Cleft Lip/Palate Reconstruction Guide

Clinical Aspects of Cleft Lip/PalateClinical Aspects of Cleft Lip/Palate
ReconstructionReconstruction
www.indiandentalacademy.com

OverviewOverview
• Relevant AnatomyRelevant Anatomy
• Embryology of Facial CleftingEmbryology of Facial Clefting
• Classification/EpidemiologyClassification/Epidemiology
• Principles of ManagementPrinciples of Management
• AssessmentAssessment
– Indications/ContraindicationsIndications/Contraindications
• Surgical TechniquesSurgical Techniques
– MillardMillard
– Wardill-KilnerWardill-Kilner
• Post-op managementPost-op management
– Complications
– Follow up
Clinical Aspects of Cleft Lip/Palate ReconstructionClinical Aspects of Cleft Lip/Palate Reconstruction

Anatomic PrinciplesAnatomic Principles
Normal LipNormal Lip
1) Central Philtrum
Lateral margins - philtral columns
Inferior border - Cupids bow and tubercle
2) Vermillion-cutaneous border

3) Muscles
Orbicularis oris (superficial and deep)
Levator labii superioris
Levator superioris alaeque
Transverse nasalis
End result of cleft lip:End result of cleft lip:
Disruption of the normal termination of the muscle fibers that cross the embryologicDisruption of the normal termination of the muscle fibers that cross the embryologic
fault line of the maxillary and nasal processes, resulting in abnormal muscular forcesfault line of the maxillary and nasal processes, resulting in abnormal muscular forces
between the normal equilibrium that exists with the nasolabial and oral groups ofbetween the normal equilibrium that exists with the nasolabial and oral groups of
musclesmuscles

Normal PalateNormal Palate
Primary palatePrimary palate
Secondary palateSecondary palate
Soft palateSoft palate
Hard palateHard palate

Embryology of CleftingEmbryology of Clefting
Facial Development - 4Facial Development - 4thth
- 10- 10thth
week of developmentweek of development
Formed by the fusion of five prominencesFormed by the fusion of five prominences
Unpaired frontonasal processUnpaired frontonasal process
-- lateral/medial nasal processeslateral/medial nasal processes
Paired maxillary swellings
Paired mandibular swelling
Nose/Philtrum of upper lipNose/Philtrum of upper lip
Cheeks/Upper lip (-philtrum)Cheeks/Upper lip (-philtrum)
Lower face (lower lip/chin)

Embryology of CleftingEmbryology of Clefting
Facial DevelopmentFacial Development
Medial nasal processesMedial nasal processes (green) migrate toward
each other and fuse
Inferior tips of medial nasal processes expand
laterally to form the intermaxillary process
Tips of maxillary swellings (yellow) grow to meet the
intermaxillary process and fuse
66thth
weekweek
7th
week
Failure of maxillary swellings to fuse with intermaxillary process = cleft lipFailure of maxillary swellings to fuse with intermaxillary process = cleft lip

Formation of the PalateFormation of the Palate
66thth
weekweek
1) As nasal pits of lateral nasal process invaginate and1) As nasal pits of lateral nasal process invaginate and
fuse, intermaxillary process extends to form primaryfuse, intermaxillary process extends to form primary
palatepalate

88thth
- 9- 9thth
weekweek
2) Medial walls of maxillary processes produce palatine shelves2) Medial walls of maxillary processes produce palatine shelves
3) Shelves grow downwards, parallel to lateral suface of3) Shelves grow downwards, parallel to lateral suface of
tonguetongue
4) End of week 9, rotate upward into a horizontal position4) End of week 9, rotate upward into a horizontal position
and fuse with each other and primary palate to formand fuse with each other and primary palate to form
secondary palatesecondary palate

Cleft VariantsCleft Variants
Great anatomic variation in types of clefts!Great anatomic variation in types of clefts!
Anatomic Classification based on:Anatomic Classification based on:
1) Location1) Location
2) Completeness (Incomplete/Complete)2) Completeness (Incomplete/Complete)
3) Extent3) Extent
Since lip, alveolus, and hard palate differ in embryologicSince lip, alveolus, and hard palate differ in embryologic
origin, any combination can occurorigin, any combination can occur

Iowa ClassificationIowa Classification
Group IGroup I
Clefts of lip onlyClefts of lip only
Group IIGroup II
Clefts of palate only (Clefts of palate only (22oo
))
Group IIIGroup III
Clefts of lip,Clefts of lip,
alveolus, palatealveolus, palate
Group IVGroup IV
Clefts of lip andClefts of lip and
alveolusalveolus (primary(primary
cleft palate andcleft palate and
lip)lip)
Group VGroup V
MiscellaneousMiscellaneous

