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Cleft Palate / Cleft lip is the the most common
Second most common congenital defect
Isolated Cleft palate
• No racial variation
• 1:2000 live birth
• M:F = 1:2
• Left : Right : B/L = 6:3:1
The palate forms a dynamic
boundary between the
oral cavity and the nasal
cavity. It is composed of
the hard palate anteriorly
and the soft palate
• Primary Palate
• Secondary Palate
The hard palate includes the
palatal processes of the maxilla
and the horizontal plate of the
palatine bone with adherent
mucoperiosteum (attached to
bone by Sharpey’s fibres).
Three pairs of foramina
mark the surface of the
• Incisive Foramen
• Greater Palatine Foramen
• Lesser Palatine Foramen
The soft palate is a
dynamic structure that
acts as a valve between
the oropharynx and
An intact and functioning
soft palate is essential
for normal speech and
• Five paired muscles &
Tensor veli palatini
Levator veli palatini
*Veli (Latin) means curtain
Origin: scaphoid fossa of the medial
pterygoid plate, the lateral part of
the cartilaginous auditory tube
then passes around the pterygoid
hamulus as a tendon
Insertion: broad triangular tendon
at the posterior aspect of the
hard palate as part of the palatine
Action: tense the soft palate to
form a platform that the other
muscles may elevate or depress.
Origin: petrous bone and the
medial part of the auditory
Insertion: middle third of
upper surface of the soft
palate at upper surface of
the palatine aponeurosis as
far as the midline
The paired muscles form
a ‘V’-shaped sling pulling
the soft palate upwards
and backwards to close
Origin: Palatine aponeurosis
Insertion: Side of tongue
Action: Pulls root of tongue
upward and backward,
diameter of oropharynx
Origin: Posterior border of
Insertion: Mucous membrane
Action: Elevates uvula
The soft palate is raised by the
contraction of the levator palati.
At the same time, the upper fibers
of the superior constrictor muscle
pull the posterior pharyngeal wall
The palatopharyngeus muscles
contract to pull palatopharyngeal
arches medially, like side curtains.
By this means The intact
periodically, selectively, an
d completely isolate the
nasopharynx from the
oropharynx during Feeding
This harmony in muscular action is necessary for
Development of the face begins in the fourth week in
utero, when neural cells migrate and fuse with
mesodermal elements to form the facial primordium.
It results from the fusion
– Two mandibular
– One frontonasal process
– Two maxillary processes
The palate develops between the 5th and the 12th week
CRITICAL period of palatal development is between the 6th and
the 9th week.
Soft palate development is completed at 12th week
Primary palate : Median palatine process from the medial nasal
Secondary palate : Lateral palatine process from the maxillary
6th – 9th week: Initially, the palatine processes are oriented vertically
on either side of the developing tongue.
The tongue is displaced inferiorly as the head grows and the neck
straightens, the lateral palatine processes are elevated and grow
medially to fuse with the septum
Is Cleft a Deficiency?
Interference with fusion results in Cleft
i) Failure of fusion of the lateral shelves
ii) Failure of mesodermal penetration of the shelves:
iii) Mechanical interference (the tongue) such as in
Pierre Robbin Sequence
Gato et al. 2002, expression of chondroitin sulfate proteoglycan is
important in palatal shelf adhesion and is supposed to be
regulated by TGF-b3
Gato A, Martinez ML, Tudela C, Alonso I, Moro JA, Formoso MA, Ferguson MWJ, Martinez-lvarez C (2002) TGF-b3-induced
chrondroitin sulphate proteoglycan mediates palatal shelf adhesion.
Bush et al. 2003; Herr et al. 2003, Expression of T box transcription
factor Tbx22 is found in the inferior nasal septum and the palatal
shelf before fusion.
