Lecture 7 Surgical Management

Cleft lip / palate involves more than just the _______

lip and palate

Cleft lip surgery is done mainly for _______

aesthetics

Cleft palate surgery is done mainly for __________

maintaining function

What is the cleft lip repair surgery?

cheilorraphy

When is clef lip repair surgery done?

at least 10 weeks of age

What are the goals of cleft lip repair?

• aligning the structures

• achieving symmetry

• achieving a white roll

• minimizing the appearance of scars

What are the two unilateral cleft lip repair techniques?

• Millard Technique: Rotation advancement

• Tennison-Randall Technique: Z-plasty

Where is the incision for the Millard Technique?

right below the nostrils

Where is the incision for the Tennison-Randall technique?

in the lips

What are the bilateral cleft lip repair techniques?

• Broadbent-Manchester

• Millard

What are the potential complications of a cleft lip repair?

• stenosis of the nasal vestibule

• difficulty in nasal breathing and sleep

What is the cleft palate repair surgery?

palatoplasty

What is the timing of cleft palate repair?

9-12 months but may be delayed

What are the goals of cleft palate repair?

• separating oral and nasal cavities

• normal VP mechanism

• minimizing the occurrence of fistulas

• optimizing facial growth

How is the palate closed?

• in three layers

• nasal, mucosa, bones

What does surgical restoration of soft tissue help to?

approximate the maxillary bony segments

What is this cleft palate repair technique?

Von Langenbeck procedure

What is this cleft palate repair technique?

Wardill-Kilner

What is this cleft palate repair technique?

Furlow Z-palatoplasty

What are the potential complications of cleft palate repair?

• airway compromise

• excessive bleeding

• velopharyngeal insufficiency

• risk for postoperative dehiscence

What is the general agreement on the technique that has the best speech results?

• early repair is better for speech results

• better results are obtained by experienced surgeons

What is the surgery for VPI?

pharyngoplasty

What is the timing for VPI surgery?

usually after 3 years of age

What are the goals for VPI surgery?

• “normalizing” VP closure for speech

• avoiding airway compromise

Who are poor candidates for VPI surgery?

• significant airway obstruction

• neurological condition, particularly if progressive

• significant cognitive disability

• severe hearing loss or deafness

• previous oropharyngeal radiation

• a bleeding disorder

• a medialized carotid artery in the area of the flap incision

What VPI surgery is this?

Furlow Z-Plasty

What VPI surgery is this?

Pharyngeal wall augmentation

What VPI surgery is this?

Sphincter Pharyngoplasty

What VPI surgery is this?

Pharyngeal flap

What VPI surgery is this?

Pharyngeal Flap

What are the potential complications of Furlow z-plasty?

• prone to oralnasal fistula development

What are the potential complications of pharyngeal augmentation?

• may cause infections

• may cause extrusion, reabsorption, or migration of the material

What are the potential complications of sphincter or flap?

• may dehisce (pull apart)

• may result in over-correction or under-correction

Where is the best placement for a flap/sphincter?

high in the nasopharynx in the area of maximum LPW and velar movement

What happens if the flap or sphincter can be seen during an intraoral evaluation?

• it is probably too low for speech

• it is more likely to cause sleep apnea because it is at the level of the tongue base

Why is this VPI surgery unsuccessful?

port is too narrow

Why is this VPI surgery unsuccessful?

pharyngeal flap is too low

Why is this VPI surgery unsuccessful?

pharyngeal flap is too narrow

What are the measures of success?

• normal resonance and no nasal emission

• adequate nasal airway and no hyponasality

• normal nasometry scores for an objective measure

What is the timing of alveolar bone grafting?

6-11 years

What are the goals of alveolar bone grafting?

• to provide bony support for permanent lateral incisor and canine

• to improve the dental arch

What are the potential complications of alveolar bone grafting?

• bleeding and infection

• inadequate bone graft take

• breakdown of repair

• persistence of the fistula

What are the oronasal fistula repair techniques?

• use of local palatal tissue

• use of flaps of tissue from turbinates, buccal surface or tongue

• often done with the alveolar bone graft (age 6-7)

• can be done earlier if it is symptomatic

• temporary palatal obturator can be used until the fistula is surgically repaired

What are the potential complications of oronasal fistula repair?

• tissue break down

• there’s about a 40% recurrence risk with a repair, which gets higher with subsequent repairs

What is the name of the maxillary advancement surgery?

orthognathic surgery

What does orthognathic surgery address?

malocclusion that often occur due to clefts and micrognathia

What is the timing of maxillary advancement surgery?

14-16 years in girls and 16-18 years in boys

What are the goals of maxillary advancement?

• to bring the maxilla into proper alignment with the mandible

• improves aesthetics and obligatory speech distortions

What is this maxillary advancement technique?

Le Fort Technique

What is this maxillary advancement technique?

distraction technique

What effect does maxillary advancement have on speech sound production?

normalization of occlusion and eliminating obligatory distortions

What effect does maxillary advancement have on upper airway and hyponasality?

when the maxilla is advanced it increases the nasopharynx eliminating airway obstruction

What effect does maxillary advancement have on velopharyngeal function?

advancement of maxilla and advances velum and makes it hard to reach PPW causing hypernasality

What are the potential complications of maxillary advancement?

• major blood loss, requiring massive transfusion

• infection of facial soft tissues

• decreased sensation in the upper lip and midface

• loss of teeth or gingiva

• relapse of the maxilla and therefore, persistent malocclusion

• velopharyngeal insufficiency

Helpful Chart

What is a prosthetic device?

• typically used when surgery is not an option or not desired

• usually fabricated by a pediatric dentist or a prosthodontist

• can be used permanently or temporarily while waiting for surgery

What are the goals of a prothetic device?

• to improve both aesthetics and function

What does a fixed bridge replace?

dental segments

What do dentures replace?

all teeth in the arch

What do overlay dentures do?

fit over existing teeth and provide more vertical dimension

What are the goals of feeding obturators?

• improving compression of the nipple

• reduce nasal regurgitation of liquids

What are the disadvantages of feeding obturators?

• dose not obturate the soft palate for suction

• extra expense

• needs to be redone with growth

What speech appliance is this?

palatal obturator

What speech appliance is this?

palatal lift

What speech appliance is this?

speech bulb obturator

What are the advantages of prosthetic devices?

• used when surgery cannot be done or is being delayed

• used for VP incompetence due to neuromotor disorders where surgery is more risky

What are the disadvantages of prosthetic devices?

• require frequent adjustments in children

• are expensive

• can be lost or damaged

• need daily cleaning

• need manual skill for insertion and removal

• may be uncomfortable

• do not result in a permanent correction