Pearls For Cleft Lip and Palate Surgery
Kevin S. Smith, DDS
Comprehensive Evaluation and Team Care for Cleft and Craniofacial
Patients
Dental Hygiene Alumni Association
September 25,2015
Kevin S Smith, DDS
Professor and Residency Program Director
Oral and Maxillofacial Surgery
University of Oklahoma
Kevin S Smith DDS
Kevin-smith@ouhsc.edu
405-271-4955
www.oralfacialsurgeons.com
Donate to:
A Smile for a Child Foundation (501c3 foundation)
1000 N Lincoln STE 2000
OKC OK 73104
www.oklahomacleft.org
Keep sight of the big picture
Interdisciplinary care is most important
Must provide a roadmap for the family
Coordinate care between critical specialties
Cleft Lip and Palate
Embryology
Embryology
etiology
Why ?
Epidemiology
Left > Right
CL/P
Isolated CP
2:1
M>F
2:1
F>M
2:1
1:660 live births (USA)
Epidemiology
Highest incidence in Asians and Native Americans (1:500)
African Americans lowest incidence(1:2000)
Increase in Incidence?
Falling perinatal mortality
Decreased operative mortality
Importance of intermarriage
Types of Clefts
Sequela of clefts
Feeding
Ear Problems
Speech Difficulties
Dental Problems
Malocclusion
Nasal Deformity
Interdisciplinary Team Care
American Cleft Lip and Palate- Craniofacial Association(ACPA)
Surgeon (OMFS, ENT or Plastics), Orthodontics, Speech and Language Pathology
The Univ. of Ok J. W. Keys and M. K. Chapman Cleft Palate-Craniofacial Clinic
Genetics, Audiology, Social work, Pediatric dentistry, Prosthodontics, Psych
Counseling,
Nursing, ENT
Interdisciplinary Team Care
American Cleft Lip and Palate- Craniofacial Association(ACPA)
Surgeon (OMFS, ENT or Plastics), Orthodontics, Speech and Language Pathology
The Univ. of OKlahoma J. W. Keys Cleft Palate-Craniofacial Clinic
Genetics, Audiology, Social work, Pediatric dentistry, Prosthodontics, Psych
Counciling,
Nursing, ENT
Funding PAtients
Funding PAtients
Keep skills with Missions
Surgical Sequence
General Therapeutic Goals
PArameters of Care (AAOMS PArCare07)
Optimization of the psychologic impact on patient and family
Limited period of disability
Improved social and psychologic development
Limited adverse maxillofacial growth and development
Minimal scar formation
General Therapeutic Goals
PArameters of Care (AAOMS PArCare07)
Appropriate understanding by patient (family) of treatment options and
acceptance of treatment plan
Appropriate understanding and acceptance by patient (family)of favorable
outcomes, known risks and complications
Absence of infection
It isn’t Really about Closing the “hole”
PRenatal Diagnosis
Prenatal Diagnosis
High resolution
3D ultrasound
Must thoroughly image the face
Cases
Comprehensive Care for Cleft Lip and Palate
4d ultrasound
Prenatal Counseling
Genetics
Feeding
Surgical repair
Educational literature and internet connections
Feeding Your Baby
Weight Gain is KEY
Haberman
Pigeon
Prenatal Counseling
Parents are knowledgeable about clefting
Feeding skills with SpecialNeeds® Feeder (Haberman) are reinforced at birth
Different Severity of Clefts
Unilateral Cleft Lip:
Incomplete
Wide
early p
Complete
Different Severity of Clefts
The Bony Cleft
For Wide Clefts…
Options to help narrow the cleft prior to surgery:
Lip Taping
Nasoalveolar Molding
Lip Adhesion Surgery
Lip Taping
Start taping at first visit & change tape daily
Nasoalveolar Molding (NAM)
Impressions, “retainer” made
Taping, elastics, nasal lift
Weekly Adjustments for 8-12 wks
Nasoalveolar Molding (NAM)
Nasoalveolar Molding Appliance for the Treatment of Primary Cleft Lip and Palate
Kevin S. Smith, DDS
University of OklahomaCenter for Cleft and Facial Deformities
Nasoalveolar Molding
Presurgical orthopedics has been controversial
growth
orthodontic benefits
Presurgical orthopedics, Latham
Presurgical orthopedics, Latham
Improves surgical results?
