cleft palate is a common congenital disorder which has numerous associated problems, including anatomical defects

1. Cleft Palate

2. INTRODUCTION
 common congenital disorder
 have numerous associated problems,
including
 basic anatomic deformity,
 deficient facial growth,
 dental problems
 speech problems
 otologic problems
 psychologic disorders, and
 additional congenital anomalies.

3. History
 400BC Hippocrates and 150AD Galen mentioned cleft lip
 500 AD 1st Operation on palate due to inflammation of the uvula
 1564 Pare described the use of obturators for palatal perforations
 1556Cleft palate recognised as a congenital disorder by Franco.
 1764 LeMonnier, a French dentist performed 1st successful
repair of a cleft velum.
 1834Dieffennbach performed the 1st closure of the hard palate
 1861Von Langenbeck described the use of mucoperiosteal flaps in
cleft palate closure
 1930Kilner and Wardill independently developed the ‘pushback’
procedure.
 1944 Schweckendiek began closing cleft defects in young patients.

4. Epidemiology and Genetics
 The incidence of cleft palate only is half the incidence of
CL/P (more than 1 : 2000 live births).
 There is usually little difference between racial groups.
 The incidence is much higher (about 4 : 1) in females
than in males.
 About 20% to 30% of human cleft palate only are
syndromic.
 Pierre-Robin Sequence,
 Treacher-Collins Malformation,
 Trisomies 13 and 18,
 Apert’s Syndrome,
 Stickler’s Syndrome and
 Waardenburg’s Syndrome.

5. Epidemiology and Genetics
 Familial risk
 One sibling with cleft, no parent with cleft 2%
 One sibling and one parent- 10-17%
 No sibling with cleft and are parent with cleft 7%
 Environmental factors exerting their
teratogenic effects
 Those with proven clefting potential in humans
include
 phenytoin,
 retinoic acid (vitamin A) derivatives,
 folic acid antagonists.,
 cigarette smoking creating fetal hypoximia
 alcohol use in the first trimester of pregnancy

6. Anatomy
 Primary palate or premaxilla is
 a triangular area of the anterior hard palate extending from the
anterior to the incisive foramen and to a point just lateral to each
lateral incisor tooth. It includes the alveolar ridge containing the
four incisor teeth.
 Secondary palate:-
 Consist of all remaining hard palate and are the soft palate.
 Hard palate-
 Formed by palatine processes of maxilla and horizontal lamina of
palatine bones.
 Blood supply internal maxillary art- greater palative Ar.
 Soft Palate
 A fibromuscular shelf made up of several muscles attached like a
sling to the posterior portion of the hard palate
 Function- close off the nasopharynx

7. EMBRYOLOGY
 The primary palate develops between 4 and 5
weeks gestation
 secondary palate between 8 and 9 weeks
gestation.
 The primary palate, lip and alveolus develop as
a mesodermal and ectodermal proliferation of
the frontonasal and maxillary processes.
 A primary cleft is a failure of proliferation, not a
failure to meet in the midline.
 The secondary palate develops as a medial
ingrowth of the lateral maxillae with fusion in the
midline.

8. EMBRYOLOGY

9. CLASSIFICATION
 no standard classification is universally
accepted.
 Cleft palate
 A. Location in reference to incisive foramen
 1. Primary—anterior
 2. Secondary—posterior
 B. Unilateral or bilateral
 C. Complete or incomplete
 Submucous cleft palate

10. Classification (Iowa system)
 Group I - cleft of lip only
 Group II - Cleft of palate only
 Group III - Clefts of lip alveolus
 Group IV - Cleft of the lip and alveolus+
Palate
 Group V - Miscellaneous

11. GENERAL MANAGEMENT
 The multidisciplinary cleft team approach
 The comprehensive multidisciplinary team
 surgeon (plastic, pediatric surgery, oromaxillofacial surgery, or
otolaryngology)
 otolaryngologist/otologist,
 dentist (pedodontist, orthodontist, prosthodontist, oral surgeon),
 speech language pathologist,
 audiologist,
 geneticist,
 Social worker,
 nurse,
 nutritionist, and
 psychiatrist/psychologist.

12. Management: Neonatal Period.
 The pediatrician is ideally suited for counseling
in the immediate postpartum period.
 Children with clefts of the secondary palate
usually have severe difficulties feeding.
 A soft bottle with a large opening is usually required.
 palatal prosthesis.
 A nasogastric tube is rarely required.
 palatal prosthetic plates.
 plates mold the palate into a more ideal position, leading to
less difficulty feeding and an easier surgical repair.
 improve facial growth and children require less intervention
throughout time

13. Management:
 The timing of the repair is controversial
 Palatal repair is performed anywhere from
6 months onward.
 delay in palatal repair results in improved midfacial
growth
 earlier repair results in better speech

14. Management: Toddler Years.
 The most important process in the toddler
years is the development of adequate
speech
 requires speech therapy
 The child is trained to speak slowly and forcefully in order to
maximize palatal elevation and minimize hypernasality
 up to 20% of patients still require
pharyngoplasty to reduce VPI
 recurrent or chronic ear infections
 growth hormone deficiency is 40 times more
common in this population

15. Management: School Years
orthodontic management
 psychological growth
psychotherapist is essential to ensure
adequate social development
high rate of depression and poor self esteem
Child abuse is also more common

16. Management: Teenage Years.
 The teenage growth spurt is marked by
midface retrusion, altering appearance.
 Palatal repair is likely responsible
 ideal timing for palatal repair so that midface retrusion is minimized is
currently an area of intense research, with many conflicting studies in
the literature
 The treatment requires maxillary
advancement through a combination of
LeForte I, II and III osteotomies.
 The treatment of midfacial retrusion requires maxillary
advancement through a combination of LeForte I, II and
III osteotomies.
 usually performed in young adulthood, after growth is complete
 Rhinoplasty, when required, is usually the last surgery
performed.