Striped YStriped Y
1 & 5 - Floor of nose on right & left sides1 & 5 - Floor of nose on right & left sides
2 & 6 - Lip2 & 6 - Lip
3 & 7 - Alveolar ridges3 & 7 - Alveolar ridges
4 & 8 - Premaxilla to incisive foramen4 & 8 - Premaxilla to incisive foramen
9 & 10 - Each half of the hard palate9 & 10 - Each half of the hard palate
11 - Soft palate11 - Soft palate
12 - Congenital velopharyngeal incompetence without obvious clefts12 - Congenital velopharyngeal incompetence without obvious clefts
13 - Protrusion of premaxilla13 - Protrusion of premaxilla

1) Isolated Incomplete1) Isolated Incomplete
Intact skin/muscle between the lip and noseIntact skin/muscle between the lip and nose
Less distortion brought on by abnormal muscle pullLess distortion brought on by abnormal muscle pull
Bilateral/UnilateralBilateral/Unilateral
Cleft LipCleft Lip
Expressed in structures anterior to incisive foramenExpressed in structures anterior to incisive foramen
- prepalatal alveolus, maxilla, lip, nasal structures- prepalatal alveolus, maxilla, lip, nasal structures
Gaping cleft of alveolus/lip structures to mereGaping cleft of alveolus/lip structures to mere
‘scar’ (‘scar’ (forme frusteforme fruste))
Deficiency in skin, muscles, mucous membranes,Deficiency in skin, muscles, mucous membranes,
maxillary/nasal bones, nasal cartilagesmaxillary/nasal bones, nasal cartilages

2) Isolated Complete *2) Isolated Complete *
Bilateral/UnilateralBilateral/Unilateral
Cleft runs entire length of lip to floor of noseCleft runs entire length of lip to floor of nose
Abnormal muscle pull distorts nose extensively and creates wideAbnormal muscle pull distorts nose extensively and creates wide
clefts between the lip segmentsclefts between the lip segments

Isolated Cleft PalateIsolated Cleft Palate
Complete/IncompleteComplete/Incomplete
Soft PalateSoft Palate
-cleft can extend into the hard palate to-cleft can extend into the hard palate to
any extentany extent
Hard PalateHard Palate
Primary Palate (CL)Primary Palate (CL)
Secondary PalateSecondary Palate

Combined CleftsCombined Clefts
Complete lip/palateComplete lip/palate
Incomplete lip/palateIncomplete lip/palate

EpidemiologyEpidemiology
Cleft lip/palate are second most common congenital abnormalitiesCleft lip/palate are second most common congenital abnormalities
Overall incidence of CP w CL and isolated CLOverall incidence of CP w CL and isolated CL
= 1 in 1000 live births= 1 in 1000 live births
Isolated CP = 1 in 2000 live birthsIsolated CP = 1 in 2000 live births
Incidence of CL/P varies with race and genderIncidence of CL/P varies with race and gender
Among total number of clefts:Among total number of clefts:
20% CL (18% unilateral, 2% bilateral)20% CL (18% unilateral, 2% bilateral)
50% CL and CP (38% unilateral, 12% bilateral)50% CL and CP (38% unilateral, 12% bilateral)
30 % CP alone30 % CP alone
Asian>Caucasian>African AmericanAsian>Caucasian>African American
Male>Female (exception isolated cleft palate)Male>Female (exception isolated cleft palate)

EpidemiologyEpidemiology
Clustering noted in particular familiesClustering noted in particular families
Associated with over 150 syndromes!Associated with over 150 syndromes!
Genetic BasisGenetic Basis
Overall incidence of associated anomalies (eg cardiac) = 30%Overall incidence of associated anomalies (eg cardiac) = 30%
Family Makeup Risk of cleft lip/palate Risk of cleft palate
One affected sibling or parent 1 in 25 (4%) 2.5%
Two affected siblings 1 in 11 (9%) 1%
One sibling and one parent 1 in 6 (16%) 15%

Risk increases with parental age (>30yrs; particular paternal age)Risk increases with parental age (>30yrs; particular paternal age)
Environmental FactorsEnvironmental Factors
Viral infections (rubella)Viral infections (rubella)
Teratogens (steroids, anticonvulsants, alcohol, retinoic acidTeratogens (steroids, anticonvulsants, alcohol, retinoic acid
derivatives)derivatives)