nasal symmetry improvement
esthetic effects on the lip
Principles
Technique
Impression of maxilla 2-4 weeks
Acrylic appliance
Perma-soft
Elastics on steri strips
Coloplast next to skin
Adjustments weekly
Four to eight weeks
Enhance with lip-tape adhesion
Goals of Alveolar Molding
Controlled movement of alveolar segments
Gingival tissue approximation
Alignment of nasal base
Nasal Stint
alveolar cleft < 6mm
.030 wire
active at apex of nasal cartilage
soft liner to prevent soft tissue damage
Nasal manipulation elevates deformed cartilage
Four weeks of molding
Unilateral Advantages
Guide alveolar segments into contact
Decrease surgical tension
Reposition nasal base
Manipulate cartilage and nasal tip
Reduction in secondary bone grafting?
Decrease costs and revisions?
Bilateral Goals
Lengthen columella
Align alveolar segments and premaxilla
Complications
Soft tissue breakdown
Premature tooth exposure
Parental non-compliance
Conclusions
Reshapes the nose
Reduces the size of cleft
Makes repair easier and less traumatic
Does not make bilateral repair easier or less complicated
Can this technique reduce secondary surgery?
Lip Adhesion
Two stage repair of WIDE Cleft Lips
Initial Visit
5 wks after stage one
Primary Repair of Cleft Lip
Rule of “over 10’s”
Wilhelmsen and Musgrave (1966)
Over 10 pounds
Over 10 g hemoglobin
Over 10 weeks old
WBC less than 10,000
Final Repair
Historical Review
Millard First Rotation-Advancement for Cleft Lip Repair, Korea, 1955.
Goals of Cleft Lip Repair
Approximation of cleft edges
Maintenance of natural landmarks
Cupids bow
Philtral dimple
Goals of Cleft Lip Repair
Muscle approximation
Alar base balance and symmetry
Scar in natural lines
Instruments and suture
15-C blade Smaller than a 15
Instruments and suture
Lorenz “Power Cut” TC curved Iris scissors
3-0 monocryl (nasal cinch)
4-0 vicryl on P-3 needle (deep and muscle) 4-0 vicryl “rapide” on P-3
5-0 plain gut on P-3
Bilateral Lip repair in 2 stages
Bilateral Cleft Lip Repair
Too Wide
Cleft Palate Repair
Is not an infection!!!
Repair Considerations
Feeding
Speech and swallowing
Maxillary growth and dental occlusion
Advantages- Early closure
Better palatal and pharyngeal muscle closure
Facilitate Feeding
Better phonation skills
Improve auditory tube function
Assist oral hygiene
Improve psychological aspects (parents and baby)
Disadvantages - Early closure
Difficult surgical closure
SCAR FORMATION
Historical Review
Obturation was the preferred method of treatment until the 19th century
Von Graefe (1816) described surgical closure of cleft
Von Langenbeck (1859) emphasized subperiosteal undermining and bipedical flaps
Historical Review
Veau (1931) described single pedicle flaps based on the greater palatine artery
Wardill and Kilner (1937) modified the Veau technique to increase palatal length
Furlow (1980) developed double reversing Z-plasty palatoplasty to facilitate
muscular reconstruction
Palatal Repair
One stage
Closure of hard and soft palate simultaneously
Early speech intervention
May cause major disturbances in maxillary growth
Palatal Repair
Two stage
Staphylorrhaphy 18 months
Palatorrhaphy
4 years
Two Stage
Advantages
Less effect on maxillary transverse growth
Disadvantages
More articulation errors
Two Flap Technique
Wardill-Kilner-Veau
Two Flap Technique
Instruments and suture
69-B Beaver
Instruments
Sinus Lift Curettes
Opposing Z-plasty
30°: 25%
45°: 50%
60°: 75%
OpPosing Z-Plasty
Furlow
Modified Bipedicle Flap
Von Langenbeck
Submucous Cleft
Velopharyngeal Insufficiency
VPI Definitions
Velopharyngeal Inadequacy
Generic term used to denote abnormal VP function
Velopharyngeal insufficiency- Structural defects of the velum or pharyngeal walls at
the level of the nasopharynx; not enough tissue or a mechanical interference that
prevents closure
Velopharyngeal incompetence- Includes neurogenic etiologies, impaired motor
control.
