© Borgis - New Medicine 1/2001, s. 30-32
Zofia Dudkiewicz, Maria Hortis-Dzierzbicka
Early surgical management of unilateral and bilateral cleft lip and palate - standards of care
Department of Paediatric and Adolescent Surgery National Research Institute for Mother and Child, Warsaw, Poland Centre of Craniofacial Disorders
Head: Associate Professor Zofia Dudkiewicz, M.D.
This paper presents standards for early surgical treatment of unilateral and bilateral cleft lip and palate as well as isolated cleft palate, developed and in use at the Centre for Craniofacial Disorders National Research Institute for the Mother and Child, Warsaw, Poland. The authors discuss the arguments for such an approach, in the light of modern views on factors influencing maxilla growth and speech development in patients with orofacial clefts.
Clefts of the lip and palate result in a functional imabalance of structures forming the facial portion of the skull and in deformities affecting the external facial appearance, dental relationships, craniofacial growth, ENT status and speech. In view of the multi-disciplinary character of treatment and rehabilitation, combined with the need for long-term follow-up of surgical results, quality and effectiveness of multi-stage treatment, the establishment of specialist centres to treat these defects is warranted, as is the establishment of databanks that might facilitate the development of standards.
The management of children with cleft lip and/or palate begins within the first year of life, and may be continued until the patient is 19-20 years old. Surgical procedures and other forms of therapy undertaken in the early period affect the patient´s vital functions and appearance throughout life. This is why it is of paramount importance to document all forms of therapy and the outcome, starting in very early childhood and ending when the growth process is completed. The outcome varies depending on the type of the anomaly and - to some degree - on the extent of the deformity.
Early restoration of the continuity of the clefted craniofacial structures facilitates the development and rehabilitation of speech (2, 3, 5, 6). No firm data is available on any association between an improvement in conditions for occlusion rehabilitation and any particular surgical technique. The common opinion is that there are numerous routes to success (1), and this success mainly depends on appropriate orthodontic treatment, continued phoniatric diagnostic and therapeutic management, and regular speech therapy.
In classifying clefts, the most popular systems are based on embryological foundations, such as the classification developed by Kernahan and Stark (4). This defines the incising foramen as the embryological border between the clefts of the phylogenetically primary and secondary palates. Thus, the authors distinguish between two major types of cleft, which form a multitude of combinations. Clefted anatomical regions situated in the anterior position vis a vis the incisive foramen (the lip, alveolar process and a part of the hard palate) have become known as clefts of the primary palate, while clefted regions posterior to the incisive foramen (the major part of the hard palate and the soft palate) have been termed clefts of the secondary palate. Appropriate marking of the side of the cleft has helped to establish a classification system that is at present the most widely recognized in the world.
The management of a craniofacial cleft is multi-specialist, often multi-stage, and long-term. Since the defect itself is clearly visible on the face, can often be heard when the patient speaks, and the stigma of cleft lip remains even after the best surgical treatment, the effects of such a deformity on the personal and social life of the patient is enormous. Hence the selection of proper surgical, orthodontic, phoniatric and otolaryngologic management, as well as speech rehabilitation at each stage of treatment, are of paramount importance.
Our standards of surgical management in primary and secondary palate clefts
In common with more and more cleft surgeons (2, 5), we believe that elevating the mucoperiosteum at the time of palate repair might be detrimental to the development of the maxilla.
After many years of surgical experience in cleft care we fully agree with Ross (7) in his comment that scarring in the areas of denuded bone is the main cause of maxillary growth impairment in orofacial clefts.
In our Craniofacial Centre in the years 1981-2000 ca 300 children with unilateral or cleft lip and palate underwent early one - stage primary surgical repair of UCLP at a mean age of 6-8 mo. During this time three methods of palatal cleft repair were employed.
In the first method (56 children now being aged 15-20 yrs), cleft palates were closed by a modified von Langenbeck procedure. A two - layer closure of the hard palate was performed. Two to five mm of denuded bone was left by the alveolus. In order to keep the facial muscular balance a rib bone graft of about 1 cm length was inserted subperiosteally at the level of the base of the nasal ala. A triangular flap for lip repair was used.
In the second method (82 children being now aged 15-10 yrs) bone grafting was abandoned. To close the palatal cleft, which was also closed with two layers, only one mucoperiosteal flap was mobilised and sutured to the clefted side. A large denuded bone area was left at the unclefted side.
In the third method (about 160 children now aged from 8 mo to 10 yrs) a raised and prolonged vomer flap was used for closing the palatal cleft. All palatal wounds were tightly sutured. No area of denuded bone was left by the alveolus. Almost all children operated on before the end of the first year of life achieved normal conditions for speech development before starting school. Minor articulation errors were caused by dental problems.
The change in surgical techniques of palatal surgery to the least traumatic one in the third group resulted in a significantly better occlusion conditions in this group.
Bilateral cleft lip and palate
3-4 months of life - a complete reconstruction of the soft palate cleft, closing of the fissure in the hard palate, and reconstruction of the lip on the narrower side. A partial closing of the contralateral hard palate. All wounds must be tightly closed.
6 weeks later - a complete reconstruction of the lip, oral vestibule and palate. Make sure the continuity of the orbicular muscle of the mouth is completely restored and the hypoplastic cartilages of the medial crus are released. Major palate-supplying vessels should not be dissected. Strive for a tight closure of all wounds.
Early closures are medically warranted due to the uncontrolled growth of the intermaxillary bone and the resultant deformity of the maxilla, which exerts a marked effect on future problems in surgical, orthodontic, phoniatric and logopedic management.
4-5 years of life - the nasal septum is lengthened and minor lip corrective procedures are performed.
9-11 years of life - elimination of the residual alveolar cleft by secondary bone grafting. Possible reconstruction of the intermaxillary bone is performed if needed.
16-18 years of life - minor cosmetic corrections, scar dermabrasion.
Unilateral cleft lip and palate
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1. Berkovitz A: A multicenter retrospective 30 study of serial complete unilateral cleft lip and palate and complete bilateral cleft lip and palate to evaluate treatment: Part 1 - The participating institutions and research aims. CP Craniofac J 1999, 36:413-424. 2. Desai SN: Early cleft palate repair completed before the age of 16 weeks: observations on a personal series of 100 children. Br J Plast Surg 1983, 36:300-304. 3. Dorf DS, Curtin JW: Early cleft palate pair and speech outcome. Plast Reconstr Surg 1982, 70:74-81. 4. Kernahan DA, Stark RB: A new classification for cleft lip and palate. Plast Reconstr Surg 1958, 22:435-441. 5. Malek R, Martinez H, Mousset MR, Trichet C: Multidisciplinary management of cleft lip and palate in Paris, France. In: Multidisciplinary management of cleft lip and palate. Saunders Comp, New York 1990. 6. Randall P, La Rossa D, et al.: Cleft palate closure at 3 to 7 months of age: a preliminary report. Plast Reconstr Surg 1983, 71:624-628. 7. Ross B: Treatment variables affecting growth in unilateral cleft lip and palate. Part 5: Timing of palate repair. CPJ 1987, 24:54-63.