Cleft Lip and Palate Surgical Repair Techniques

DR. GENOEY GEORGE
CLEFT LIP AND PALATE
(SURGICAL)
PART 3

CONTENTS
• Introduction
• Cleft Lip Repair
• Cleft palate Repair
• Velo pharyngeal Insufficiency
• Alveolar Bone Grafting
• Types Of Graft
• Complications
• Pre surgical orthodontics
• Post surgical Orthodontics
• Advancements
• Conclusion
• References

LIP REPAIR
INTRODUCTION
• Cleft lip repair is a surgical procedure that may be approached with a wide
array of different techniques.
• The ultimate goal of cleft lip repair is to restore the sphincter function of
the orbicularis oris muscle and obtain a cosmetically favourable outcome
for the developing child.

ANATOMY
• During the sixth to seventh weeks of embryonic development, the bilateral
maxillary prominences grow medially towards the medial nasal prominences, and
fusion occurs, leading to the formation of the upper lip
• In unilateral cleft lip, The columella will be found on the noncleft side. These
anatomical abnormalities lead to nasal tip deviation towards the noncleft side with
nasal septum deviation towards the noncleft side and a laterally, inferiorly, and
posteriorly displaced alar base on the cleft side.
• In bilateral cleft lip, lack of orbicularis oris muscle in the prolabial segment causes
anterior premaxillary protrusion. This causes columellar skin to be deficient,
leading to a shortened, almost absent, columella. These findings lead to a broad
nasal tip with laterally displaced alae.

TIMING
Although some have proposed surgical correction of the cleft lip as early as 48 hours
after birth, surgical repair is generally performed following the rule of 10s, which
states that:
• Surgery should be performed at 10 weeks of age,
• Patient weighs 10 lbs
• haemoglobin is at 10 g/dL.
Repair between 2 to 3 months of age allows the patient to be adequately evaluated for
other congenital anomalies

TECHNIQUES OF LIP REPAIR
UNILATERAL CLEFT LIP BILATERAL CLEFT LIP
Millard’s rotational advancement Straight line closure
Modifications Columella lengthening
Millard II Millard repair
Skoog’s Technique Tennison-Randall triangular flap
Mohler’s Technique Other techniques:
Tennison-Randall Triangular flap Bauer Method
Delaire’s Functional lip closure Manchester method
Skoog method
Wynn method

STRAIGHT LINE REPAIR
• Historically, the first cleft lip repairs relied on freshening the edges of the cleft and
suturing them together. These have been largely replaced by various Z-plasty-
based techniques.
Rose Thompson repair:
• Straight-line repair that can be used for minor clefts with lip length nearly equal on
both sides of cleft .
• Fusiform excision with straight-line closure.

Indications:
• Still used for mild forms of cleft lip
• Lengthening effect achieved
Advantages
• Straightforward
Disadvantages
• Minimal lengthening is obtained
• Destroys important landmarks
STRAIGHT LINE REPAIR

MILLIARD ROTATION-ADVANCEMENT
• Ralph Millard developed the rotation-advancement technique by operating the
children with cleft lip during his military service in the Korean War
• The rotation advancement repair of the unilateral cleft lip deformity was described
by Millard
• Introduced in 1957
• Most widely used procedure for unilateral cleft lip repair

MARKINGS
1. Center/low point cupids bow
2. Peak of bow on NCS
3. Peak of bow on medial side of cleft
4, Alar base, NCS
5. Columellar base, NCS
6, Commissure, NCS
7. Commissure, deft side
8. Peak cupids bow lateral side of cleft
9. Superior extent of advancement flap
10. Alar base, cleft side
Point x: Back-cut point

ADVANTAGES
• The main advantage of this technique is its flexibility and application.
• The rotation advancement technique relies on a "cut as you go" strategy that
allows continuous modifications during the design and execution of the repair.
• Another advantage is that the suture line approximates a new philtral column.
• The aesthetic philtral subunit is not violated, and this tends to create a scar that is
more camouflaged.
• Minimal tissue is discarded during the rotation advancement technique, and this
tends to put less tension on the closure.
• Lip often short due to under rotated lip
• Tension across repair of wide clefts
• May have constricted nostril on side of repair
DISADVANTAGES

TENNISON-RANDAL TRIANGULAR FLAP
Tennison - Z plasty
• Tennison (1952) -frustrated by straight-line scar contraction.
• He preserves the cupid’s bow and places it in normal position
• He inserted a wedge from the lateral lip into the lower portion of the medial lip,
and achieved good results - and called it ‘stencil method’ - came to be known as
the Tennison triangular flap technique.

