Cleft Palate Treatments

Cleft Palate Treatments

Cleft lip and palate is usually treated with surgery. Other treatments may be needed to treat

associated symptoms, such as speech therapy or dental care. The primary purpose of cleft palate

repair is to provide an intact mechanism for normal speech production.

Palatoplasty

The purpose of palatoplasty is to separate between oral and nasal cavity, to form waterproof and

hemetic velofaringeal valve, and obtain the growth of maksilofasial which aproaches normal.

The challenge of palatoplasty nowadays is not only how to cover the defect crack of the palate,

but also how to obtain optimal speech function without interfere the growth of maxillofacial.

The most proper time to do palatoplasty is still being a controversy. Some surgeons prompt the

palatoplasty time before the age of 12 months because it will be favorable to the speech growth

of the patient because the learning process of speaking starts within the age of 12 months1. The

postponement of palatoplasty will be profitable to the growth of maxillofacial2. Somehow the

palatoplasty this far hasn’t been proved yet most of the surgeons agreed that palatoplasty must

have been done before the age of 2 years3.

Principles of Palatoplasty

Closure of the defect.

Correction of the abnormal position of the muscles of the soft palate, especially

LevatorPalati.

Reconstruction of the muscle sling.

Retropositioning of the soft palate so much so that during speech the posterior part of the

soft palate comes in contact with the posterior pharyngeal wall during speech.

Minimal or no raw area should be left on the nasal side or the oral surface.

Tension-free suturing.

Two-layer closure in the hard palate region and a three-layer closure of the soft palate.

Various factors as operation technique, the surgeons skill, and the poor standards of speech

therapy evaluation also play a major role and influence the result of palatoplasty4.

There are some kind of palatoplasty technique yet the most commonly used is von langenbeck

and V-Y push back (Veau-Wardill-Kilner) techniques. Both of them have some excess and

shortage.

Von langenbeckPalatoplasty

Von langenbeck technique uses mukoperiosteal flap bipedikel in palatum durum and palatum

molle to cover the defect crack of the palate. The basis anterior and posteriol bipedikel flap

aproximates toward medial to cover the defect crack of the plate. This technique refers to the

importance of separating oral and nasal cavity.

Excess: This technique is easy to do within short operating time.

Shortage: It’s not able to elongate palatum to posterior thus the possibility of velopharingeal

incompetence is higher and speech function is not optimal.

V-Y push back (Veau- Wardill-Kilnerpalatoplasty

Till a few years back this procedure was the commonest technique of palatoplasty. In this

technique V-Y procedure is performed so that the whole mucoperiosteal flap and the soft palate

are retroposed and the palate is lengthened5. However, it leaves an extensive raw area anteriorly

and laterally along the alveolar margin with exposed bare membranous bone. The raw area heals

with secondary intention. This causes shortening of the palate and results in velopharyngeal

incompetence. The raw area adjacent to the alveolar margin also results in alveolar arch

deformity and dental malalignment.

To increase the lengthening of the soft palate George Dorrance advocated horizontal back-cut in

the nasal lining at the junction of hard and soft palate6. This leaves a large raw area on the nasal

surface which is left open. This may contract after hea00ling with secondary intention and may

undo the palatal lengthening. Since there is single-layer repair in the region of the back-cut, the

incidence of palatal fistula is high.

Excess:

1. To elongate palatum towards posterior

2. To increase the speech function as the result of lengthen palatum towards posterior

Shortage:

1. The possibility of the fistula emergence in between palatum durum and palatum molle area

because of the thin mukoperiosteum in that area.

2. Leave the wide denuded bone on de edge of lateral crack palate. This area afterwards forms

the scarring which roles in maxillary arch constriction.

3. Longer operating time.

The Evaluation of Operation Result

The procedure of patient with the cleft lip and palate needs few operation within years. That is

important to evaluate the succeed of operation such as subjective and objective checks.

The Subjective check includes:

1. Complaints of the speech function

2. Complaints of the eating and drinking function

3. The behavior changes after the operation

The Objective check includes:

1. The succeed or not operation considers by clinical condition of the operation scars

happened to cover or not.

