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Postoperative deformities of the upper lip and palate: etiology, pathogenesis, clinical features, surgical treatment of deformities. Voles of the maxillofacial area, salivary glands, etiology, symptoms, diagnosis, surgical treatment. Cleft Variants. Great anatomic variation in types of clefts!.

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slide1
Postoperative deformities of the upper lip and palate: etiology, pathogenesis, clinical features, surgical treatment of deformities. Voles of the maxillofacial area, salivary glands, etiology, symptoms, diagnosis, surgical treatment.
cleft variants
Cleft Variants

Great anatomic variation in types of clefts!

Anatomic Classification based on:

1) Location

2) Completeness (Incomplete/Complete)

3) Extent

Since lip, alveolus, and hard palate differ in embryologic origin, any combination can occur

Clinical Aspects of Cleft Lip/Palate Reconstruction

iowa classification
Iowa Classification

Group I

Clefts of lip only

Group II

Clefts of palate only (2o)

Group III

Clefts of lip, alveolus, palate

Group IV

Clefts of lip and alveolus (primary cleft palate and lip)

Group V

Miscellaneous

Clinical Aspects of Cleft Lip/Palate Reconstruction

cleft variants1
Cleft Variants

Cleft Lip

Expressed in structures anterior to incisive foramen

- prepalatal alveolus, maxilla, lip, nasal structures

Deficiency in skin, muscles, mucous membranes, maxillary/nasal bones, nasal cartilages

1) Isolated Incomplete

Bilateral/Unilateral

Intact skin/muscle between the lip and nose

Less distortion brought on by abnormal muscle pull

Gaping cleft of alveolus/lip structures to mere ‘scar’ (forme fruste)

Clinical Aspects of Cleft Lip/Palate Reconstruction

slide8
2) Isolated Complete *

Bilateral/Unilateral

Cleft runs entire length of lip to floor of nose

Abnormal muscle pull distorts nose extensively and creates wide clefts between the lip segments

Clinical Aspects of Cleft Lip/Palate Reconstruction

cleft variants2
Cleft Variants

Isolated Cleft Palate

Primary Palate (CL)

Secondary Palate

Soft Palate

Hard Palate

Complete/Incomplete

-cleft can extend into the hard palate to any extent

Clinical Aspects of Cleft Lip/Palate Reconstruction

cleft variants3
Cleft Variants

Combined Clefts

Complete lip/palate

Incomplete lip/palate

Clinical Aspects of Cleft Lip/Palate Reconstruction

surgical management
Surgical Management

Cleft Lip and Palate

Multidisciplinary approach

Beyond lip repair are other issues:

Hearing (otolaryngologists)

Speech (speech pathologists)

Dental (oromaxillofacial surgeons)

Nutrition

Psychosocial

Integration with team-based approach

Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her development

Clinical Aspects of Cleft Lip/Palate Reconstruction

surgical management1
Surgical Management

Staging and Timing of Surgery

Different institutions = different practice

Cleft Lip

Cleft Palate

Rule of 10’s

IWK - 9-12 months of age

Hgb = 10g

Weight of 10lbs

Age 10wks

IWK - 6-8 weeks

Clinical Aspects of Cleft Lip/Palate Reconstruction

surgical management2
Surgical Management

Unilateral Complete Cleft Lip

Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral dimple and columns; natural appearing Cupid’s bow; functional muscle repair

Surgical Principle: Lengthen medial side of cleft so that it equals the vertical dimensions of non-cleft side

Flap designs:

1) Triangular (Tennison-Randall)

2) Quadrangular

3) Rotation-advancement (Millard*, Mohler)

Clinical Aspects of Cleft Lip/Palate Reconstruction

millard technique
Millard Technique

“Cut as you go” technique

Preserves’ cupid’s bow and philtral dimple

Scar placed in more anatomically correct position along philtral column

Tension of closure under the alar base; reduces flair and promotes better molding of the underlying alveolar processes

In simple medical student terms:

1) Medial flap rotates downward to achieve necessary lengthening

2) Lateral flap advances into the defect produced by downward displacement of medial flap

3) Small pennant-shaped medial flap can be used to restore nostril sill or lengthen the columella

