Closure of the hard palate in unilateral cleft palate cases following previous closure of the soft palate according to the Widmaier-Perko technique

Overview This update focuses on current practices and controversies in surgical repair of the hard and soft palate posterior to the alveolus. Our current understanding of the advantages and disadvantages of presurgical active and passive manipulation of the hard palate shelves including the use of periosteoplasty is reviewed. The evolution of the multiple methods of repair of the hard and soft palate is given in a historical context along with a discussion of the concerns about timing of palate repair.

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Speech Outcomes in Isolated Cleft Palate: Impact of Cleft Extent and Additional Malformations

The Cleft Palate-Craniofacial Journal ◽

10.1597/1545-1569_2002_039_0397_soiicp_2.0.co_2 ◽

2002 ◽

Vol 39 (4) ◽

pp. 397-408 ◽

Cited By ~ 16

Author(s):

Christina Persson ◽

Anna Elander ◽

Anette Lohmander-Agerskov ◽

Ewa Söderpalm

Keyword(s):

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Reference Group ◽

University Hospital ◽

Perceptual Judgment ◽

Cross Sectional ◽

Velopharyngeal Function ◽

Isolated Cleft Palate ◽

The Impact

Objective The purpose of the study was to study the speech outcome in a series of 5-year-old children born with an isolated cleft palate and compare the speech with that of noncleft children and to study the impact of cleft extent and additional malformation on the speech outcome. Design A cross-sectional retrospective study. Setting A university hospital serving a population of 1.5 million inhabitants. Subjects Fifty-one patients with an isolated cleft palate; 22 of these had additional malformations. Thirteen noncleft children served as a reference group. Interventions A primary soft palate repair at a mean of 8 months of age and a hard palate closure at a mean age of 4 years and 2 months if the cleft extended into the hard palate. Main outcome Measures Perceptual judgment of seven speech variables assessed on a five-point scale by three experienced speech pathologists. Results The cleft palate group had significantly higher frequency of speech symptoms related to velopharyngeal function than the reference group. There were, however, no significant differences in speech outcome between the subgroup with a nonsyndromic cleft and the reference group. Cleft extent had a significant impact on the variable retracted oral articulation while the presence of additional malformations had a significant impact on several variables related to velopharyngeal function and articulation errors. Conclusion Children with a cleft in the soft palate only, with no additional malformations, had satisfactory speech, while children with a cleft palate accompanied by additional malformations or as a part of a syndrome should be considered to be at risk for speech problems.

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Musculature of the Soft Palate: Clinico-anatomic Correlations and Therapeutic Implications in the Treatment of Cleft Palates

The Cleft Palate-Craniofacial Journal ◽

10.1597/1545-1569_1997_034_0189_motspc_2.3.co_2 ◽

1997 ◽

Vol 34 (3) ◽

pp. 189-194

Author(s):

Christian Vacher ◽

Bernard Pavy ◽

Jeffrey Ascherman

Keyword(s):

Surgical Technique ◽

Cleft Palate ◽

Nasal Mucosa ◽

Soft Palate ◽

Hard Palate ◽

Surgical Repair ◽

Posterior Border ◽

Therapeutic Implications ◽

Sagittal Orientation

Objective Hypoptasia of the maxilla, often described as a classic sequela to surgical repair of the cleft palate, has been rare In our experience. We believe that our surgical technique, which includes dividing the nasal mucosa and the abnormal muscular insertions at the posterior border of the hard palate, is an important factor in preventing this sequela. Method We compared the anatomy of 12 normal palates in cadavers to the anatomy of cleft palates seen at operation and to the anatomy of one cleft palate in a fetus aged 34 weeks. Results In cleft palates, the muscular fibers have an abnormal sagittal orientation, inserting on the posterior border of the hard palate. Conclusion The division of both the nasal mucosa and these abnormal muscular insertions at the posterior border of the hard palate enables the surgeon to eliminate the abnormal posterior pull of these fibers on the maxilla.

