Cleft

Question 1

Embryology of cleft lip and palate

Answer 1

Upper lips: 
Anterior maxillary alveolus:
Primary palate —->
Failure of fusion of Medial nasal processes + lateral nasal processes + maxillary processes
Happens at 6-7 weeks gestation

Secondary palate:
Failure of Palatal shelves elevation & fusion
8-12weeks gestation

Question 2

Muscles involved in cleft lip

Answer 2

Orbicularis oris

Question 3

Muscles involved in cleft palate

Answer 3

Levator veli palatini
Tensor veli palatini
Palatopharyngeus
Palatoglossus
Uvular

Question 4

Whats the blood supply of palate?

Answer 4

1. Greater & lesser palatine art (branch of DPA)
2. Palatine artery (branch of ascending pharyngeal art)
3. Ascending palatine branches of facial art
4. Tonsillar br of dorsalis linguae

Question 5

Diagnosis of cleft

Answer 5

Prenatal diagnosis - transvaginal ultrasound at 12wks gestation (More accurate after 20wks)

• experience of operator
• gestational age at time of study
• indication of the study
• technology used

Question 6

When is cleft deformity detectable prenatal

Answer 6

Prenatal USG at approx 15 weeks

• lip more easily seen in coronal
• palate at axial view

Question 7

Name some feeding aids for cleft babies

Answer 7

Mead Johbson compressible bottle
Pigeon Nipple - modified nipple that is longer
Haberman - one way valve

Question 8

Considerations in their feeding

Answer 8

They swallow more air
Feed upright at 45degree
Burp frequently

Question 9

Cleft classification

Answer 9

unilateral vs bilateral
complete vs incomplete
cleft of lip, nose, alveolus (primary palate), palate (secondary palate)

LAHSHAL
Eg: right complete cleft lip 
LA——-
Left incomplete cleft lip, with right conplete cleft palate
- - H S - - L

Question 10

Issues in cleft patients

Answer 10

1. Feeding
2. Ear infection
3. Speech impairment (VPI)
4. Midface growth restriction

Question 11

Consequences of unrepaired cleft palate

Answer 11

1. unable to achieve suction
2. nasal regurg
3. hypernasal speech
4. recurrent ear infection
5. breathing problems esp if assoc. with retruded chin like in pierre robin sequence
6. malocclusion where teeth angled into cleft

Question 12

Give the timing of surgical correction of cleft patients

Answer 12

1. Cleft lip repair- Rule of 10s (10lbs, 10g/dL, 10 weeks)
2. Primary palate repair - 6-9months; 12-18mo in devolepmental delay kids/syndromic kids
3. VPI tx - 3-5 yes of age (depending on speech development)
4. ABG with cancellous bone and BMP - early secondary grafting to allow eruption of incisors
5. ABG with illiac autografts - 9-12yrs of age depending on canine/lat incisor development to allow their eruption
6. Cleft orthognathic surgery - 16 - 18 until skeletal development matured
7. Cleft rhinoplasty - once skeletal maturation achieved after ogs
8. Lip revision - any time

Question 13

Issues or anatomical defect in cleft lip (UCLP)

Answer 13

Soft tissue:
Discontinuity of the skin, muscle and oral mucosa
Vertical soft tissue deficiency on cleft side
Muscle:
Medial muscle attaches to the base of columella
Lateral muscle attached to the alar base
Nasal:
Rotation of septum, columella and nasal spine away from cleft side
Separation of domes of alar cartilages at nasal tip
Kinking of lateral crus
Displacement and flattening of nasal bone

Question 14

Issues of BCLP

Answer 14

Central segment contains prolabium and premaxilla and short columella
Alar domes and middle crura are splayed, caudally rotated (bucket handle)

Question 15

Timing of lip repair

Answer 15

Rule of 10s
10weeks age
10lbs weight
10g/dL Hb

Question 16

Lip repair

Answer 16

Lip adhesion
Millards rotation advancement flap
Tennison randall triangular flap
Delaire

Question 17

What are important steps in lip repair

Answer 17

Skin incision design (symmetry, equal lip length, cupids bow, inconspicuous scarring)
Sub periosteal mobilization
Muscle repair
Nasal floor restoration
Alar base positioning and primary nasal dissection