TENNISON-RANDAL TRIANGULAR FLAP
• This repair technique is conceptually similar to the rotation advancement
repair.
• The primary difference is that the rotation backcut in the noncleft
segment is performed more inferiorly, closer to the vermilion border.
• Similarly the advancement segment on the cleft side is designed to occur
inferiorly near the vermilion cutaneous border.

ADVANTAGES
• They are used to close wide clefts without having to perform lip adhesion
or presurgical tissue manipulation.
• The operation is done on strictly geometric methods of mathematical
principles and measurements, leaving not much room for errors in
judgment. Therefore, many experts consider the triangular flap technique
to be well suited for experienced surgeons.
• zigzag scar prevents scar contracture and lip shortening leading to a
vermilion notch that can be sometimes observed in the rotation
advancement technique.
• Minimal soft tissue dissection
• Preservation of cupids bow

DISADVANTAGES
• Difficulty in modifying the repair or performing secondary revision at a
later stage due to the zigzag scars.
• Late vertical lengthening may occur.
SKOOG REPAIR
• Consists of two Zplasties.
• Violates Cupid's bow and the philtral dimple

DELAIRE’S FUNCTIONAL LIP CLOSURE
• Does not make use of flaps – accurate reconstruction of the 3 rings of muscles
of the Lip and nose
• Creates a highly symmetric nose and a functional lip
• NASO-LABIAL/UPPER RING: Transverses nasi, levator labii superiorisalequi nasi,
levator labii superioris, zygomaticus minor and the levatoranguli oris.
• BILABIAL/MIDDLE RING: Represents oral sphincter, consisting of theupper and
lower lip orbicularis oris muscle.
• LABIO-MENTAL/LOWER RING: Lower ring has an incomplete circumference and
consists of orbicularis inferior, triangularis labiiand quadrates labii inferioris.
Brusati, Roberto & Mannucci, N. & Mommaerts, Maurice. (2006). The Delaire
philosophy of cleft lip and palate repair. Maxillofacial Surgery. 1027-1047.

• The integrity of the first ring is fundamental for sustaining and allowing
normal functioning of the other two.
• The lower ring acts by remodelling the dento alveolar complex and chin
portion of the mandible vertically and transversely.
DRAWBACKS
• Straight-line scar and inability to achieve adequate lengthening of the lip,
resulting in a notching.

BILATERAL CLEFT LIP REPAIR
• Achieve symmetrical result
• Reconstruction of vermillion & white roll
• Muscle repair - allow upper lip to function as a single unit
• Reconstruction of gingival-labial sulcus
• Form medial tubercle & vermillion-cutaneous ridge from lateral lip tissue (in
caseswhere the prolabium is deficient)
• Primary improvement of columellar length and nasal tip projection
• Proper philtral size and shape

MANCHESTER REPAIR:
• For less severe bilateral deformities in which the prolabium has adequate
white roll and vermillion →these structures are preserved in the repair (in
contrast with Millard, Mulliken, etc. which discard this tissue
Advantages
• Comparatively straightforward
• Less tension on repair
• decreased chance of tight upper lip
Disadvantages
• whistle-notch deformity if used in cases with deficient prolabial vermillion

MILLARD TECHNIQUE
Advantages
• Good result even when prolabial white roll and vermillion are deficient
Disadvantages
• Rectangular columella without a normal-appearing
• Sharp columella-labial angle
• Abnormally elongated nostrils
• Columellar over-elongation
• Downward drift of the columellar base
• Requires multiple procedures