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Morphologic Significance of Bifid Uvula

PEDIATRICS ◽

10.1542/peds.75.3.553 ◽

1985 ◽

Vol 75 (3) ◽

pp. 553-561

Author(s):

Robert J. Shprintzen ◽

Richard H. Schwartz ◽

Avron Daniller ◽

Lynn Hoch

Keyword(s):

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Velopharyngeal Insufficiency ◽

Pediatric Practice ◽

Submucous Cleft Palate ◽

Hypernasal Speech ◽

Definition Of

Bifid uvula is often regarded as a marker for submucous cleft palate although this relationship has not been fully confirmed. The reason for the tacitly assumed connection between these two anomalies has, in part, been perpetuated by the generally accepted definition of submucous cleft palate as the triad of bifid uvula, notching of the hard palate, and muscular diastasis of the soft palate. Recently, investigations have provided evidence of more subtle manifestations of submucous cleft palate by the use of nasopharyngoscopic examination of the palate and pharynx. It has been determined that submucous cleft palate can occur even when a peroral examination shows an intact uvula. This finding places the "marker" relationship in question. In order to determine the frequency of association between bifid uvula and submucous clefting, a total ascertainment of children with bifid uvula from a suburban pediatric practice was examined nasopharyngoscopically. It was determined that in all but two cases, children with bifid uvula had some or all of the landmarks of submucous cleft palate. Several of the children were found to have velopharyngeal insufficiency and mildly hypernasal speech. This finding prompts caution in the recommendation of adenoidectomy in the presence of bifid uvula.

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On the Frequency of Oronasal Fistulation After Primary Cleft Palate Repair

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665619856243 ◽

2019 ◽

Vol 56 (10) ◽

pp. 1302-1313

Author(s):

Ana Tache ◽

Maurice Y. Mommaerts

Keyword(s):

Systematic Review ◽

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Cleft Lip ◽

Oronasal Fistula ◽

Type Iv ◽

Cleft Palate Repair ◽

Palate Repair ◽

Fistula Rate

Objective: The aims of the study were to assess the postoperative oronasal fistula rate after 1-stage and 2-stage cleft palate repair and identify risk factors associated with its development. Design: Systematic review. Setting: Various primary cleft and craniofacial centers in the world. Patients, Participants: Syndromic and nonsyndromic cleft lip, alveolus, and palate patients who had undergone primary cleft palate surgery. Intervention: Assessment of oronasal fistula frequency and correlation with staging, timing, and technique of repair, gender, and Veau type. The results obtained in this systematic review were compared with those in previous reports. Outcome: The main outcome is represented by the occurrence of the oronasal fistula after 1-stage versus 2-stage palatoplasty. Results: The mean fistula percentage was 9.94%. In the Veau I, II, III, and IV groups, the respective fistula rates were 2%, 7.3%, 8.3%, and 12.5%. Oronasal fistula locations based on the Pittsburgh Fistula Classification System were soft palate (type II), 16.2%; soft palate–hard palate junction (type III), 29.3%; and hard palate (type IV), 37.3%. There were no statistically significant differences between 1-stage and 2-stage palatoplasty, syndromic and nonsyndromic, or male and female patients. Primary palatoplasty timing was not a significant predictor. Conclusion: Some disparities arose when comparing studies, mainly regarding location and types of clefting prone to oronasal fistulation. Interestingly, the fistula rate does not differ between 1- and 2-stage closure, and timing of the repair does not play a role.

