Cleft Lip And Palate Surgery
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A cleft forms when the failure of normal lip and/or palate development leaves a gap or channel in the lip and/or palate. The severity can range from an isolated unilateral cleft lip or palate to having a bilateral cleft lip and palate.
A patient may have an isolated cleft lip or palate, or a combination of both.
These are the most severe of congenital anomalies which affect the mouth and related structures. The roof is shaped from the palate and flooring from the constructions at the floor of the mouth. Laterally, it's bounded from the cheeks. A cleft is a congenital abnormal space or gap in the upper lip, alveolus, or palate.
Overall incidence of cleft lip and palate is approximately 1 in 600 to 800 live births (1.42 in 1000) and isolated cleft palate occurs approximately in 1 in 2000 live births. Thus, the typical distribution of cleft types are (Gaurishankar S. Textbook of orthodontics. 1st ed. Paras Medical Publication; 2011)
The potential problems of the condition include social handicaps such as impaired suckling and resultant failure to thrive, speech impediment, deafness, malocclusion, gross facial deformity and severe psychological problems. The clefting of lip and/or palate occurs at such a strategic place in the orofacial region, at such a crucial time (before birth) that it becomes a complex congenital deformity( Gaurishankar S. Textbook of orthodontics. 1st ed. Paras Medical Publication; 2011.)
Patient with oro-facial cleft deformity needs to be treated at right time and at right age to achieve functional and aesthetic well-being. The treatment process is complex, multidisciplinary and interdisciplinary approach. (Banerjee M, Dhakar A. Epidemiology-clinical profile of cleft lip and palate among children in india and its surgical consideration.) Successful management of the child born with a cleft lip and palate requires coordinated care provided by a number of different specialties including oral/maxillofacial surgery, otolaryngology, genetics/dysmorphology, speech/language pathology, orthodontics, prosthodontics, and other. This successful reconstruction routinely requires multiple phase of surgical intervention.
The cause of clefts among most babies is unknown. It is widely agreed that clefts usually arise from a combination of genetic and environmental factors during pregnancy. They may also arise due to a genetic syndrome.
Risk factors which increase the risk of a baby being born with a cleft include:
Around 15% of clefts arise secondary to a genetic syndrome, where a genetic mutation results in a wide range of birth defects.Some of these conditions include microdeletion syndrome (DiGeorge), Pierre-Robin sequence and Treacher-Collins syndrome.
A cleft lip is usually diagnosed during the anomaly ultrasound scan during weeks 18-21 of pregnancy.
If it is not diagnosed then, it should be picked up immediately after birth or during the newborn physical examination (NIPE) within 72 hours of birth. This examination includes direct visualisation of the hard and soft palate using a torch and a tongue depressor
When a cleft lip or palate is diagnosed, the family is immediately referred to a specialist multidisciplinary cleft team and seen by a cleft specialist nurse within 24 hours.
An untreated cleft lip or palate can cause several problems.
A specialist cleft nurse will visit within 24-48 hours of birth to provide information and support. The first few months after diagnosis involve giving the family support and information on the diagnosis and ensuring that the baby grows adequately to allow future surgery.
Initial management requires a multidisciplinary approach
CInitial cleft lip surgery is usually performed when the child is at least three months old.
This typically takes 1 to 2 hours to complete under general anaesthetic. Patients are typically required to stay in hospital overnight and can usually return home once they are drinking adequately and are comfortable
Potential complications of cleft lip repair may include
One commonly used surgical technique to repair a unilateral cleft lip is the rotation-advancement technique, which is also known as the Millard technique.
This technique involves making several incisions in the lip to create a rotational flap from the medial segment of the cleft and an advancement flap from the cleft’s lateral segment. These flaps can then be brought together and sutured to correct the cleft in the muscle, subcutaneous tissue and skin.
Palatoplasty to repair a cleft palate usually takes place when the child is 6-12 months old so the child’s cleft palate will not prevent adequate speech and language development.
The aim is to correct the palatal defect and reattach the soft palate muscles to create a normally functioning velopharyngeal mechanism.the velopharyngeal mechanism
The velopharyngeal mechanism functions to separate the oral and nasal cavities during swallowing and speech.
The velopharyngeal port is the passage between the nasopharynx and oropharynx. The velopharyngeal mechanism consists of a muscular valve that extends from the back of the hard palate to the posterior pharyngeal wall and includes the soft palate (the velum) and the sides of the throat (lateral pharyngeal walls).
Several different velopharyngeal muscles contract when swallowing to close off the velopharyngeal port by creating a tight seal between the velum and pharyngeal walls, thus preventing communication between the oral and nasal cavities.
The most important muscle to reconstruct is the levator veli palatini as it elevates the soft palate during swallowing and speech. It is therefore essential for the velopharyngeal mechanism. Failure to reattach this muscle properly can lead to velopharyngeal insufficiency and result in nasal reflux during swallowing and hypernasal speech
After the initial repair of their cleft lip and/or palate, patients will require regular follow-up until they are around 20 years of age. This may include.
Following a palatoplasty, the tissues may heal in such a way that an oronasal fistula through the palate is created. This may cause nasal regurgitation during swallowing and speech problems, and so is often closed in a palate revision surgery (secondary palatoplasty).
Speech surgery may be offered to children aged 4-6 who still have hypernasal speech from velopharyngeal mechanism insufficiency, despite their cleft palate being closed.
Such speech operations include palatal lengthening with a double-opposing Z-palatoplasty (Furlow’s) or a posterior pharyngeal flap secondary palatoplasty, which is where a square of tissue from the back of the throat is attached to the palate, can be used to block some of the air leaking from the nose.
An alveolar bone graft is performed when there is insufficient bone around the alveolar (gum line) defect for the adult teeth to erupt properly.
Bone marrow (cancellous bone) is taken from the iliac crest and grafted into the cleft defect to improve the bone support for the adult teeth and allow the orthodontist to align the teeth in the cleft area.
This procedure is usually completed at around 9-11 years old, once all the baby teeth have been lost, but before the child’s lateral incisors or upper canines have erupted through the gum.
Revision surgery can be completed at any age to improve the contour or shape of the lip and/or nose. However, it is often suggested to delay revision surgery until the patient has finished growing at around 16 years of age or older to prevent the need for extra revision surgeries.
Orthognathic surgery involves re-aligning the upper and lower jaws to improve the function of the patient’s bite and side profile. It is offered when there are jaw problems which can’t be treated with orthodontics alone. Orthognathic surgery is performed by a maxillofacial surgeon in conjunction with an orthodontist.
Jaw surgery is completed after growth stops, which is usually around the age of 14-16 years in girls and 17-21 years in boys.
A restorative dentist may replace missing teeth with fixed or removable prosthetics, and tooth-coloured fillers can be used to reshape the teeth to improve how they look. They can also treat any complex gum or tooth root issues.
This treatment can often not be completed until all the patient’s orthodontic treatment has been completed and all their adult teeth have erupted.