MILLARD TECHNIQUE
Variations of this technique are widely used (mulliken)
• Repair brought lateral vermillion flaps under the prolabium, avoiding the
whistle notch deformity of some earlier repairs
• Restores orbicularis continuity deep to the prolabium
• Uses forked flaps derived from the prolabial
parings to lengthen the columella;
these are banked in the alar bases
until they are required

MULLIKEN TECHNIQUE
Many similarities with millard repair, but:
• Emphasized importance of how the repaired lip will grow over time
• Advocated lengthening the columella by repositioning the alar
cartilages rather than deriving tissue from prolabial forked.
Advantages
• Good result even when prolabial white roll and vermillion are deficient
• Good scar position - hidden in philtral columns
• Addressed nasal deformity with repositioning of cartilage elements
rather than with external flaps → less external scarring
• Avoids characteristic prolabial wideness of bilateral cleft lip repairs
Disadvantages
• Can get tight upper lip

POSTOPERATIVE CARE
A. Orders
• Arm restraints for 3 weeks to prevent disruption of repair.
• Specialized nipple/bottle to decrease sucking effort when bottle-feeding.
• Breast-feeding is controversial; based on surgeon preference.
B. Leave Steri-Strips in place over the incision for reinforcement.
C. Follow up in 1 week for suture removal if nonabsorbable
skin sutures were used.

CLEFT PALATE REPAIR
TIMING
• Age of surgery (6-14 months)
TECHNIQUES
• Bardach Two Flap
• Von Langenbeck
• Furlows
• Delaire
• Sommerlads
• Morphofunctional

CLEFT PALATE REPAIR
BARDACH
The design of the flap entirely depends on the greater palatine nuerovascular
pedicle and it provides versatility to cover the cleft.
A modification of von Langenbeck's technique by extending the lateral alveolar relaxing
incisions to the edge of the cleft.
ADVANTAGES
• Complete closure of entire palate in one stage
• Creation of physiological soft palate muscle sling
and a layered closure.
DISADVANTAGES
• Does not provide additional length to the
repaired palate to allow normal speech production
Bardach J. Two-flap palatoplasty: Bardach's technique. Operative techniques in
plastic and reconstructive surgery. 1995 Nov 1;2(4):211-4.

CLEFT PALATE REPAIR
VON LANGENBECK
The Vonlangenbeck technique is almost similar to bardach palatoplasty but
preserves the anterior pedicle for increased blood supply to the flaps.
It is used in isolated cleft cases.
ADVANTAGES
• 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
Rossell-Perry P. Flap Necrosis after Palatoplasty in Patients with Cleft Palate. Biomed Res Int.
2015;2015:516375. doi: 10.1155/2015/516375. Epub 2015 Jul 26. PMID: 26273624; PMCID:
PMC4529936.

CLEFT PALATE REPAIR
VEAU-WARDILL-KILNER PUSHBACK PALATOPLASTY
VEAU-WARDILL-KILNER PUSHBACK PALATOPLASTY is used for the incomplete
clefts of hard and soft palate
ADVANTAGES
• Lengthening of palate
• Repositioning the Levator muscle in a
favorable position
DISADVANTAGES
• Adversely affects midfacial growth
of the cleft palate patients
because of scar tissue anteriorly.
• Higher rate of fistula in complete cleft palate
than other techniques because it provides
single nasal mucosal layer anteriorly
Agrawal K. Cleft palate repair and variations. Indian Journal of Plastic Surgery. 2009 Oct;42(S
01):S102-9.

CLEFT PALATE REPAIR
FURLOW
Alternating the reverse 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 submucous cleft palate and secondary correction of
marginal velopharyngeal insuffieciency
ADVANTAGES
• No need to raise large muccoperiosteal
flaps from the hard palate
• The soft palate can be lengthened (Good speech Outcome)
DISADVANTAGES
• Non anatomical palatal closure
• Ignores musculus Uvulae
• Difficult to close wider clefts
• Larger raw areas need to be covered
with buccal flap
Leow AM, Lo LJ. Palatoplasty: evolution and controversies. Chang Gung Med J. 2008 Jul 1;31(4):335-
45.