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A Pitfall in Prenatal Ultrasonic Detection of Submucous Cleft Palate

Ear Nose & Throat Journal ◽

10.1177/0145561320974867 ◽

2020 ◽

pp. 014556132097486

Author(s):

Jia-Qi Hu ◽

Yu-Guo Zhang ◽

Wei Feng ◽

Hua Shi

Keyword(s):

Prenatal Diagnosis ◽

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Detailed Examination ◽

Bony Defect ◽

Ultrasound Screening ◽

Fetal Ultrasound ◽

Submucous Cleft Palate ◽

3D Ultrasonography

Objective: We present a case with prenatal diagnosis of submucous cleft palate (SMCP) which was described using 2- and 3-dimensional (3D) ultrasonography in utero. Case Report: A 25-year-old pregnant woman was referred to our department for fetal ultrasound screening. After the detection of cardiac and spinal malformations of fetal, further detailed examination detected SMCP, which showed a gap within the hard palate on axial transversal view with the soft palate visible on sagittal view. The imaging of a defective hard palate in prenatal 3D ultrasonography is similar to that in postmortem 3D computed tomography reconstruction. Conclusion: A gap within the hard palate and verification of the visibility of the soft palate should be key points in the prenatal diagnosis of SMCP. Three-dimensional ultrasonic imaging is helpful for displaying the shape and extent of the bony defect in SMCP.

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Cleft Palate Repair Using a Marginal Musculo-Mucosal Flap

The Cleft Palate-Craniofacial Journal ◽

10.1597/05-011 ◽

2006 ◽

Vol 43 (6) ◽

pp. 651-655 ◽

Cited By ~ 9

Author(s):

Hisao Ogata ◽

Tatsuo Nakajima ◽

Fumio Onishi ◽

Ikkei Tamada ◽

Makoto Hikosaka

Keyword(s):

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Primary Repair ◽

Formation Rate ◽

Fistula Formation ◽

Mucosal Flap ◽

Periosteal Flap ◽

Oronasal Fistula ◽

Palate Repair

Objective: To describe a modified procedure consisting of a mucoso-periosteal flap palatoplasty with a marginal musculo-mucosal flap (3M flap). This is also the first report of a primary repair for complete cleft palate using the 3M flap. We describe the lengthening effect of the nasal mucous layer of the soft palate and evaluate the fistula formation rate associated with this method. Methods: This procedure has been performed on 21 patients with unilateral complete clefts and on 27 patients with incomplete clefts. A mucoso-periosteal flap raised from the hard palate was used mainly for closure of the cleft and not for the push-back. The 3M flap repaired the deficit of the nasal mucosa, making sure that the soft palate was lengthened. Intravelar veloplasty was performed also. Results: The dimension of the nasal mucosal defect that can be filled with the 3M flap is 10 to 12 mm in length, oriented anterior-posterior, and 15 to 20 mm wide. Oronasal fistula formation was recognized in only 3 of 48 cases (2 of 21 complete clefts, 1 of 27 incomplete clefts) and were located at the hard-soft palate junction at the anterior portion of the 3M flap. Conclusions: This method has the theoretical advantages of (1) preventing fistula formation by filling the tissue deficiency with the 3M flap; (2) achieving better velopharyngeal function due to elongation of the soft palate and retropulsion of the muscular bundle, utilizing the 3M flap; and (3) minimizing maxillary growth retardation by adopting a non–push-back method of hard palate repair.

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Cleft palate repair and variations

Indian Journal of Plastic Surgery ◽

10.1055/s-0039-1699382 ◽

2009 ◽

Vol 42 (S 01) ◽

pp. S102-S109

Author(s):

Karoon Agrawal

Keyword(s):