Principles of ManagementPrinciples of Management
AssessmentAssessment
IndicationsIndications: restoring normal morphologic form and function: restoring normal morphologic form and function
Important for normal dentition, mastication, speech, hearing, and breathingImportant for normal dentition, mastication, speech, hearing, and breathing
ContraindicationsContraindications: malnutrition, anemia or other conditions that render infant: malnutrition, anemia or other conditions that render infant
unable to tolerate general anesthesiaunable to tolerate general anesthesia
- airway obstruction, otitis media with CP- airway obstruction, otitis media with CP
Work-upWork-up
(1) Thorough PE to uncover any associated anomalies(1) Thorough PE to uncover any associated anomalies
Additional work-up determined by physical findings that suggest involvementAdditional work-up determined by physical findings that suggest involvement
of other organ systemsof other organ systems
(2) Weight, oral intake, growth/development are of primary concern(2) Weight, oral intake, growth/development are of primary concern
and must be followed closelyand must be followed closely
(3) Routine lab studies generally not required; Hgb level before surgery(3) Routine lab studies generally not required; Hgb level before surgery

Surgical ManagementSurgical Management
Multidisciplinary approachMultidisciplinary approach
Beyond lip repair are other issues:Beyond lip repair are other issues:
Hearing (otolaryngologists)Hearing (otolaryngologists)
Speech (speech pathologists)Speech (speech pathologists)
Dental (oromaxillofacial surgeons)Dental (oromaxillofacial surgeons)
PsychosocialPsychosocial
Integration with team-based approachIntegration with team-based approach
Each case is assessed independently by those involved and a global treatment planEach case is assessed independently by those involved and a global treatment plan
is instituted based on present need in his/her developmentis instituted based on present need in his/her development
Cleft Lip and PalateCleft Lip and Palate
NutritionNutrition

Staging and Timing of SurgeryStaging and Timing of Surgery
Different institutions = different practiceDifferent institutions = different practice
Rule of 10’sRule of 10’s
Hgb = 10gHgb = 10g
Weight of 10lbsWeight of 10lbs
Age 10wksAge 10wks
IWK - 6-8 weeksIWK - 6-8 weeks
Cleft LipCleft Lip Cleft PalateCleft Palate
IWK - 9-12 months of ageIWK - 9-12 months of age

Unilateral Complete Cleft LipUnilateral Complete Cleft Lip
Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well definedGoal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined
philtral dimple and columns; natural appearing Cupid’s bow; functionalphiltral dimple and columns; natural appearing Cupid’s bow; functional
muscle repairmuscle repair
Surgical Principle: Lengthen medial side of cleft so that itSurgical Principle: Lengthen medial side of cleft so that it
equals the vertical dimensions of non-cleft sideequals the vertical dimensions of non-cleft side
Flap designs:Flap designs:
1) Triangular (Tennison-Randall)1) Triangular (Tennison-Randall)
2) Quadrangular2) Quadrangular
3) Rotation-advancement (Millard*, Mohler)3) Rotation-advancement (Millard*, Mohler)

Millard TechniqueMillard Technique
Scar placed in more anatomically correct position along philtral column
““Cut as you go” techniqueCut as you go” technique
1) Medial flap rotates downward to1) Medial flap rotates downward to
achieve necessary lengtheningachieve necessary lengthening
2) Lateral flap advances into the defect produced2) Lateral flap advances into the defect produced
by downward displacement of medial flapby downward displacement of medial flap
3) Small pennant-shaped medial flap can be3) Small pennant-shaped medial flap can be
used to restore nostril sill or lengthen theused to restore nostril sill or lengthen the
columellacolumella
Preserves’ cupid’s bow and philtral dimplePreserves’ cupid’s bow and philtral dimple
Tension of closure under the alar base; reduces flair and promotes better molding ofTension of closure under the alar base; reduces flair and promotes better molding of
the underlying alveolar processesthe underlying alveolar processes
In simple medical student terms:In simple medical student terms:

In Complex Resident/Staff Terms:In Complex Resident/Staff Terms:

Post-op ManagementPost-op Management
1) Feedings administered with catheter tip syringe fitted1) Feedings administered with catheter tip syringe fitted
with small red rubber catheter for the first 10 days post-with small red rubber catheter for the first 10 days post-
opop
2) Nipples are avoided to minimize strain on the2) Nipples are avoided to minimize strain on the
muscle/skin suturesmuscle/skin sutures
3) Velcro arm restraints to protect repair from3) Velcro arm restraints to protect repair from
flailing hands/fingersflailing hands/fingers
4) Suture line care: PRN cleansing with half strength4) Suture line care: PRN cleansing with half strength
peroxide followed with polymixin B-bacitracin ointmentperoxide followed with polymixin B-bacitracin ointment
Cleft LipCleft Lip

