preserves an anterior pedicle for increased blood supply to the flaps. Used in isolated cleft palates. Advantage:- • Easy to perform. • Requires less dissection • Results in decreased raw area of palate. Disadvantages:- Cannot be used in wider and complete clefts. Failure to provide additional palatal length. Palatoplasty : Evolution and controversies Chang Gung medical journal 31(4):335-45·Nov 2007.
- 19. Cleft Palate Repair: Veau-Wardill-Kilner Technique – Pushback Palatoplasty Used for incomplete clefts of the hard and soft palate. Advantages:- Lengthening the palate and repositioning the levator muscle in a more favorable position. Disadvantages:- Adversely affects midfacial growth in cleft palate patients because of scar tissue anteriorly. Higher rate of fistula in complete cleft palate than other techniques because it provides only a single nasal mucosa layer anteriorly Agrawal K. Cleft palate repair and variations. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India. 2009;42(Suppl):S102-S109.
- 20. Cleft Palate Repair: Furlow Alternating the reversing Z-plasties of the nasal and oral flaps and repositioning the levator veli palatini muscle within the posteriorly mobilized flaps. Effective for primary closure of a submucous cleft palate and secondary correction of marginal velopharyngeal insufficiency. Advantages:- No need to raise large mucoperiosteal flaps from the hard palate. The soft palate can be lengthened. [Good speech outcome] Disadvantages:- Nonanatomical palatal closure Ignores musculus uvulae. Difficult to close wider clefts. Large raw area - needs to be covered with buccal flap. Palatoplasty : Evolution and controversies Chang Gung medical journal 31(4):335-45 Nov 2007.
- 21. Cleft Palate Repair: Delaire Stage I Stage II Two stage Palatoplasty – Lip + Soft Palate [6 months] Horizontal incision posterior to greater palatine vessels. Advantages • Encourages normal function of the soft palate and the tongue. • Facilitates closure of the hard palate. • Prevents arch collapse. • Good palatal lengthening, fewer hearing problems. Disadvantages • Two stage procedure. Markus AF, Smith WP, Delaire J. Primary Closure of cleft palate: a functional approach. British Journal of Oral and Maxillofacial Surgery. 31:71-774.1993
- 22. Cleft Palate Repair: Sommerlad Radical retropositioning of the velar musculature and tensor tenotomy using an operating microscope to allow accurate levator muscle reconstruction. Advantages:- • Non tension closure even in wider palates. • Good speech outcomes. Disadvantages:- Recurrent ear infections due to tensor tenotomy. High fistula rates due to radical muscle relieving from the nasal area. Loss of tautness of soft palate. Sommerlad BC. A technique for cleft palate repair. Plastic and Reconstructive Surgery. 112(6): 1542-1548.2003
- 23. Medial and Lateral incisions to expose the soft palate musculature and mobilize the hard palate flaps. Gosla Reddy, S. (2017). Morphofunctional palatoplasty: evidence based recommendations. International Journal of Oral and Maxillofacial Surgery. 46. 21. 10.1016/j.ijom.2017.02.077. Two flap technique with optimal muscle dissection Morphofunctional Cleft Palate Repair
- 24. Optimal muscle dissection Dissection only of Levator muscle bundle (Levator Myoplasty) Tensor tendon is not dissected Two flap technique with optimal muscle dissection SOFT PALATE MUSCLE DISSECTION Tensor veli Palatini Tensor veli Palatini Gosla Reddy, S. (2017). Morphofunctional palatoplasty: evidence based recommendations. International Journal of Oral and Maxillofacial Surgery. 46. 21. 10.1016/j.ijom.2017.02.077.
- 25. Intervelar Veloplasty Dissection of the Levator Palati from the posterior border of the hard palate, nasal and oral mucosa and posterior repositioning. Suturing of the muscle with that of the opposite side for the reconstruction of the Levator sling. Sommerlad dissects the levator palatini belly separately and sutures independently as the Levator is the dominant muscle for elevation of the soft palate during speech. Also tensor tenotomy is performed. Court transects the Tensor Palati and to keep its function intact, the cut end is transfixed with the hook of the hamulus.
- 26. VELOPHARYNGEAL INSUFFICIENCY Inability to achieve complete closure of the velopharyngeal apparatus during speech. Velopharyngeal apparatus (Regulation of airflow from the lungs and larynx) Soft Palate + Pharyngeal Structures. Velopharyngeal insufficiency: inability to achieve complete closure of the velopharyngeal apparatus during speech. [Structural Defect] Velopharyngeal incompetence: Imperfect closure of velopharyngeal apparatus that is caused by neuromuscular dysfunction. i;e impaired motor programming of velopharynx. [Neurogenic Defect] Velopharyngeal inadequacy: Imperfect closure of the velopharyngeal apparatus caused by the tissue defect. [Tissue insufficiency]
- 27. Assessment of the Velopharyngeal Function Perceptual Speech Evaluation by a well trained speech pathologist. Pressure Flow measurements. Nasopharyngeal endoscopy. Videofluoroscopy
- 28. • Secondary Palatoplasty aims at correcting the velopharyngeal inadequacy (VPI). • VPI is defined as inadequate closure of the soft palate during speech to the posterior pharynx during speech, resulting in air leak up into the nasopharynx. (Lindsey and Davis, 1996). • 5% to 36% of patients who have undergone primary palatoplasty have persisiting VPI. (Dorf and Curtin, 1982; Bardach and Morris, 1990; Peat et al., 1994; Hudson et al., 1995) VPI correction
- 30. Incision marking Modified Furlows ‘Z’ Plasty with Levator Myoplasty
- 31. Modified Furlows ‘Z’ Plasty with Levator Myoplasty Levator Myoplasty
- 32. Closure Modified Furlows ‘Z’ Plasty with Levator Myoplasty
- 33. Complications Preoperative Otitis media Aspiration pneumonia Nutritional Deficiency Intraoperative Blood Loss Damage to the Pedicle Immediate Post Operative Bleeding Airway obstruction Wound Dehiscence/ Infection Hanging Palate Erosion of corner of mouth Late Post Operative Fistula formation Velopharyngeal incompetence Maxillary Hypoplasia Recurrent ear infections
- 34. Wound Dehiscence Erosion of corner of mouth
- 36. Murthy J. Descriptive study of management of palatal fistula in one hundred and ninety- four cleft individuals. Indian J Plast Surg. 2011 Jan;44(1):41-6. doi: 10.4103/0970- 0358.81447. Algorithm for the management of palatal fistula
- 37. Tongue Flap Guerrero-Santos and Altamirano, were the first to report on the use of tongue flaps for palatal defect closure. The tongue flap is easy and reproducible with excellent esthetical and functional results. Advantages: The advantages are the use of adjacent tissue, the excellent blood supply and the low morbidity in donor site. Disadvantage: Inability in swallowing and speech until depedicling of the flap and in some cases the attachment of the flap can be lost due to traction.
- 38. Buccal Myomucosal Flap BMMF is a vascular and dependable flap. Vascular supply of the flap is consistent and profuse. The buccinator myomucosal flap is effective in reducing/eliminating hypernasality in patients with cleft palate and velopharyngeal insufficiency. Advantages: Flap congestion is occasional and necrosis is rare. It tolerates stretching, folding, and twisting. Disadvantages: Fibrosis. Secondary healing. Parotid duct orifice injury.
- 39. Postoperative Management Postoperative antibiotic dressing. Postoperative feeding: Clean, clear and filtered fluids for 1 month. Plenty of oral fluids. Parent counselling.