Bush JO, Lan Y, Maltby KM, Jiang R (2002) Isolation and developmental expression analysis of Tbx22, the mouse homolog of the human x-linked cleft
palate gene. Dev Dyn 225: 322-326
Herr A, Meunier D, Mller I, Rump A, Fundele R, Ropers H-H, Nuber UA (2003) Expression of mouse Tbx22 supports its role in palatogenesis and
glossogenesis. Dev Dyn 226:579–586
Veau Classification 1931
Veau Class I: isolated soft
Veau Class II: isolated hard
and soft palate
Veau Class III: unilateral
Veau Class IV: bilateral
Striped Y by Kernahan 1971
Pierre Robin syndrome
Van der Woude’s syndrome
Patients with cleft deformities experience a multitude of problems
Midface growth impairment.
The infant is usually not able
to suck efficiently due to
inability to achieve negative
Feeding regimen: includes the
use of squeeze bottles and
holding in a nearly sitting
position during feeding
Patients are unable to produce
high intra-oral pressure.
Normal velopharyngeal closure is
crucial for production of
intelligible speech; any
abnormalities in this
mechanism can result in
hypernasality, nasal emissions,
imprecise production of
Serous otitis media.
Abnormality of LVP which aids the TVP to dilate ET.
Treatment with myringotomy tubes is required pre- and postcleft repair.
Restoring the morphologic form & function
Production of a competent velopharyngeal
Closure of the defect
Correction of the abnormally inserted muscles
Reconstruction of the palatine sling
Tension free repair
2 layer repair of the hard palate & 3 layer repair of the soft
Von Langenbeck 1861 pioneered the first bipedicle
mucoperiosteal flaps and relaxing incisions for palate closure
surgery in one stage.
Langenbeck v, B. Uranoplasty by means of raising mucoperiosteal flaps. Arch klin chir. 1861;2:205
Veau 1931, The vomer flap and suturing of velar muscles
aiming at lengthening the palate
Wardill and Kilner 1937, “pushback” theory V-Y retro
positioning of the palate increases the length further.
By connecting the lateral incisions to the incisions made for the
nasal turn in flaps.
Wardill WEM. The technique of operation for cleft palate. Br J Surg. 1937;25: 117-130
A different approach was described by Furlow 1986 with the
double-opposing z-plasty without relaxing incisions
Furlow LT, Jr. Cleft palate repair by double opposing Z-plasty. Plastic and reconstructive
The Bardach 1991 two-flap palatoplasty uses two large fullthickness hard palate flaps that are mobilized and closed
anteriorly and medially without pushback
Bardach, J. and P. Nosal: Geometry of the two-flap palatoplasty. (2nd). St. Louis,
Mosby-Year Book, 1991
Rohrich et al., 2000 & Sommerlad et al., 2002
Closure of the palate can be performed in two stages. This
closing the soft palate early, between 3 and 6 months involves
of age, and delaying the repair of the hard palate.
Sommerlad BC, Mehendale FV, Birch MJ, Sell D, Hattee C, Harland K. Palate rerepair
revisited. Cleft Palate Craniofac J. 2002;39:295-307.
To limit the effect of the hard palate repair on maxillary growth.
It is suggested that the subperiosteal scarring impairs
• Age: 9-12 month
• Associated anomalies
• Routine Lab. Investigations
• Booking a unit of packed RBCs after G/XM
• Otologic and audiologic assessment
i) RAE tube
iii) Shoulder roll
iv) Head Donut
v) Local anesthetic with
vi) Position: supine, neck
Extended, reverse trendlenberg
vii) Throat pack
i) Inject 1 :200 000 epinepherine into the palate.
ii) Don't inject in areas sutures will be placed
iii) Wait 7 minutes for the epinephrine to take effect
iv) Make incision along the medial side of the cleft
v) Make releasing incision to get to bone on both sides
vi) Use freer to elevate mucoperiosteal flap
vii) Dissect nasal mucosa
vii) Strip LVP muscle off abnormal insertion & create palatine
viii) Three layer repair
Keep your eye on the airway
Feeding: fluids, soft diet, no bottles for 3w
Tissue engineering advancements over the last decade
has provided a plethora of materials that may be
suitable for the healing of craniofacial defects like the
Future directions with regards to the use of stem cells
especially ASCs in craniofacial repair are
discussed, including possible scaffold for reconstruction
of palatal defect
Embryogenesis of primary & secondary palate?
Muscles of soft palate?
Principles of repair?