Cleft Palate ◽

Soft Palate ◽

Hard Palate ◽

Cleft Lip ◽

The Face ◽

Cleft Palate Repair ◽

Palate Repair ◽

Pharyngeal Flap ◽

The One ◽

Ideal Technique

ABSTRACTCleft palate affects almost every function of the face except vision. Today a child born with cleft palate with or without cleft lip should not be considered as unfortunate, because surgical repair of cleft palate has reached a highly satisfactory level. However for an average cleft surgeon palatoplasty remains an enigma. The surgery differs from centre to centre and surgeon to surgeon. However there is general agreement that palatoplasty (soft palate at least) should be performed between 6-12 months of age. Basically there are three groups of palatoplasty techniques. One is for hard palate repair, second for soft palate repair and the third based on the surgical schedule. Hard palate repair techniques are Veau-Wardill-Kilner V-Y, von Langenbeck, two-flap, Aleveolar extension palatoplasty, vomer flap, raw area free palatoplasty etc. The soft palate techniques are intravelar veloplasty, double opposing Z-plasty, radical muscle dissection, primary pharyngeal flap etc. And the protocol based techniques are Schweckendiek's, Malek's, whole in one, modified schedule with palatoplasty before lip repair etc. One should also know the effect of each technique on maxillofacial growth and speech. The ideal technique of palatoplasty is the one which gives perfect speech without affecting the maxillofacial growth and hearing. The techniques are still evolving because we are yet to design an ideal one. It is always good to know all the techniques and variations so that one can choose whichever gives the best result in one's hands. A large number of techniques are available in literature, and also every surgeon incorporates his own modification to make it a variation. However there are some basic techniques, which are described in details which are used in various centres. Some of the important variations are also described.

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Oronasal fistula in cleft palate surgery

Indian Journal of Plastic Surgery ◽

10.1055/s-0039-1699385 ◽

2009 ◽

Vol 42 (S 01) ◽

pp. S123-S128 ◽

Cited By ~ 1

Author(s):

Partha Sadhu

Keyword(s):

Cleft Palate ◽

Recurrence Rate ◽

Surgical Procedures ◽

Soft Palate ◽

Hard Palate ◽

Local Flaps ◽

Oronasal Fistula ◽

Palate Repair ◽

Vascular Accidents ◽

Nasal Regurgitation

ABSTRACTOronasal fistula (ONF) is the commonest complication associated with cleft palate surgery. The main symptoms associated with ONF are nasal regurgitation of food matter and hypernasality of voice. Repair of cleft palate under tension is considered to be the main reason of ONF though vascular accidents and infection can also be the cause. Most of the ONFs are situated in the hard palate or at the junction of hard and soft palate. Repair of ONF depends on its site, size and mode of presentation. A whole spectrum of surgical procedures starting from small local flaps to microvascular tissue transfers have been employed for closure of ONF. Recurrence rate of ONF is 25% on an average after the first attempt of repair.

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Speech in Children with an Isolated Cleft Palate: A Longitudinal Perspective

The Cleft Palate-Craniofacial Journal ◽

10.1597/04-071.1 ◽

2006 ◽

Vol 43 (3) ◽

pp. 295-309 ◽

Cited By ~ 20

Author(s):

Christina Persson ◽

Anette Lohmander ◽

Anna Elander

Keyword(s):

Cleft Palate ◽

Outcome Measures ◽

Soft Palate ◽

Hard Palate ◽

Surgical Intervention ◽

University Hospital ◽

Speech Sounds ◽

Velopharyngeal Function ◽

Isolated Cleft Palate

Objective To describe articulation and speech symptoms related to velopharyngeal impairment in children born with an isolated cleft palate. Design Blind assessment of speech at 3, 5, 7, and 10 years of age was performed. Two subgroups were formed based on the results at age 5 years, the no-VPI group and the VPI group, and they were compared with controls. Setting A university hospital. Patients Twenty-six children born with isolated cleft palate. Seventeen children served as controls. Interventions Soft palate closure at 7 months and hard palate closure at a mean age of 3 years and 11 months if the cleft extended into the hard palate. Main Outcome Measures Perceptual assessments of four variables related to velopharyngeal function and of articulation errors were performed at all ages. Phonetic transcriptions of target speech sounds were obtained at 5, 7, and 10 years and nasalance scores were obtained at age 10 years. Results The no-VPI group continued to have no or minor difficulties. The VPI group improved but continued to have moderate velopharyngeal impairment. Both groups differed significantly from the controls at age 10 years. Persistent velopharyngeal impairment, as well as glottal misarticulation, were mostly found in children with the cleft as a part of a syndrome or together with multiple malformations. Conclusion Small changes in velopharyngeal impairment were found across ages. Improvement seemed to be related to surgical intervention, and persistent problems seemed to be related to the presence of additional multiple malformations or syndromes.

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