CLEFT PALATE REPAIR
SOMMERLAD
Radicular retropositioning of velar musculature and tensor tenotomy using a operating
microscope to allow accurate levator muscle reconstruction
ADVANTAGES
• Non tension closure in wider palates
• Good speech Outcomes
DISADVANTAGES
• Reccurent 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. 2003 Nov
1;112(6):1542-8.

CLEFT PALATE REPAIR
MORPHOFUNCTIONAL
TWO FLAP TECHNIQUE WITH OPTIMAL MUSCLE DISSECTION
Gosla Reddy, S. (2017). Morphofunctional palatoplasty: evidence based recommendations.
International Journal of Oral and Maxillofacial Surgery
Medial and Lateral incisions to expose the soft palate musculature and mobilize the hard
palate flaps.

CLEFT PALATE REPAIR
MORPHOFUNCTIONAL
SOFT PALATE MUSCLE DISSECTION
• Optimal muscle dissection
• Dissection only of Levator muscle bundle (Levator Myoplasty)
• Tensor tendon is not dissected

CLEFT PALATE REPAIR
MORPHOFUNCTIONAL

CLEFT PALATE REPAIR
MORPHOFUNCTIONAL
• Postoperative antibiotic dressing for 5 days
• Postoperative feeding: Clean, Clear and filtered fluids for 1 month.
• Plenty of oral fluids.
• Parent counselling.

VELOPHARYNGEAL INSUFFICIENCY
Inadequate closure of the soft palate during speech to the posterior pharynx
during speech, resulting in air leak up to the nasopharynx
LINDSEY AND DAVIS 1995
Velopharyngeal Insufficiency: Inability to achieve complete closure of the
velopharyngeal apparatus during speech
Velopharyngeal Incompetence: Imperfect closure of velopharyngeal
apparatus caused by nueromuscular dysfunction(Impaired motor
programming of velopharynx.
Velopharyngeal Inadequacy: Imperfect closure of velopharyngeal apparatus
caused by tissue defect

ASSESMENT OF VELOPHARYNGEAL
INSUFFICIENCY
• Speech evaluation by well trained speech pathologist
• Pressure flow measurements
• Nasopharyngeal Endoscopy
• Videoflouroscopy

CORRECTION OF VPI
• Secondary Palatoplasty aims at correcting velopharyngeal inadequacy
• 5% to 36% patients who have undergone primary palatoplasty have
persisting VPI
SURGERIES
VELOPHARYNGEAL NARROWING
PALATAL LENGTHENING
V-Y
PUSHBACK
INTRAVELAR
VELOPLASTY
DOUBLE OPPOSING Z
PLASTY
SPHINCTER
PALATOPLASTY
PHARYNGEAL
FLAP
SUPERIORLY
PLACED
INFERIORLY
PLACED
Dorf DS, Curtin JW. Early cleft palate repair and speech outcome. Plastic and reconstructive surgery.
1982 Jul 1;70(1):74-9.

INTERVELAR VELOPLASTY
A triangular flap is designed comprising new epithelial
tissue which will be turned over.
Using a single hook, the oral mucosa and gland layer
is separated from the muscle layer.
Dissection of the greater palatine nerve-vessel bundle.
The anterior palatal flap is raised by a curved elevator.
The closure of the nasal mucosa and muscle is
completed.

CORRECTION OF VPI
This Study conducted to determine the effectiveness of a modified secondary Furlow
Zplasty in improving VPI
Reddy RR, Reddy SG, Banala B, Bronkhorst E, Kummer AW, Kuijpers-Jagtman AM, Bergé SJ. Use of a
modified Furlow Z-plasty as a secondary cleft palate repair procedure to reduce velopharyngeal
insufficiency. International Journal of Oral and Maxillofacial Surgery. 2016 Feb 1;45(2):170-6.

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 use of adjacent tissue, the
excellent blood supply and the low
morbidity in donor site.
Disadvantage
• In some cases the attachment of the
flap can be lost due to traction.