Scar contractureScar contracture
ErythemaErythema
FirmnessFirmness
Inform the parents of:Inform the parents of:
Avoid placing in direct sunlight until the scar fully maturesAvoid placing in direct sunlight until the scar fully matures

ComplicationsComplications
• AestheticAesthetic
– vermilion-cutaneousvermilion-cutaneous
mismatchmismatch
– vermilion notchingvermilion notching
– tight appearing lateraltight appearing lateral
lip segementlip segement
– lateral muscle buldgelateral muscle buldge
– laterally displaced alalaterally displaced ala
– constricted appearingconstricted appearing
nostrilnostril
• OtherOther
– dehiscencedehiscence
– excessive scarexcessive scar
formationformation

Cleft PalateCleft Palate
Goal: Production of a competent velopharyngeal sphincterGoal: Production of a competent velopharyngeal sphincter
Two most common repairs:Two most common repairs:
1) V-Y (Veau-Wardill-Kilner)*1) V-Y (Veau-Wardill-Kilner)*
2) von Langenbeck2) von Langenbeck
Main difference: V-Y repair involvesMain difference: V-Y repair involves elongation of the palateelongation of the palate, while, while
von Langenbeck does notvon Langenbeck does not

Wardill-KilnerWardill-Kilner
1) Incisions made along free margins of cleft and extend1) Incisions made along free margins of cleft and extend
anteriorly to apexanteriorly to apex
2) Dissection continued posteriorly along oral side of2) Dissection continued posteriorly along oral side of
alveolar ridge to retromolar trigonealveolar ridge to retromolar trigone

3) Mucoperiosteal flaps are elevated from3) Mucoperiosteal flaps are elevated from
nasal/oral surfaces of bony palatenasal/oral surfaces of bony palate
4) Dissection of the greater palatine vessels from4) Dissection of the greater palatine vessels from
the foramen lengthens the pediclethe foramen lengthens the pedicle
5) Tensor veli palatini muscle is elevated off the5) Tensor veli palatini muscle is elevated off the
hamulus to aid in relaxing the midline closurehamulus to aid in relaxing the midline closure

6) Nasal mucosa freed from bony palate6) Nasal mucosa freed from bony palate
and closed to either side, or if necessaryand closed to either side, or if necessary
closed by using vomer flapsclosed by using vomer flaps
7) Muscle and oral mucosa closed in a7) Muscle and oral mucosa closed in a
second single layer in a horizontal fashionsecond single layer in a horizontal fashion

8) Anteriorly, the oral mucoperiosteal flaps are8) Anteriorly, the oral mucoperiosteal flaps are
attached to the third flap (mucosa overlying theattached to the third flap (mucosa overlying the
primary palateprimary palate
9) Posteriorly, the palate is closed in 3 layers9) Posteriorly, the palate is closed in 3 layers
Nasal mucosaNasal mucosa
Levator muscleLevator muscle
Oral mucosaOral mucosa

Cleft PalateCleft Palate
Immediate concerns:Immediate concerns:
1) Airway management1) Airway management
2) Analgesia2) Analgesia
Risk of oversedation and subsequent airway comprimiseRisk of oversedation and subsequent airway comprimise
Acetominophen, Codeine sufficient: cont’d for 7-10 daysAcetominophen, Codeine sufficient: cont’d for 7-10 days
Arm restraints to prevent placing fingers in mouthArm restraints to prevent placing fingers in mouth
Diet restricted to liquids, soft foods (x3wks): bottles avoidedDiet restricted to liquids, soft foods (x3wks): bottles avoided
Change in nasal/oral airway dynamicsChange in nasal/oral airway dynamics

• Airway obstructionAirway obstruction
• Intraoperative bleedingIntraoperative bleeding
• Palatal fistulaPalatal fistula
• Midface abnormalities (early interventions)Midface abnormalities (early interventions)
ComplicationsComplications

Cleft Palate ClinicsCleft Palate Clinics
Through a protocol of sequential, regular evaluations by aThrough a protocol of sequential, regular evaluations by a
team composed of plastic surgeon, speech pathologist,team composed of plastic surgeon, speech pathologist,
orthodontist, and audiologist, great strides have been made inorthodontist, and audiologist, great strides have been made in
improving all aspects of care of the child with cleft palateimproving all aspects of care of the child with cleft palate

Cleft Lip/Palate Reconstruction Guide

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Cleft Lip/Palate Reconstruction Guide

Similar to Cleft Lip/Palate Reconstruction Guide (20)

More from Indian dental academy

More from Indian dental academy (20)

Recently uploaded

Recently uploaded (20)

Cleft Lip/Palate Reconstruction Guide