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summary of management of cleft lip and palate
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Part -2 REVISION & REVIEW
PROBLEMS AND MANAGEMENTThe Neonatal PeriodThe Neonatal Period & InfancyThe Toddler YearsThe School YearsThe Teenage YearsControversies Conclusion
The Neonatal PeriodPROBLEMS
COSMESISSUCKLING SWALLOWING & FEEDING
Breast Feeding may not be Possible Special Bottles- Droppers, Spoons
ASPIRATION Pneumonia During Feeding
Patience is needed In Sleep –Regurgitation
Burping Sleeping in Lateral or Prone position
The Neonatal PeriodPROBLEMS (contd)
MIDDLE EAR Eustachion tube dysfunction (22% to 88%) CSOM HEARING LOSS SPEECH DEFECT Abnormal curvature of the eustachian tube lumen Abnormal insertions of the tensor and levator veli palatini
muscles into the cartilages Reflux of food into the tube REPEATED TYMPANOSTOMY TUBE PLACEMENT
The Neonatal Period & InfancyPROBLEMS (contd)
PROTRUDING PREMAXILLA Presurgical Nasoalveolar MouldLatham ApplianceGrayson, presurgical nasal alveolar moulding (PSNAM)
Grayson’s Latham’s
Management Schedule
PALATAL OBTURATOR
LIP REPAIR
SOFT PALATE REPAIR
HARD PALATE REPAIR
TYMPANOSTOMY TUBE
PHAYNGOPLASTY
BONE GRAFTING
ORTHODNTICS
COSMETIC REVISIONS
AGE
MONTHS YEARS
0 3 6 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
The Neonatal Period & InfancyREPAIR OF LIP
Unilateral Various methods Most Commonly used MILLARD’s
Z-PLASTY ON MUCOSAL SURFACE
A
B
C
MUCOSAL FLAPS FOR RECON NASAL FLOOR
MEDIAL FLAP LATERAL FLAP MEDIAL FLAP LATERAL FLAP
The Neonatal Period & InfancyREPAIR OF LIP
Unilateral Residual Deformity
AT STITCH REMOVAL
AT STITCH REMOVAL
SMALL NOSTRIL ALA?
PERFECT WHITE ROLL
ALAR DEFORMITY
VERMILLION BULGE
AT 8 YEARS
GOOD PALATE REPAIR
The Neonatal Period & InfancyREPAIR OF LIP
Unilateral Residual Deformity
SHORT UPPER LIP
TIGHT WHITE ROLL
DEPRESSED ALAR CARTILAGESTEP DEFORMITY
PERFECT WHITE ROLL
VERMILLION BULGE
ALAR BASE ROTATED UP
LIP LONGER ON CLEFT SIDE
AT PALATE REPAIR
The Neonatal Period & InfancyREPAIR OF LIP
Unilateral Residual Deformity
AT PALATE REPAIR
AT STITCH REMOVAL
AT 3YEARS AGE
PER OPERATIVE
NEAR PERFECT RESULTS
The Neonatal Period & InfancyREPAIR OF LIP
Bilateral Problems The premaxilla is extremely protrusive The premaxilla and prolabium can be of variable size The columella is deficient/almost nonexistent Prolabium is devoid of muscles
The Neonatal Period & Infancy Protruding Pre Maxilla
Presurgical Naso Aleolar MouldingSurgical Set-BackAggressive Advancement
NOSE
PROLABIUM
PREMAXILLA
VOMER
PREMAXILLARY-VOMERINE SUTURE
RESECTION OF VOMER
BEFORE RESECTION AFTER RESECTION OF VOMER
UPPER LIP
The Neonatal Period & InfancyREPAIR OF LIP
Bilateral Methods
ManyMillard’s Procedure : St line repair
FOR INCOM PLETE CLEFT
FOR COMPLETE CLEFT
The Neonatal Period & InfancyMyoplastic Repair
INCISION LINES
PROLABIUM LIFTED OFF PREMAXILLA
REPAIR OF MUSCLESWHITE ROLL EXCISED
INCISION LINES DE-EPITHELIZED
PROLABIUM LIFTED OFF PREMAXILLA
REPAIR OF MUSCLES
INCISION IN GINGIVO-BUCCAL SULCUS WITH A CUT-BACK
PRE-OP STITCH REMOVAL PALATE REPAIR
The Neonatal Period & InfancyREPAIR OF PALATE
Timing : 9-18 months SPEECH/ MAXILLARY HYPOPLASIASoft palate: FIRST?Hard palate : TOGETHER
The Neonatal Period & InfancyREPAIR OF PALATE
1. Schweckendick’s Primary Veloplasty2. V-Y Pushback3. Von Langenbeck Palatal Repair4. Furlow Palatoplasty
SCHWECKENDICK’S
WARDILL’S PUSH-BACKWARDILL’S
The Neonatal Period & InfancyREPAIR OF PALATE
1. Schweckendick’s Primary Veloplasty2. V-Y Pushback3. Von Langenbeck Palatal Repair4. Furlow Palatoplasty
