Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!

1. Palatal Fistula and Syndromes
associated with CLCP
Part - I
Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2. INTRODUCTION
• The dictionary meaning of cleft is a crack,
fissure, split or a gap.
• The zones affected by common orofacial
clefts are as follows:
– Upper lip
– Alveolar ridge
– Hard palate
– Soft palate
– Nose (not so common)
– Eyes (not so common).

3. BIRTH DEFECTS
Severe
Psychological
stress
Parents
Family Members
Patients

4. EFFECTS ON CHILD
• Feeding problems
• Improper growth of face
• Delayed & Improper Speech
• Delayed or abnormal tooth
eruption
• Ear infections & hearing
problems
• Recurrent chest infections
• Social & Psychological problems

5. INCIDENCE
• In India: (C.M.C. Vellore) 1:700
• Racial variations: (By Gopalkrishnan:
Dharwad Cleft Unit)
– American Black 0.21 - 0.41
– Japanese 1.14 – 2.13
– Caucasian 0.77 – 1.40
– Indian 0.13 – 1.90

6. ETIOLOGY
• Clefts may be caused by hereditary
– Sex-linked recessive gene.
– Family history of cleft lip and palate (40%)
• Environmental
– Infections during pregnancy (viral)
– Nutrition deficiencies ( Folic acid)
– Anemia , seizures during pregnancy
– Harmful drug intake
– Excessive consumption of alcohol

7. EMBRYOLOGY
Cleft Lip:
Failure of fusion of medial nasal process and
maxillary processes
Cleft Palate:
Failure of fusion of palatine processes of maxilla

8. DEVELOPMENT OF PALATE
INTERMAXILLARY
SEGMENT – formed by
Median nasal process
fusion at deeper level .
Composed of
labial component
upper jaw component
PRIMARY PALATE
portion of nasal septum

9. DEVELOPMENT OF PALATE
Palate develops from the
primary palate &
secondary palate
Secondary palate derived
from maxillary
prominences
Outgrowth of palatine
shelves appear in sixth week
& on each side of tongue

10. DEVELOPMENT OF PALATE
In 7th week palatine
shelves attain horizontal
position & fuse with each
other to form secondary
palate
Secondary palate fuse with
nasal septum and posterior
part of primary palate
Bone extend from maxilla
to ossify hard palate

11. DEVELOPMENT OF PALATE
Posterior part of
palatine process do not
get ossified and extend
posteriorly to form
soft palate
The median palatine
raphe indicates line of
fusion of processes

12. DEVELOPMENT OF PALATE
Nasopalatine canal
persists in median
plane between
premaxilla and
secondary palate &
represented in adult
as incisive fossa.

13. TYPES OF CLEFT PALATE
Incomplete cleft palate
Unilateral complete cleft lip and
palate
Complete Cleft Palate
Bilateral complete CLP

14. • Kernahan has simplified it
• representing various clefts in the form of Y.
• Anterior portion of Y depict the lip (1 and 4)
• Middle alveolus (2 and 5)
• Incisive foramina and the posterior portion (3 and 6)
• Posterior to the incisive foramen, the hard (7 and 8)
and the soft (9) palate.

15. MUSCLES OF PALATE

16. Tensor veli palatini (TVP)
• Function-stiffens soft palate and
opens eustachian tube
• Innervation-Cranial nerve V3
Levator veli palatini (LVP)
• Function-elevates soft palate in
speech and swallowing
• Innervation-Cranial nerve IX and X

17. Uvula
• Fnction-elevates uvula
• Innervation-Cranial nerve IX and X
Palatopharyngeus
• Function-narrow and seal nasal pharynx
• Innervation-Cranial nerve IX and X

18. Complete Cleft Palate :
 Palatal shelves fail to fuse
 The greater palatine foramen is
located more anteriorly and laterally
 Gap in the soft palate does not always
correspond to the gap of the hard
palate
 A layer of the mucosa can extend and
conceal a long underlying cleft in the
bone structure
 The palatal aponeurosis is missing at
the midline

19. Major muscles, levator
veli palatini and palato
pharyngeus do not join on
the midline, fibres run
parallel to the margins of
the cleft
Two halves of the uvula
are converged towards
one another
There is a difference in
the colour of the mucosa,
oral mucosa is paler, nasal
mucosa is redder

20. Cleft Palate Team
– Cleft Audiologist
– Orthodontics
– Cleft surgeon
– Social worker
– Psychologist
20
Assessment and Treatment of Cleft Palate.