BUCCAL MYOMUCOSAL FLAP
BMMF is a vascular and dependable flap.
Vascular supply of the flap is consistent and profuse.
It 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.
Disadvantage
• Fibrosis.
• Secondary healing.
• Parotid duct orifice injury

COMPLICATIONS
PRE OPERATIVE
• Otitis Media
• Aspiration Pnumonia
• Nutritional Deficiency
INTRA OPERATIVE
• 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 Insufficiency
• Maxillary Hypoplasia
• Reccurent Ear Infections

ALVEOLAR BONE GRAFTING
Usually done at the time of lip repair
TIMING - 0-2.5 years usually at the time of lip repair
Disadvantage
• Poor maxillary growth
• Negative effects on anterior and
inferior growth of maxilla
• inadequate contour of bone graft
• higher propensity for cross bites
PRIMARY ABG

• Usually done in childhood before the eruption of permanent incisors
• Early surgery is not evaluated as thoroughly as late surgery
• Boyne indicated this when permanent central and lateral incisors appear to be
developing in such a direction that it may erupt abnormally into the cleft resulting
in inadequate tooth position or severe malposition jeopardized bone support
because of anatomy of tooth eruption.
SECONDARY ALVEOLAR BONE GRAFTING
ADVANTAGES:
• classic time for alveolar grafting
• High percentage of good results
• Allows eruption of canine
• Healthy teeth on either side of cleft
• Minimal impact on facial growth
• Allows for orthodontic alignment
EARLY SECONDARY ABG
Boyne PJ. Use of marrow-cancellous bone grafts in maxillary alveolar and palatal clefts.
Journal of dental research. 1974 Jul;53(4):821-4.

DISADVANTAGE
• central and lateral incisors must have erupted
• carries increased risk of periodontal bone loss and root resorption.
• Posnick mentions that waiting allows maximum transverse growth of maxilla to
occur before bone grafting.
• 95% of anteroposterior and transverse growth of maxilla is completed by the age
of 8yrs.
• It is done after the eruption of canine
• It has got lower incidence of successful grafts due to Poor oral hygiene and
decreased blood supply or altered oral flora in older children.
Hall HD, Posnick JC. Early results of secondary bone grafts in 106 alveolar clefts. Journal of Oral
and Maxillofacial Surgery. 1983 May 1;41(5):289-94.
LATE SECONDARY ALVEOLAR BONE GRAFTING

TIMIMNG
• Primary ABG : 0-2.5 years usually at the time of lip repair
• Early secondary ABG : 2-5 years before the eruption of permanent incisors
• Secondary ABG : 6-13years before the eruption of permanent canines
• Late secondary ABG : >13 years after the eruption of permanent canines
TYPES OF GRAFT
AUTOGENOUS GRAFT ALLOGENOUS GRAFT ALLOPLASTIC GRAFT

RELEVANCE TO ALVEOLAR CLEFT
Various factors affecting in decision making process :
• choosing an appropriate donor site for alveolar cleft
• size of the cleft
• volume of bone needed
• whether teeth will erupt through graft material
• health of donor site
• healing potential of the patient
Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A.
Rawashdeh, H.Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

ILIAC BONE
• Gold standard, Easy access & high success rates
• Rapid bone formation and calcification
( large supply of pleuripotent / osteogenic cells )
• Earlier cortico-cancellous blocks were used but
lately only cancellous bone is harvested using
cylindrical punch with minimal incision.
• High content of osteogenic cells
• Rapid revascularization of graft ( 3 weeks )
• While choosing the anteromedial approach care should be taken to preserve the
attachment of tensor fascia lata - Anterior Illiac Crest
• For Larger Quantities of bone - Posterior Illiac Crest
Rawashdeh, H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

ILIAC BONE CREST
ADVANTAGES
• Adequate quantity, easily condensed and placed
• proven successful results
• little donor site morbidity
• two team approach
DISADVANTAGES
• Questionable effects on growth
• possible gait disturbance
• post operative hematoma
• Donor site morbidity

TIBIAL BONE CREST
• Johanson and Ohlsson,Drachter 1941 – facial clefts
• medial, slightly curved incision with excellent
exposure of the tibial shafts.
• Large supply of cancellous bone is available.
• Cosmetically the post operative incision appears
to be quite acceptable.
ADVANTAGES
• Adequate volume
• Quality similar to iliaccrest
• Predictable results
• Two team approach
DISADVANTAGES
• concern with ambulation
• Epiphyseal injury