Question 18

Debate about timing of palate repair

Answer 18

10-12 months vs 18-24months

speech development vs palate growth and occlusion

Question 19

What are goals of palate repair

Answer 19

1. obtain 3 layered closure at soft palate, 2 layered closure at hard palate
2. recreate normal anatomy and function of soft palate musculature (esp LVP)
3. preserve facial growth

Question 20

List techniques for palate repair

Answer 20

Vomer flap 
Langenback palatoplasty
Bardach 2 flap palatoplasty
Furlow z plasty
Intravelar veloplasty ( sommerlad microsurgical recons of LVP)
V-Y pushback Wardhill-Killner

Question 21

Describe the Sommerlad technique used most commonly in the UK

Answer 21

Sommerlad technique - to repair cleft palate
AKA Radical microdissection
1. Incision of cleft margin
2. Mobilization of mucoperiosteum
3. Dissection of oral mucosa from muscle and nasal layer
4. Suturing of the nasal lining
5. Dissection of muscle layer from the nasal layer keeping the nasal layer intact
6. Muscle layer esp the LVP is realigned transversely and sutured
7. Oral mucosa closure
8. Lateral releasing incisions to reduce tension in the midline
9. May use buccal fat pad flap to close any gaps at the sides

Question 22

Common postop complication for palate repair

Answer 22

Hypernasal speech
Fistula at either ends (anterior or posterior)
Restriction of maxillary growth (late complication)

Question 23

Describe Langhenback palatoplasty

Answer 23

2 flap palatoplasty where incision is made along the cleft margin and alveolar margin and maintaining the anterior attachment to make it a bipedicled flap - greater palatine vessels and incisive vessels.

Question 24

Vomer flap

Answer 24

Uses the vomer mucoperiosteum to close the cleft

- mucoperiosteal flap raised and can be used as nasal lining or oral lining

Question 25

Advantages of vomer flap

Answer 25

Simple surgery | Similar tissue with nasal lining

Question 25

Disadvantages of vomer flap

Answer 25

It has varying size and visibility (if small and not visible- unable to use vomer flap) Not aesthetically same with oral mucosa Affects the midfacial growth

Question 26

Timing of ABG

Answer 26

Primary - 0-2yrs usually at time of lip repair Early secondary 2-5 yrs - prior to eruption of incisors and grafted using BMPS only Late secondary 5-12yrs - when 1/2 or 2/3 of canine root is formed and using autologous bone graft from anterior iliac crest for its abundant marrow Late - >12yrs after canines erupted

Question 27

Objectives of ABG

Answer 27

``` Provide alveolar arch stability Restore arch continuity Allow tooth to erupt Provide bone for orthodontic alignment Close oronasal fistula Recreate piriform rim and provide support to alar base Optimize orthognathic surgery Create platform for prosthetic replacement ```

Question 28

Investigations required prior to ABG

Answer 28

OPG, Occlusal, Periapical, CBCT - to assess presence and position of unerupted teeth at cleft area - to look at the root formation of unerupted teeth - to see the size and extent of cleft

Question 29

Principles of surgery

Answer 29

1. Mucoperisoteal flap raised on both buccal and palatal sides of cleft 2. Nasal dissection superiorly to pyriform rim and nasal floor 3. Recons of nasal floor & nasal seal +/- collagen membrane 4. Bone filled between nasal and oral layer, bridging the alveolar segments, extending posteriorly into palatal cleft area, superiorly to nasal floor, laterally to paranasal region 5. Overfilling recommended as it will resorb 30% 6. Transpositional flap bringing the flap medially to seal orally 7. Lateral buccal relieving site will leave exposed bone and allowed to heal secondarily

Question 30

Parameters to look for success of alveolar bone grafting

Answer 30

1. Success of fistula closure 2. Eruption of impacted teeth 3. Bony support for adjacent teeth

Question 31

How to assess outcome of ABG

Answer 31

Assess using occlusal/panaromic/cbct to assess bone height and width ``` Bergland scale: comparing level of interdental septum on graft side to normal side I. Normal height II. >75% of normal height III. 50-75% of normal height IV. <50% of normal height ```