Velopharyngeal mislearning- other causes
Surgical management of mechanical and soft tissue problems can have great
Surgical management for neurologic etiologies can be difficult. (Velopharyngeal
Incompetence)
Resonance changes
The sound waves of speech enter both the oral cavity and the nasal cavity
This resonance change is typically called hypernasality
Factors include structural differences, tissue mass, lingual/labial/tongue movement,
nasal resistance and timing.
Etiology
Cleft palate
Etiology
Submucous Cleft
Etiology
Short palate
Removal of adenoids
Etiology
Neuromuscular Deficits
VCFS
Diagnosis
Speech and Language Pathologist
Will usually be the first line finding the problem
Pediatricians or parents will say that there is a problem with intelligibility
VPI may be found very early but objective clinical assessment usually doesn’t take
place until cooperation of the child.
Diagnosis
Speech and Language Pathologist
Signs and Symptoms
Nasal Grimace
Nasal Emissions
Increased Nasal Airflow
Hypernasality
Speech and Language Pathologist
Need adequate speech sample
List of sentences with a particular phonetic makeup of each utterance
Mama made lemon jam.
Give Gary the chocolate cake.
Cleft team patient will usually be monitored
School age screening in schools is important as a catch-all
Burned Bridges and Missed Opportunities
Infants with glottal stops and pharyngeal fricatives
Can be recognized and intercepted
Therapy contrary to speech development
Sign
Can the child communicate with more than just his parents?
Are the parents learning sign?
Limited application might be OK???
Alternative to Sign Language
Work on articulation
Work on correction of Glottal Stops and Fricatives regardless of Resonance
Activate the velopharyngeal valve
Questions about what to do should be directed to colleagues who work in this area
Multi-view Videofluoroscopy
Must have consistent VPI
Evaluation by SLP
Articulation correction (attempted) by SLP
Work to over come glottal stops
Age- must be cooperative (Average age- 4.5 years)
Multi-view Videofluoroscopy
Barium coating of pharynx
Views
Lateral
SMV (Base view)NormaVPIToo young!!!
Velopharyngeal Insufficiency
Diagnosis
SLP or Surgeon
Nasopharyngoscopy
Nasal spray- 2% Pontocaine in atomizer
Insertion into larger size nostril
Evaluate palatal movement
Evaluate lateral wall movement
Evaluate tonsils and adenoids
Removal of adenoids
Medical Intervention
Prosthetics
Palatal lengthening
Pharyngeal flaps
Posterior wall implants
Sphincter Pharyngoplasty
Obturation, Bulbs and Lifts
Posterior Wall Implants
Small Defects
Silastic
Autogenous
Opposing Z-plasty
30°: 25%
45°: 50%
60°: 75%
OpPosing Z-Plasty
Furlow
Two Flap Technique
Wardill-Kilner-Veau
Two Flap Technique
Pharyngeal Flap
Superiorly based
Pharyngeal Flap
Pharyngeal Flap
Inferiorly Based
Pharyngeal Flap
Pull Through
Sphincter Pharyngoplasty
Bardach
Consider for VCFS
with obturator
Hospital Course
PICU
Tongue Stitch
Steroids
Cautious pain control
Velopharyngeal Insufficiency
Must include intensive speech therapy in the post surgical phase
Child will still have resonance problems after surgical intervention
Complications
Bleeding
OSAS
Acute airway obstruction
Nasal obstruction
Continued VPI (~10%)
22q11.2 deletion syndrome
Cardiac Abnormality (Tetralogy of Fallot)
Abnormal facies
Thymic aplasia
Hypocalcemia
Cleft palate
Apraxia
Alveolar Cleft Repair
Sequela of Alveolar Clefts
Unsupported alar bases producing nasal asymmetry
Oronasal fistula
Maxillary transverse hypoplasia
Lack of bone support for teeth adjacent to cleft
Sequela of Alveolar Clefts
Crowding of teeth
Speech misarticulations
Frequent supernumerary teeth
Missing lateral incisors
Sequela of Alveolar Clefts
Bilateral clefts
Mobile premaxilla
More transverse hypoplasia
Protrusion of the premaxilla
Indications for Grafting
Functional
Unite dento-osseous segment
Prevent arch collapse after expansion
Augmentation of alveolar ridge
Osseous support of teeth
Closure of oronasal fistula
Improvement of speech
Indications for Grafting
Aesthetic