RIB BONE CREST
• An eccentrically placed H shaped rib strut is wedged into
the cleft with the more prominent portion facing the
labial side to elevate the depression caused by cleft.
• A solid piece of rib can be used for linear
separation at the ends exposing the
cancellous part of the bone.
• The rib can be broken into many small chips
and packed into the cleft
ADVANTAGES
• for infants
• two team approach
DISADVANTAGES
• Donor site morbidity
• unpredictable results

MANDIBULAR SYMPHYSIS
• Bosker & Von Dijt – Mandibular symphysis
• Low morbidity
LIMITATIONS
• Limited volume
• increased percentage of impacted canines(increased cortical content)
• loss of unerupted permanent teeth early mixed dentition
• Necrosis of the pulp, or devitalisation of teeth;
• Injury to the mental nerve
ADVANTAGES
• Embryonic origin and earlier vascularization
• less resorption
• No external scar
DISADVANTAGES
• Limited amount of bone
• Inability to remove bone graft simultaneously with preparation of recipient site.

PRE SURGICAL ORTHODONTICS
2 orthodontic considerations integrate with timing of alveolar cleft grafting
• Correction of cross bites
• Alignment of anterior teeth
• cross bite due to narrowed transverse dimension of maxilla
(maxillary expansion performed before grafting)
• when graft is performed before expansion
(3 months should elapse before expansion)
• Bilateral cleft with a pre-maxilla
(maxilla must be expanded first before distalizaton of pre-maxilla to ensure proper
space)
• It better not to begin teeth alignment before grafting as movement of teeth
adjacent to cleft may result in root exposure through this alveolar bone in this
area.
Full revascularization of cancellous bone takes place in 3 weeks

PREPARATION OF CLEFT ALVEOLUS
Five Principles in approaching the cleft alveolus:
• Wide exposure and appropriate Flap design.
• Reconstruction of Nasal floor closing the oro nasal fistula
• Adequate graft material harvest.
• Adequate packing of the defect with cancellous bone
• Watertight closure of bone graft with gingival mucoperiosteal flaps.
Bajaj AK, Wongworawat AA, Punjabi A. Management of alveolar clefts. J Craniofac Surg. 2003
Nov;14(6):840-6..

PROCEEDURE

Vemagiri CT, Damera S, Pamidi VR, Pampana SG. Management of Alveolar Cleft Defect by Iliac Crest
Secondary Bone Grafting: A Case Report. International Journal of Clinical Pediatric Dentistry. 2022 Dec
17;15(4):472-4.

TYPES OF TISSUE FLAPS USED FOR BONE GRAFTS
LOCAL FLAPS
• Local flaps obtained from the labial alveolar ridge and rotated in a hinge
like fashion based either medially or laterally towards the palate exposing
the alveolar clefts.
• The labial defect is then closed with any of the labial flaps which can be
rotated from the medial or lateral side.

TYPES OF TISSUE FLAPS USED FOR BONE GRAFTS
DISTANT FLAPS
• Distant flaps ( one stage vomer ) used for the closure of wider alveolar
clefts.
• It was used by Stellmach and Schrudde
• It is easily elevated and transferred in one stage directly anteriorly to meet
oncoming flap from the labial side.
• Bilateral vomer flaps used in bilateral clefts are formed in two stages with
intervals of two or three months as simulatenous denudation and
elevation of two vomer flaps jeopardize the blood supply to vomer

COMPLICATIONS
• Infection
• Wound dehiscence
• Loss of intact of graft
• Incomplete closure of oronasal fistula

POST SURGICAL ORTHODONTICS
• 3 months after the bone graft procedure, depending on the radiographic
image of the area orthodontic treatment is restarted to correct the
position of the permanent teeth.
• The pattern of eruption of the maxillary central incisor follows the pattern
of alveolar development in the cleft subjects.
• Dental alignments are possible if the alveolar cleft is grafted
• Correction of malpositioned teeth - fixed / Semi-fixed or fully bonded
appliance permitting adjacent teeth to migrate or orthodontically move
into the grafted bone.
• Canine brought into the space of the lateral incisor moving the tooth
through the alveolar bone graft and reshaped into a lateral incisor and
residual spaces closed with fully fixed bonded appliance.