Clinical Aspects of Cleft Lip/Palate Reconstruction

slide15
In Complex Resident/Staff Terms:

Clinical Aspects of Cleft Lip/Palate Reconstruction

post op management
Post-op Management

Cleft Lip

1) Feedings administered with catheter tip syringe fitted with small red rubber catheter for the first 10 days post-op

2) Nipples are avoided to minimize strain on the muscle/skin sutures

3) Velcro arm restraints to protect repair from flailing hands/fingers

4) Suture line care: PRN cleansing with half strength peroxide followed with polymixin B-bacitracin ointment

Clinical Aspects of Cleft Lip/Palate Reconstruction

post op management1
Post-op Management

Inform the parents of:

Scar contracture

Erythema

Firmness

Avoid placing in direct sunlight until the scar fully matures

Clinical Aspects of Cleft Lip/Palate Reconstruction

post op management2
Aesthetic

vermilion-cutaneous mismatch

vermilion notching

tight appearing lateral lip segement

lateral muscle buldge

laterally displaced ala

constricted appearing nostril

Other

dehiscence

excessive scar formation

Post-op Management

Complications

Clinical Aspects of Cleft Lip/Palate Reconstruction

surgical management3
Surgical Management

Cleft Palate

Goal: Production of a competent velopharyngeal sphincter

Two most common repairs:

1) V-Y (Veau-Wardill-Kilner)*

2) von Langenbeck

Main difference: V-Y repair involves elongation of the palate, while von Langenbeck does not

Clinical Aspects of Cleft Lip/Palate Reconstruction

wardill kilner
Wardill-Kilner

1) Incisions made along free margins of cleft and extend anteriorly to apex

2) Dissection continued posteriorly along oral side of alveolar ridge to retromolar trigone

Clinical Aspects of Cleft Lip/Palate Reconstruction

wardill kilner1
Wardill-Kilner

3) Mucoperiosteal flaps are elevated from nasal/oral surfaces of bony palate

4) Dissection of the greater palatine vessels from the foramen lengthens the pedicle

5) Tensor veli palatini muscle is elevated off the hamulus to aid in relaxing the midline closure

Clinical Aspects of Cleft Lip/Palate Reconstruction

wardill kilner2
Wardill-Kilner

6) Nasal mucosa freed from bony palate and closed to either side, or if necessary closed by using vomer flaps

7) Muscle and oral mucosa closed in a second single layer in a horizontal fashion

Clinical Aspects of Cleft Lip/Palate Reconstruction

wardill kilner3
Wardill-Kilner

8) Anteriorly, the oral mucoperiosteal flaps are attached to the third flap (mucosa overlying the primary palate

9) Posteriorly, the palate is closed in 3 layers

Nasal mucosa

Levator muscle

Oral mucosa

Clinical Aspects of Cleft Lip/Palate Reconstruction

post op management3
Post-op Management

Cleft Palate

Immediate concerns:

1) Airway management

Change in nasal/oral airway dynamics

2) Analgesia

Risk of oversedation and subsequent airway comprimise

Acetominophen, Codeine sufficient: cont’d for 7-10 days

Arm restraints to prevent placing fingers in mouth

Diet restricted to liquids, soft foods (x3wks): bottles avoided

Clinical Aspects of Cleft Lip/Palate Reconstruction

post op management4
Post-op Management
  • Airway obstruction
  • Intraoperative bleeding
  • Palatal fistula
  • Midface abnormalities (early interventions)

Complications

Clinical Aspects of Cleft Lip/Palate Reconstruction

problems in cleft lip and cleft palate
Problems in Cleft Lip and Cleft Palate
  • Feeding
  • Frequent upper respiratuary tract infection
  • Frequent gas regurtation
  • Otitis media
  • Nasal regurtation of food
  • Aspiration pneumenia
  • Growing retardation
  • Other anomalies
  • Psycological problems (family)
cleft lip and palate treatment team
Cleft lip and palate treatment team
  • Surgeon experienced in cleft management
  • Pediatrist
  • Orthodontist
  • Pediatric Otorhinolaryngologist
  • Pediatric dentist
  • Geneticist
  • Spech Terapist
  • Social Worker
  • Nurse experienced in cleft problems
feeding rules
Feeding Rules
  • Swallowing is not impaired, oral feeding is possible
  • Bottle feed with additional cross cut in the end
  • Elastic plastic bottle
  • Bulb syringe with a nipple
  • Feeding with a spoon
  • The child should be held in a head-up position at about 45 º during and after feeding
  • Lateral position during sleeping
when to operate
When to Operate