Alar base support
Restore contour of anterior maxilla
Improving lip support
Base for improving dental aesthetics
Timing of Grafting
Primary bone grafting
< 2 years
Rib or tibia used as graft
Restricts facial growth potential
Resorption of graft, need for second graft
Timing of Grafting
Early secondary grafting 2-6 years
Iliac crest may be used
Restricts facial growth potential
Resorption of graft, need for second graft
Timing of Grafting
Secondary grafting
7-12 years
Dental age versus chronological age
Grafting in mixed dentition has highest success
Permanent cuspid should be high in alveolus
1/2 to 3/4 root formation
90% of palatal transverse growth is complete at age 7
Timing of Grafting
Late secondary
After cuspid eruption
Minimal influence over maxillary growth
Potential loss of teeth
Considered only when patient presents late
Orthodontics
Depending on orthodontic technique expansion takes place 3-6 months prior to
grafting
Easier to graft expanded maxilla than and cleft alveolus that is collapsed
Cuspid Eruption
27% spontaneous eruption
17% require surgical exposure
56% require surgical exposure and orthodontic traction
El Deeb (1982)
rHBMP-2
Volumetric Cleft Changes in Treatment with
Recombinant Human BMP-2/Absorbable Collagen Sponge/ Beta-Tricalcium
Phosphate versus Grafts
Robert Lawrence Trujillo, D.M.D.
Frans Currier, DDS, MSD, M.Ed
Kevin S Smith, DDS
Research finished
September 18, 2013
Materials and Methods: Surgical Protocol
Three surgical protocols were used
BMP/ACS/b-TCP
Iliac Crest
Mandibular Symphyseal
Materials and Methods: Initial Cleft defect volume analysis
Materials and Methods: Residual Cleft defect volume analysis
Results:
Percent Bone fill by treatm ent group
Discussion
The findings indicated
Modified BMP protocol is acceptable
Comparable to autogenous controls
Age, initial defect volume, months to follow up CBCT
Do not significantly influence % bone fill
Weak correlation
BMP Advantages
Cost savings
No hospital stay
Spares autogenous bone options for tx
DECREASE MORBIDITY!
More research needed
consider the effect (of what you do) on the end result
Orthognathic Surgery
Indications for Orthognathic Surgery
Maxillary (midface) hypoplasia
Class III malocclusion (Underbite)
Apertognathia (Open Bite)
Mandible can have variable growth
Asymmetry
Facial Growth needs to be complete
Goals
Normalize occlusion for functional and aesthetic improvement
Able to move teeth into stable position in alveolus
Improves prosthetic reconstruction potential Correction of skeletal base prior to soft
tissue revision
Surgical Procedure
Splint to stabilize expansion
Rigid fixation
Overcorrection?
Bone grafts (osteotomy and pyriform rim)
Repair of nasal floor
Problems with Orthognathic Surgery
Scar tissue
Speech
Hearing
Early Maxillary Distraction
Done prior to completion of facial growth
May eliminate need for future orthognathic surgery
Always discuss the potential for future orthognathic surgery due to growth
Psychosocial reasons
Early Maxillary Distraction
Cleft Distraction
Orthognathic (Jaw) Surgery
Before Orthognathic Surgery
Distraction Osteogenesis
Combination Treatment
Large discrepancy done with distraction
Final occlusion with traditional orthognathic surgery
Must relate multiple surgeries to patient during initial treatment plan
Combination Treatment
Before, During & After Distraction
Secondary procedures
Secondary Rhinocheiloplasty
Skeletal foundation must be intact
Normalize facial proportions
Implant restoration of Cleft Patients
Endosseous Implants
1991 (Verdi, et al):
First to report endosseous implant to restore the edentulous alveolar cleft region
Implant successfully placed 18 months following closure of the oronasal fistula and
reconstruction of the alveolar cleft with autogenous cancellous bone.
Endosseous Implants
Provides satisfactory functional and esthetic outcome
Avoid the disadvantage associated with either prosthodontic or orthodontic
options.
Implant prerequisite:
Adequate volume and quality of bone within alveolar cleft
Implant Success Rates
Conclusions