This slide share regarding anatomy and preoperative evaluation only. Details of operation will be uploaded later on by second slide

1. DR GAURAV CHATURVEDI

2. SOFT PALATE
The soft palate is a mobile musculomembranous
structure attached anteriorly to the hard palate and
blending laterally with the pharynx.
It separates the nasal cavity from the oral cavity and
forms a
partial partition between the nasopharynx above it
and the oropharynx below it.

3. MUSCLES OF SOFT PALATE
 The velopharyngeal musculature consists of several
muscular slings formed by the following:
 Levator veli palatini
 Tensor veli palatini
 Palatopharyngeus
 Palatoglossus
 Musculi uvulae
 Superior pharyngeal constrictor.

7. Ventral view of the velopharyngeal musculature.
1, Tendon of tensor palatini; 2, palatine
aponeurosis; 3, pterygoid hamulus; 4, palatopharyngeus;
5, levator palatini; 6, palatoglossus; 7, palatothyroideus;
8, superior pharyngeal constrictor

8. Figure 15-12 A: Posterior view of the nasopharyngeal
isthmus. 1, Auditory tube; 2, tensor veli palatini; 3, levator
veli palatini; 4, superior pharyngeal constrictor;
5, pterygoid hamulus; 6, palatine aponeurosis; 7,
palatopharyngeus and palatothyroideus; 8, Passavant's
ridge; 9, palatoglossus; 10, musculi uvulae. The major
parts of the palatopharyngeus muscle and Passavant's
ridge were removed on the left side to expose the levator
sling and the palatine aponeurosis.

9. PALATINE APONEUROSIS
 The palatine aponeurosis is a sheet of fibrous tissue
that provides stability and flexibility to the soft palate
and serves as an anchoring point for a number of its
muscles.
 Along its attachment to the hard palate, the palatine
aponeurosis continues with the periosteum and
submucosal connective tissue on the oral and nasal
surfaces on the hard palate.

10. Levator veli palatini
 The levator arises from:
The rough quadrate area on the inferior surface of the
petrous portion of the temporal bone in front of the
carotid canal,
The carotid sheath,
Part of the medial surface of the cartilaginous portion
of the auditory tube.

12. Fibers are inserted:
into the nasal surface of the palatine aponeurosis and
blend with the muscle fibers of the opposite side,
forming the V-shaped levator sling that occupies the
middle portion of the soft palate.

13.  Contraction of the levator sling pulls the soft palate
upward and backward,
 The fibers attached to the auditory tubes open them
during deglutition.
 The levator veli palatini is the principal mover.

14. Tensor Veli Palatini
 The tensor veli palatini muscle arises from:
 The lateral part of the medial pterygoid plate.
 The spine of the sphenoid.
 The major bulk of the muscle is attached to the lateral
hook of the cartilage of the auditory tube and the
fibrous tissue forming the membranous portion of the
auditory tube.

21. PATIENT PRESENTATION
 Cleft palate with cleft lip and alveolus –
 Alveolar portion of the cleft lies between the maxillary
lateral incisor and canine tooth roots.
 In comparison to noncleft individuals, patients with
unilateral cleft lip and palate have overall reduction in
crown size and delay of eruption of permanent
dentition.

22.  The nasal septum is deviated and buckled toward the
cleft side.
 The absence of a portion of the inferior piriform
aperture and the hypoplasia of the lateral nasal bony
platform at the maxillary wall contribute to the cleft
nasal deformity; the nasal base is depressed, the ala
collapses, and the floor widens.

23.  In the bilateral complete cleft lip and palate, the pre-
maxillary segment containing the central and lateral
incisor tooth roots is discontinuous from the alveolar
arch.
 The lateral segments often collapse inward and
lingually, resulting in “locking out” of the premaxilla.

24.  Clefts of the secondary palate
 Also called incomplete cleft palate, a cleft of the
secondary palate may be variable, from an opening in
the posterior soft palate to a cleft extending up to the
incisive foramen. There is almost always a separation
of the bony shelves of the hard palate.
 Most commonly, dentition is normal and symmetric.

25.  Submucous cleft palate
 Submucous cleft palate occurs when the palate has
mucosal continuity but the underlying levator palatini
muscle is discontinuous across the midline and
longitudinally oriented, similar to the muscle anatomy
in overt clefts of the palate.
 Calnan’s classic triad is present.

26.  Ear pathology
 In multicenter studies, incidence of otitis media
effusion has been found to be 96–100% in cleft
patients, measured by both middle ear effusions on
otoscopy and impedance testing and middle ear
aspiration.

