Cleft Lip and Palate – Comprehensive Review

These question-and-answer flashcards cover epidemiology, embryology, classification, genetics, clinical problems, prenatal and postnatal management, surgical techniques, orthodontics, and multidisciplinary aspects of cleft lip and palate care.

What are the three most common congenital craniofacial anomalies treated by plastic surgeons?

Cleft lip, cleft palate, and cleft lip with palate.

Why must cleft care be delivered by a multidisciplinary team?

Because optimal outcomes require coordinated expertise in surgery, speech, hearing, dentistry, genetics, nutrition, psychology, and social work.

Which cleft presentation is most common in live births?

Cleft lip and palate combined (46%).

How does the incidence of cleft lip with/without palate differ among racial groups?

Occurs 1 : 1,000 in Whites, twice as common in Asians, half as common in African Americans.

Name two environmental teratogens strongly associated with cleft formation.

Maternal phenytoin use and maternal smoking.

What is the most common syndrome associated with cleft lip and/or palate?

Van der Woude syndrome.

Which syndromes are most commonly linked to isolated cleft palate?

DiGeorge (conotruncal anomaly) syndromes.

During which weeks of gestation does the primary palate form?

4th–8th weeks.

From which embryonic primordia does the primary palate arise?

Premaxilla derived from the frontonasal prominence.

During which gestational weeks does the secondary palate form?

8th–12th weeks.

Fusion failure between which prominences produces a cleft lip?

Frontonasal and maxillary prominences.

List four theories proposed to explain palatal cleft formation.

Intrinsic shelf force alteration, failure of tongue drop, non-fusion of shelves, rupture of fusion cysts.

What questions define the basic clinical classification of a cleft?

Is it combined or isolated? Unilateral or bilateral? Complete or incomplete?

Which classification system uses the mnemonic LAHSHAL?

Kriens’ classification system.

What does a lowercase letter in LAHSHAL indicate?

An incomplete cleft in that anatomic segment.

Describe a microform cleft lip.

A very mild cleft presenting as a lip dent or scar; underlying muscle may be deficient.

What are the classic triad findings of a submucous cleft palate?

Bifid uvula, absent posterior nasal spine, midline muscular diastasis (zona pellucida).

At what prenatal stage is cleft lip usually detected by ultrasound?

Second trimester (around 18–22 weeks).

List two major advantages of prenatal diagnosis of cleft lip/palate.

Allows time for parental education/psychological preparation and evaluation for associated anomalies.

How does sibling recurrence risk change with number of affected relatives for CL/P?

4% with one affected child; 9% with two; 17% if one parent and one child affected.

Which nonsyndromic sequence is most often associated with cleft palate?

Pierre Robin sequence (micrognathia, glossoptosis, airway issues).

Name three common cleft-associated syndromes and one hallmark of each.

Stickler (ocular/hearing/joint issues), Velocardiofacial/CATCH-22 (22q11 deletion), Van der Woude (lower-lip pits).

List five functional problems resulting from cleft lip/palate.

Feeding difficulty, dental anomalies, nasal deformity, ear disease/hearing loss, speech disorders.

Why do infants with cleft palate struggle to feed?

Cannot generate negative intra-oral pressure; milk regurgitates into nasal cavity.

What rule guides timing for primary cleft lip repair?

The Rule of 10s: 10 weeks age, 10 lb weight, Hb ≥10 g/dL, WBC ≤10,000.

Which presurgical orthopedic device molds the nasal cartilage and alveolus in infants?

Nasoalveolar molding (NAM) appliance.

What is the most common unilateral cleft lip repair technique?

Millard rotation-advancement flap.

At what age is primary cleft palate repair usually performed and why?

9–18 months; earlier repair (<1 yr) reduces articulation errors and VPI.

Name four classic palatoplasty techniques.

Schweckendick primary veloplasty, Von Langenbeck, V-Y pushback (Wardill-Kilner), and Furlow double-opposing Z-plasty.

Which palatoplasty both lengthens the palate and reconstructs the levator sling?

Furlow palatoplasty.

What percentage of children with cleft palate eventually require tympanostomy tubes?

About 96% need tubes; 50% need repeat placement.

Give two anatomic reasons for eustachian tube dysfunction in cleft palate.

Abnormal insertion of tensor/levator veli palatini muscles and aberrant skull-base angulation.

What is velopharyngeal insufficiency (VPI)?

Failure of the velum and pharyngeal walls to separate oral and nasal cavities during speech, causing hypernasality.

List three surgical goals in correcting VPI.

Close palatal gap, recreate functional muscle sling, and sufficiently lengthen the palate.

At what dental stage is secondary alveolar bone grafting (ABG) ideally performed?

Before eruption of permanent canine (root 1/3–2/3 formed), typically age 8–10.

Name four benefits of alveolar bone grafting.

Allows tooth eruption/orthodontic movement, closes oro-nasal fistula, supports alar base, stabilizes premaxilla.

What is the preferred autogenous donor site for cancellous bone in ABG?

Anterior iliac crest.

Why are alloplasts generally avoided for alveolar grafts?

Teeth cannot erupt through alloplastic material and osteoinduction is absent.

Which orthodontic appliance is commonly used to expand the maxillary arch before ABG?

Quad-helix or other rapid palatal expanders.

What craniofacial surgery may be necessary during puberty for midface hypoplasia in CL/P?

Le Fort I (± II/III) midfacial advancement and possible mandibular surgery.

At what age is definitive rhinoplasty usually performed in cleft patients?

17–20 years (post-skeletal maturity).

What is the purpose of presurgical infant facial taping?

To approximate lip segments, mold nasal cartilage, and reduce cleft width before surgery.

Which feeding positions help reduce nasal regurgitation in cleft palate infants?

Upright or semi-sitting position.

Name two specialized cleft feeding bottles or nipples.

Haberman (Special Needs) feeder and Pigeon feeder.

What is the “Latham appliance” used for?

Premaxillary orthopedic repositioning in wide bilateral cleft lip/palate.

How do speech outcomes compare when palatoplasty is done before vs. after 18 months?

Earlier repair has significantly fewer hypernasality and articulation errors.

What multidisciplinary professional performs genetic counseling in cleft care?

Medical geneticist (or genetic counselor).

State two reasons hypernasal speech may persist after palatoplasty.

Residual VPI due to short palate or poor muscular function; scar contracture limiting mobility.

Which muscles form the functional levator sling of the soft palate?

Paired levator veli palatini muscles.

Describe Pierre Robin sequence’s triad and its airway implication.

Micrognathia, glossoptosis, and often cleft palate; leads to airway obstruction requiring early attention.

What proportion of bilateral cleft lips are associated with cleft palate?

Approximately 86%.

Why are associated anomalies more common in isolated cleft palate than in combined clefts?

Because many syndromes primarily present with cleft palate only, reflecting broader embryologic field defects.

What surgical maneuver does a pharyngeal flap accomplish in VPI correction?

Creates a bridge of posterior pharyngeal wall tissue to the velum, narrowing the nasopharyngeal port.

Which dietary deficiency during pregnancy increases cleft risk?

Folic acid (also vitamin A deficiency).

What dental malocclusion tendencies are common in cleft patients?

Class III tendency and anterior/posterior cross-bites.