17. Surgical Techniques
 The child with CLAP usually undergoes
numerous surgical procedures.
 The first procedure is repair of the lip, which occurs around
10 weeks.
 The palate is usually repaired between 6 and 18 months,
with newer studies advocating earlier repair
 Pharyngeal flaps, if required, are performed around age 4.
 Alveolar bone grafting occurs between ages 9 and 11,
 definitive orthodontics at age 12-13.
 Maxillary advancement and rhinoplasty are delayed until
the later teenage years.

18. Surgical Techniques
Palatoplasty
 The basic surgical techniques of palate repair
include Schweckendiek’s procedure or primary
veloplasty,
 Von Langenbeck’s palatoplasty,
 V-Ypush-back
 double reversing Z-plasty (Furlow’s palatoplasty),
and two-flap palatoplasty.
 A combination of palatoplasty and pharyngeal flap
may be used for the repair of extremely large
clefts15 and occasionally for primary palate repair.

19. • Pre-Surgical
Orthopedics allowing
gingivoperiosteoplasty.
A: Wide unilateral cleft lip with separation of
the arch and collapse of the lesser segment.
B: Improved arch alignment and nasal shape
after presurgical orthopedic treatment.
C: Results after rotation-advancement lip
repair, nasal repair, and
gingivoperiosteoplasty, all performed at the
first operation, when the child is
approximately 3 months of age.

20. Palatoplasty Technique. A: Cleft palate closure after healing of
gingivoperiosteoplasty at 11–12 months of age. Bilateral, unipedicle
mucoperiosteal flaps based on the greater palatine arteries are elevated. B:
Anteriorly, the nasal floor is repaired by suturing the vomerine mucosa to the nasal
mucosa on the cleft side.

21. Palatoplasty Technique. The levator
muscles are dissected free from the oral and nasal mucosa and released from the
posterior edge of the hard palate. The levator muscles are approximated to each other
in the midline. D: The oral mucosa is reapproximated in the midline with interrupted
horizontal mattress sutures.

22. Double opposing Z-plasty
closure of an isolated cleft palate. A: Design of the incisions

23. Double opposing Z-plasty
closure of an isolated cleft palate. B: Muscle included in the posteriorly
based flap.

24. Double opposing Z-plasty
closure of an isolated cleft palate. C: Final result with recreation of the
levator sling.

25. SUBMUCOUS CLEFT PALATE
 The submucous cleft palate is traditionally defined by a triad of
deformities:
 a bifid uvula,
 a notched posterior hard palate, and
 muscular diastasis of the velum.
 A submucous cleft palate can vary considerably, however, and
muscular diastasis can occur in the absence of a bifid uvula.
 The majority of patients with are asymptomatic, although
approximately 15% will develop velopharyngeal insufficiency.
 Velopharyngeal incompetence (VPI) correlates with short palatal
length, limited mobility, and easy fatigability of the palate.
 Since the majority of patients remain asymptomatic, a
nonoperative approach is recommended until speech can be

26. Otologic Disease
 Children with cleft palate suffer from a greater
incidence of middle ear disease and hearing loss,
 the primary pathology being eustachian tube dysfunction due to
abnormal insertion of the palatal musculature
 Robinson et al performed a prospective study of 150
cleft palate children whose palates were repaired
between 2 and 18 months.
 They found 92% of these children developed chronic otitis media
with effusion which required tympanostomy tubes
 Muntz et al,
 who found 96% of cleft palate children developed chronic middle
ear effusions
 decreasing incidence of middle ear disease with age.

27. Otologic Disease
 An aggressive approach is required in the
management of middle ear disease including
 frequent myringotomy and
 tympanostomy tube placement
 the goal of the management of ear disease in
cleft palate patients is to
 provide adequate hearing,
 maintain ossicular continuity,
 Maintain adequate middle ear space, and
 prevent deterioration of the tympanic membrane until the
patient develops adequate eustachian tube function.

28. Otologic Disease
 Indications for myringotomy and
insertion of ventilating tubes
include
 persistent middle ear effusion with a
conductive hearing loss despite
adequate medical management,
 recurrent acute otitis media failing
prophylaxis,
 a combination of both, or
 presence of a retraction pocket

29. Otologic Disease
 Abnormal insertion of the levator and tensor veli palatini
muscles
 into the posterior margin of the hard palate and the muscular
hypoplasia appears to be the primary cause of eustachain tube
dysfunction in cleft patients.
 Recent evidence that the nature of middle ear effusions in
cleft patients is different from that in noncleft patients.
 Hutton and others recently published a study on the characterization
of mucin from the effusions of cleft patients.
 When compared with mucoid and serous effusions from
noncleft patients, the mucin in the middle ears of cleft
patients, contained larger glycopeptides with a larger
hydrodynamic size.
 This suggests that infections in cleft patients may be
different from those in noncleft patients.