21. Cleft Palate Team
– Cleft Audiologist
– Orthodontics
– Cleft surgeon
– Social worker
– Psychologist
21
Assessment and Treatment of Cleft Palate.

22. Preoperative Evaluation
• Pediatric evaluation
• Anesthetic evaluation
• Blood investigation
• Ear infection
• Malnutrition
• Anaemia
• Other congenital anomalies particularly
cardiac.
• Milestones
• Chest x-ray
– Upper respiratory tract infection

23. Surgical Repair- Cleft Palate
• Several Techniques- Trend is towards
less scarring and less tension on palate
• Scarring of palate may cause impaired
mid-facial growth(alveolar arch collapse,
midface retrusion, malocclusion)
• Facial growth may be less affected if
surgery is delayed until 18-24 months,
but feeding, speech, socialization may
suffer.

24. Complications
- Palatal Fistula

25. • Introduction:
Palatal defects are common complications seen after primary
cleft palate repair. Small fistulas may be asymptomatic while
large fistulas produce various symptoms. There are many
methods proposed for closure of palatal defects.

26. • Symptomatic fistula may cause :
 Regurgitation of food and fluid to the nasal cavity,
 Malodor
 Escape of air during speech resulting in hyper nasality
 Impaired suction
 Increased nasal discharge
(Cleft palate journal, january 1978, vol. 15 No. 1 )

27. Most Common Site :
Hard Palate ( most often at the junction of Hard &
soft Palate)
Incidence :
0% to 34%
(Cohen SR, Kalinowaski J et al : Cleft palate fistula: A multivariate stastical
analysis of prevalence, etiology & surgical management. Plast Reconstr Surg 87:
1041, 1991)
27

28. • Causes of fistula formation:
type of cleft,
 type of repair,
wound tension,
 single-layer repair,
 infection and
dead space deep to the mucoperiosteal flap
(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

30. Classification
A. By Shultz
1. Pinpoint
2. Slit
3. Oval or Total dehiscence

31. B. Based on anatomical location by Smith:
 type I referred to bifid uvula;
 type II means fistula in the soft palate;
 type III means fistula at junction of the soft and hard palates;
 type IV means fistula in the hard palate;

32.  type V indicates that the fistula at junction of the primary and
secondary palates;
 type VI means lingual alveolar fistula; and
 type VII means labial alveolar fistula
(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

33. B. According to site :
1. Anterior
2. Middle
3. Posterior

34. C. ( According to size)
1. Small ( < 3mm )
2. Medium ( 3-5mm)
3. Large ( > 5mm )
(Cohen SR, Kalinowaski J et al : Cleft palate fistula: A multivariate stastical
analysis of prevalence, etiology & surgical management. Plast Reconstr Surg 87:
1041, 1991)

35. Causes of Fistula
 Improper Mobilization
 Tension Across the Suture Line
 Compromised Vascularity
 Flap Necrosis
 Infections
 dead space deep to the mucoperiosteal flap
(International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–
1057)

36. Closure of Palatal Fistula

37. Principals of fistula closure:
1) Elevation of large palatal flaps based on the
original incisions

38. 2) Excision of the scarred margins of the fistula;
No scar epithelium can be left traversing the
fistula anywhere around its perimeter,

39. 3) Accurate tension free closure of the nasal &
oral mucosa

40. 4 )Use of additional unscarred tissue to close
anterior defects or large palatal defects;
Mucobuccal flap & tongue flap are most
useful;

41. 5) Bone graft when indicated;
But it is not necessary for successful fistula
closure.