27.  In the cleft palate, impairment of tubal dilation is
thought to occur from complex misalignment of the
paratubal musculature.
 In addition, intrinsic abnormalities of tubal cartilage
framework rendering a Eustachian tube more
collapsible have been noted.

28.  In addition, some theorize that constant bathing of
the tube orifice with oropharyngeal refluxed material
leads to inflammation and obstruction of drainage.
 Pierre Robins Syndrome has high risk of hearing loss.

37. Pierre Robin sequence
 Pierre Robin described the triad of micrognathia,
glossoptosis, and respiratory distress.
 Of the children diagnosed with Pierre Robin sequence,
60–90% have cleft palate4
 Palatal cleft is usually isolated to the velum and can be
V shaped or, more typically, U-shaped

38. GROWTH
 At birth, the average weight is the same for cleft and
unaffected newborns.
 Studies observing infants with cleft lip and palate
show initial growth retardation by the time they
undergo surgical lip repair.
 When the same children reach the age for palatoplasty,
they have significantly lagged on the growth curve.

39.  Average growth returns to normal compared with
unaffected children by the age of 4 years.
 Children with orofacial clefting stabilize and continue
normal growth to at least 6 years of age, with no
statistically significant differences in height and weight
when compared to unaffected children.

40.  In later childhood, however, average weight and height
of children with cleft appear to diminish compared
with those of control subjects.
 Duration of puberty and pubertal skeletal growth were
prolonged an average of 1 year,

41. FEEDING
 Infants with cleft lip can usually be fed by breast or
regular bottle.
 For breastfeeding babies, the soft breast tissue often
will fill the opening in the lip and/or gum line well,
sealing off the mouth and allowing the baby to create
adequate suction. Sometimes it is helpful for
the mother to hold a finger across the cleft during
feeding.

42.  When starting a feeding, hold the baby in a slightly
upright position.
 Try to keep the nipple in the center of the baby's
mouth. Do not let it slip up into the cleft.

43.  Babies with cleft palate usually need special bottles
and techniques to feed adequately.
 We encourage mothers who planned to breastfeed to
express their milk and feed it to their infants using a
special bottle.

44.  There are three types of bottles that we recommend for
feeding babies with clefts –
 Mead-Johnson Cleft Palate Nurser.
 The Haberman Feeder.
 The Pigeon Nipple.

46. Haberman Feeder
 The baby can obtain milk by compressing the nipple
against the roof of the mouth, without need for
suction as reservoir is present just above the nipple.

47. Mead- Johnson
 As the baby begins to suck, squeeze the bottle with a
firm steady pressure to the count of "squ-e-e-ze-two-
three," relaxing your squeeze on the two-three count.
This provides the baby with an intermittent flow of
milk

48. Pigeon Nipple
 Pigeon Nipple works by compression only. The nipple
has a firm side that goes toward the roof of the mouth
and a softer side that goes on the tongue.
 A small notch at the base of the nipple serves as an air
vent. This notch should be uppermost under the
baby's nose when feeding.
 Tightening the nipple and collar slows the flow of
milk. Loosening it makes the flow faster.

49. Timing of palate repair
 Victor Veau first made the observation of a correlation
between age at repair and speech outcome in 1931.
 He noted that children who had undergone repair
before 12 months of age were much more likely to have
normal speech than those with repair between 2 and 4
years of age.

50.  Despite the absence of hard evidence supporting
earlier palate repairs, a growing body of opinion seems
to support palate repair around 9–10 months of age for
children with apparently normal development.

53. Maxillary growth
 Palatoplasty has been shown to detrimentally affect
maxillary growth.
 Transverse growth of the maxillary arch is narrowed in
comparison with that in noncleft patients, resulting in
typical malocclusion traits of crowding, lateral cross-
bite, and open bite.

54.  Whether the narrowed arch and maxillary growth
inhibition result from surgical scarring or intrinsic
maxillary underdevelopment remains a matter of
debate; most likely it is a combination of the tw0
 Although it might seem preferable to wait until a more
advanced age for palate repair, given the growth effects
on the maxilla, it is far more difficult to establish
normal speech.

55. Congenital Palatal Insufficiency
(CPI)
It has been said that cleft palate is a type of defect that
can be “seen, felt, and heard.
Palatal insufficiency may be caused by the velum
being too short and/or by a deficiency in the antero-
posterior dimension of the hard palate.