Generally (Rules of 10’s)

  • Weight > 10 pound (4500 gr)
  • Hb > 10 gr
  • Age > 10 weeks

Cleft lips between 3-6 months

Cleft palate between 12-18 months (preferred before speech devolops)

cleft lip treatment
Cleft Lip Treatment
  • Cleft lip
      • Mikroform cleft lip
      • Unilateral cleft lip
      • Bilateral cleft lip
  • Associated nasal deformity is classified as mild, moderate or severe
  • Alveolar arc position evaluated. If necessary “presurgical maksiller orthodontics” applied
slide36
Surgical technique for unilateral cleft lip

(Millard Rotation-Advancement)

slide38
Surgical technique for unilateral cleft lip and palate

Millard techniques provides primary lip and nasal repair . It is possible “gingivoperiostoplasy” after “Presurgical maksiller ortopedics”

slide39
Pre -Orthodontic treatment

After 3 months of Grayson molding plate application

a m kul right unilateral primary and secondary cleft palate
A.M.Kul, right unilateral primary and secondary cleft palate

Pre -Orthodontic therapy

After 3 months of Grayson molding plate application

bilateral cleft lip
Bilateral Cleft Lip
  • More complex and difficult to treat
      • Projectil premaksilla
      • Broad and flared nasal tip
      • Prolabium
      • Short columella or absent columella
  • Incomplet or complet
  • It is important to retropositon the premaksilla with presurgical orthopedic treatment
  • Surgical techniques used for unilateral cleft lip repair are used for bilateral cleft lip repair in one or two stage operation (Millard, Tennison...)
treatment of premaksilla
Treatment of Premaksilla
  • Lip repair or “Lip-adeshion”
  • Elastic traction ( with a Head Bonnett)
  • Premaksillary retantion (Latham)
  • Nazoalveoler molding (Grayson)
  • Surgical premaksilla excision or set-back (severe maxillary retrusion)
slide57
Bilateral Incomplet Cleft lip Operation Technique

Straight Line Closure (One stage)

cleft palate
Cleft Palate
  • Palate and palatal muscles close the velopharengeal valve
  • Velofarengial closure can not be done in cleft palate patient.
  • Patient can not create intraoral pressure
  • Feeding and speach are effected
problems with cleft palate
Problems with cleft palate
  • Feeding
  • Speech
  • Hearing and middle ear problems
  • Additional anomalies (% 30)
  • Psychological problems
goal of palatal repair
Goal of Palatal Repair
  • Understanble speech
  • No maxillary retrusion
  • No hearing problem
  • Good occlusion
slide65
Surgical treatment of isolated cleft palate

Von Langenback Method

“Double opposing Z Plasty”

pierre robin sequence
Pierre Robin Sequence
  • Micrognathy
  • Glossoptosis
  • Airway obstruction

Cleft palate( % 50 )

Breathing and feeding problem

treatment of velopharyngeal insufficency
Treatment of Velopharyngeal Insufficency
  • Patient should evaluate by speech terapist before any treatment
  • Nasendoscopic evaluation and Multiview videofluoroscopy is importany diagnostic tests
  • Goal is to provide normal velopharyngeal anatomy
surgical treatment of velopharyngeal insufficency
Surgical Treatment of Velopharyngeal Insufficency
  • Pharyngeal Flaps (Superior, inferior pedicled)
  • Pharyngoplasty (Hynes, Orticochea)
  • Soft palate lengtening and levator muscle repair
  • Posterior wall augmentation (teflon, proplast)
other operations
Other Operations
  • Fistula Repair
  • Velopharyngeal Insufficency correction (5 yeras)
  • Secondary Onarımlar (preschool age)
  • Alveolar bone grafting (before canine theth eruption)
  • Orthodontic Surgery (12-14 years)
      • (Le-Fort I Maksillary osteotomy, Mandibular split ramus osteotomy)
  • Rhinoplasty (16-18 years)
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