RECENT ADVANCES
AUTOGENEOUS BONY SUBSTITUTES
• Reduce morbidity
• Not necessary to harvest autogenous bone,
• Reduce the cost of rehabilitating patients with clefts.
LIMITATIONS
• Unpredictability in resorption / amount of bone formed

RECOMBINANT HUMAN BONE MORPHOGENETIC
PROTEIN (RHBMP).
• rhBMP-2 is effective in the regeneration of alveolar bone and associated
periodontal attachment apparatus
• It promotes the differentiation of pluripotential cells into bone forming
cells that lay down new host bone in the site of the defect (osteoinduction)
• Remodelling equilibrium prevents loss of bone through resorption
• However, it requires a suitable carrier for its clinical applications in human
conditions to prevent rapid diffusion of the protein

PROTEIN (RHBMP).
Scalzone A, Flores-Mir C, Carozza D, d’Apuzzo F, Grassia V, Perillo L. Secondary alveolar bone grafting using
autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and
meta-analysis. Progress in Orthodontics. 2019 Dec;20:1-0.

PROTEIN (RHBMP).
Scalzone A, Flores-Mir C, Carozza D, d’Apuzzo F, Grassia V, Perillo L. Secondary alveolar bone grafting using
autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and
meta-analysis. Progress in Orthodontics. 2019 Dec;20:1-0.
• Autologous bone and rh-BMP2 graft showed a similar effectiveness in
maxillary alveolar reconstruction
• patients with unilateral cleft lip and palate with rh-BMP2 graft showed a
relative shorter length of hospital stay

CONCLUSION
• The primary aim in CLP is to educate parents and future mothers and
fathers. Cleft lip and palate are both birth defects that affect different
structure and function such as speech difficulty, aesthetic, eating, nutrition
etc.
• Patients with oro-facial cleft deformity needs to be treated at right time
and at right age to achieve functional and aesthetic well-being.
• Treatment involves a number of specialists who decide the best treatment
plan depending on the site of defect and age of the infant
• The multidisciplinary approach towards this problem will lead to a steady
improvement in its end results.

REFERENCES
• Brusati, Roberto & Mannucci, N. & Mommaerts, Maurice. (2006). The Delaire philosophy of
cleft lip and palate repair. Maxillofacial Surgery. 1027-1047.
• Bardach J. Two-flap palatoplasty: Bardach's technique. Operative techniques in plastic and
reconstructive surgery. 1995 Nov 1;2(4):211-4.
• Leow AM, Lo LJ. Palatoplasty: evolution and controversies. Chang Gung Med J. 2008 Jul
1;31(4):335-45.
• Agrawal K. Cleft palate repair and variations. Indian Journal of Plastic Surgery. 2009
Oct;42(S 01):S102-9.
• Sommerlad BC. A technique for cleft palate repair. Plastic and reconstructive surgery. 2003
Nov 1;112(6):1542-8.
• Gosla Reddy, S. (2017). Morphofunctional palatoplasty: evidence based recommendations.
• Reddy RR, Reddy SG, Banala B, Bronkhorst E, Kummer AW, Kuijpers-Jagtman AM, Bergé SJ.
Use of a modified Furlow Z-plasty as a secondary cleft palate repair procedure to reduce
velopharyngeal insufficiency. International Journal of Oral and Maxillofacial Surgery. 2016
Feb 1;45(2):170-6.
• Hall HD, Posnick JC. Early results of secondary bone grafts in 106 alveolar clefts. Journal of
Oral and Maxillofacial Surgery. 1983 May 1;41(5):289-94.

REFERENCES
• Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and
Morbidity M.A. Rawashdeh, H.Telfah / British Journal of Oral and Maxillofacial
Surgery 46 (2008) 665–670
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