FURLOW’S PALATOPLASTY
INCISIONS PALATAL MUCOSA INCISIONS NASAL MUCOSA
LEVATOR PALATII LEVATOR PALATII VON LANGENBECK’S
The Toddler YearsPRIORITY: SPEECHVELOPHARYNGEAL DYSFUNCTION
A. VELOPHARYNGEAL MISLEARNING SPEECH THERAPYi.e. Phoneme Specific Nasal Air Emission”
B. VELOPHARYNGEAL INCOMPETENCY SURGERY i.e.“Apraxia neurological deficit
C. VELOPHARYNGEAL INSUFFICIENCY SURGERY i.e. Anatomical deficit
The Toddler YearsPriority: Speech
“CLEFT ERRORS OF SPEECH” in 30% PRIMARY ERROR - due to VPD (hypernasality)
consonants are most difficult sounds (plosives) SECONDARY ERROR - due to attempted correction
Glottic Stops, Nasal GrimaceVELOPHARYNGEAL DYSFUNCTION
Diagnosed By Fiberoptic Laryngoscopy Or Ba-swallow Surgical Repair After Failed Speech Therapy - Usually
Around Age 4
SIGNS AND SYMPTOMSHistory of NASAL REGURGITATION post cleft
palate repairHistory of need for multiple placement of PE tubesNasal GRIMACEHOARSE Vocal Quality Decreased INTELLIGIBILITY
VELOPHARYNGEAL DYSFUNCTION
Surgical TechniquesVELOPHARYNGEAL
INCOMPETENCESuperior Based
Pharyngeal FlapSphincter
Pharyngoplasty Palatopharyngeus
Complications CONTINUED VPI STENOTIC SIDE
PORTS
The Toddler YearsGrowth hormone deficiency
40 Times More Common In CLAPSUSPECT: when below 5% on growth chart
The School YearsThree primary issues
ORTHODONTICS Poor Occlusion Congenitally Absent Teeth
ALVEOLAR BONE GRAFTING Fills Alveolar Defect - Around Age 12
PSYCHOLOGICAL GROWTH Considered Standard Of Care
The Teenage YearsMIDFACE RETRUSION
ETIOLOGY - ?Early Palatal Repair CORRECTIVE OSTEOTOMY: Around Age 18
PSYCHOLOGICAL DEVELOPMENT Counseling Standard Of Care
RHINOPLASTY Usually Last Procedure Performed, Around Age 20
Surgical TechniquesAlveolar Bone
GraftingIliac Crest Bone GraftComplications
Infected Donor Site Hematoma
Failed Graft Dehiscence Palatal Prosthesis
Surgical TechniquesMidfacial Advancement
LeForte(I,II,III) Osteotomies Leave Vascular Pedicle
Attached In Back Of Maxilla - Prevents Necrosis
Complications Malocclusion Infection Necrosis
Surgical TechniquesRhinoplasty
Standard Techniques Tip: Projection Alar: Rotation/Buckling/
Base/ Alar Facial angle Columellar : Length/
Rotation of cruraComplications
Alar Stenosis
Controversies: Otologic Disease>90% have COME (chr. otitis media + effusion)
Robinson, et al prospective, 150 patients - 92%
Muntz, et al. retrospective, 96%
Pathology: Eust.Tube Dysfunction (controversial) abnormal muscular attachment/abnormal canal Huang, et al. - Cadaveric study
palatal repair restores ET function. ?Midface growth?
Controversies:Timing of RepairEARLY REPAIR
ADVANTAGE: improved speech Rohrich, et. al; retrospective study. The earlier the repair, the
better speech. DISADVANTAGE: worsening midface retrusion
Rohrich, et. al; people with unrepaired palates have less midface retrusion
Controversies: VPISurgical Repair
Reserved for failure of speech therapyPHARYNGEAL FLAP - superiorly based
Advantage: time tested, severe cases Disadvantage: passive obturator
SPHINCTER PHARYNGOPLASTY (palatopharyngeus rotation flap) Advantage: active sphincter Disadvantage: new technique
ControversiesPresurgical Nasal
Alveolar Moldingmolds palate, alveolus
and nose Advantage: excellent
early results Disadvantage: no long
term resultsGrayson, et al. (2009)
Conclusion and Future DirectionsMultidisciplinary approachNot merely a “surgical problem”Evaluation of controversies for Consensus
Alveolar bone grafting: PRE-OR POST- ORTHODONTICS
PSNAM? (Pre Surgical Nasoalveolar Moulding)Pharyngoplasty vs. pharyngeal flap