2. The presence of fistula

3. The continuation lip or palatum

Cleft Lips Treatment

Surgery to repair the lip shape quickly performed in cases with any age, but the babies were all

done at an early age, usually around the age of 3 months based on the “Rules of Ten”. There are:

Body weight at least 4,5kg (10 pon)

Age at least 10 weeks

Hemoglobin level more than 10%

The number of leukosit less than 10.000/mm3

The Evaluation of Operation Result

The procedure of patient with the cleft lip and palate needs few operation within years. That is

important to evaluate the succeed of operation such as subjective and objective checks.

The Subjective check includes:

1. Repair the Ala Nasiorder forms and located symmetrically

2. Gives a good basic shape nose

3. Improve the shape and position of the columella

4. Improve the shape and function of the upper lip

5. Forming vermillon

The Objective check includes:

1. The succeed or not operation considers by clinical condition of the operation scars

happened to cover or not.

2. The presence of fistula

3. The continuation lip or palatum

Surgery Technique

Various techniques Labio closure or palatoschisis have been developed in the last twenty years.

Most plastic surgeons choose Millard engineering or modification. Some of the surgical

technique used to Labio or palatoschisis what use in common is :

Milliard Surgery

The rotation-advancement procedure for cleft lip repair, also known as the Millard Repair, is

designed to create a softer, more natural-looking lip. Surgery performed prior to the Millard

procedure involved pulling both sides of the cleft lip together resulting in a tightly closed upper

lip. The Millard Procedure rotates the tissue and creates a "Z" shaped scar instead. The "Z" shape

gives the tissue more elasticity, resulting in greater flexibility and restoration of the Cupid's bow

"Medicine: CLeft-Lip Craft". TIME. 1976-08-23. Retrieved 2010-07-16.

Onizuka Surgery

Same like Milliard Surgery, but this is the modification from Milliard Surgery. Therefore the

percentage of the success surgery can be increased.

Advantages :

Obtained satisfactory thickness bottom lip.

Can maintain the boundaries of the skin and mucous membranes of the Cupid's bow

shape good.

Quite thick lips and eversion

Curved bow lips can be formed naturally

Basic nostrils raised

Can restore collumella base in the correct position, especially in the gap

Disadvantages :

Scar tissue damage philtrum line and tends to occur due to changes in growth, so that the

operative site will grow longer to vertical network.

Operation Technique

1. Determine the fixed points without measurement is point A, B, C, D, E, F, G and H.

2. Specifies the first point by measuring CH = HI

3. Measuring curved nose AB, then transferred to the side of the gap becomes a point D

with AB = CD.

4. Determine the point C

5. Measure the length of the nasal base AB

6. Determine the point D '' derived from the length AB = CC '+ D'D + DD' '.

7. Determine the point K, the length CC '= BK.

8. Measuring high point h = length KG.

9. Make an incision on the medial side of the line. Pull the line C'I then create a line IL,

with IL form an angle of 120 to the CI that ill pass contralateral philtrum. C'I + IL = h.

then added a line rotation from point I to point M, with C'I = IM.

10. Make an incision on the lateral side of the line. Determine the point N, which is obtained

from D''N = C'I and long D'' N + NJ = h. Determine the point O, the provisions JN = JO =

ON, which form an equilateral triangle. Then added a line of rotation of the point D ''

following the gap hidungsisi lateral lobe to the point P with the provisions D''P = D'' N =

C'I = IM.

Tennison-Randall Surgery

It is use the method of triangular repair. Why used it? Because the rotation advancement

technique of Millard has the greatest number of followers and is recognized as a simple method

once experience is obtained… However, a number of surgeons prefer a triangular technique,

since it seems simpler to lay out and perform and is less of a “cut as you go” free hand

performance. For some surgeons it seems simpler and easier to teach. It is also possibly more

reliable for those performing and teaching a small number of cases. Bardach J &Salyer KE (1991).

Surgical techniques in cleft lip and palate. Second Edition. St. Louis: Mosby-Year Book, Inc.

Sumber Gambar xSmith HW (1983). Comprehensive surgical atlases in otolaryngology and head and neck surgery: The atlas of cleft lip and cleft palate surgery. New York: Grune & Stratton, Inc.