Maxillary sequels in labial-alveolar-velopalatine clefts. Orthodontic management

Routine othodontic management is unavoidable in all patients with cleft lip and palate after primary surgery. This management combines dental arch alignment with maxillary expansion of the lesser fragment before alveolar bone grafting. To treat dental arch asymmetry, the space of the missing lateral incisor is preserved until the age of dental implant. Otherwise, dento-orthopedic treatment attempts to normalize transversal dental dimension once alveolar bone grafting is done in order to prepare the surgical advancement of the maxilla.     

Otologic sequels in velopalatine clefts. Analysis and management

As early as in 1878, medical teams managing children born with a velopalatine cleft had noted the prevalence of middle-ear pathologies largely related to anatomic and inflammatory Eustachian tube dysfunction. The aim of this study was to describe otologic sequels related to a velopalatine cleft and to suggest an adapted management. These sequels are evolving presentations of chronic serous otitis; they worsen the functional prognosis (hypoacousia) and more rarely the vital prognosis (cerebral or infectious complications of cholesteatoma). We must stress the importance of prevention: during the initial management, by Eustachian tube rehabilitation, and by ENT (Ear, Noseand Throat) follow-up allowing to prevent these sequels and to bring hearing to normal as soon as possible, so as to support cognitive development, language skills, and sociofamilial integration of the children.     

Maxillary sequels in labial-alveolar-velopalatine clefts. Role of distraction osteogenesis

A high rate of cleft patients present with maxillary hypoplasia. Most of the growth defects concern the anteroposterior axis of the maxilla. Before bone lengthening by distraction osteogenesis, orthognathic surgery was the only alternative treatment for maxillary hypoplasia. Several studies showed the lack of stability after conventional surgery. In this article reviewing the literature concerning all bone lengthening procedures, the authors discuss published data on maxillary distraction osteogenesis by external and internal devices. Indications of distraction in growing children as an interceptive step are discussed.     

Velopharyngeal sequels in labial-alveolar-velopalatine clefts. Orticochea dynamic pharyngoplasty

Sphincter pharyngoplasty is one of the treatments for velopharyngeal insufficiency, in cleft palate patients. After Hynes, Orticochea described a procedure which became the reference. After studying 2 series of patients treated by two different surgical procedures, it appeared that the speech improvement was nearly the same. Improvement of the results was obtained when the surgical procedure took into account the physiopathology of the velopharyngeal insufficiency. When the velar mobility was weak or absent, but with an effective mobility of lateral pharyngeal walls, a pharyngoplasty with a pharyngeal flap and a superior pedicle was chosen. On the opposite, with an effective velar mobility, sphincter pharyngoplasty was chosen. When both were poor (velar and lateral pharyngeal walls), it seems that using a pharyngeal flap with a velum pushback gave the best result. If hypernasality persisted after pharyngoplasty, a second procedure had to be performed.     

Velopharyngeal sequels in labial-alveolar-velopalatine clefts. Analysis, conclusions and speech therapy management

The association of voice and speech defines phonation. Phonation depends on various organs: the lungs for air, the larynx as a vibration generator, and cavities of resonance modeling articulation and tone. The role of the soft palate is important in French and for everyday conversation. Velopharyngeal incompetence is defined as a voice and articulation disruption by anatomic and/or functional deficiency between the soft palate and pharynx. Hypernasality is studied on an acoustic, phonetic, and vocal level and graded in various degrees of hypernasality. The various clinical and perceptive tests of velopharyngeal incompetence are described according to age. The difficulty to modelize hypernasality is discussed based on a recent study published in 2007. The differential diagnosis with hyper-closed nasality is discussed. The treatment for this condition is essentially speech therapy associated with pharyngoplasty in some cases. The assessment of children born with a labial-alveolar-velopalatine cleft is mainly clinical and perceptive. Therapeutic management is necessary for the child and his family. The follow-up requires a multidisciplinary approach.     

Nasal sequels of unilateral clefts: analysis and management

Usually, the nasal sequels of unilateral cleft patient are just considered as an esthetic problem to be addressed after the growth spurt of adolescence. This very narrow vision has led the cleft lip and palate treatment to a deadend. Actually, nasal sequels are the worst in terms of consequence on facial growth. 75% of complete unilateral cleft children are more oral than nasal breathers. Today, we know about the bad consequences of oral breathing on facial growth. It is not surprising to observe a high rate of small maxilla with cleft maxilla scars. In the fetus, the unilateral cleft nose deformities are well explained by the rupture of the facial envelope and the ventilatory dynamics of the amniotic fluid. Every step of the primary treatment threatens the nasal air way patency, whether when repairing lip and nose, suturing the hard palate that is the floor of the nose, or closing the alveolar cleft which controls the width of the piriform aperture. The functional and esthetic nasal sequels reflect the initial deformity, but are also the surgeon's skill and protocol choice. Before undertaking treatment, we must analyze the deformity at every level. Usually, the best option is to reopen the cleft completely to perform a combined revision of the lip, nose, and alveolar cleft after an adequate anterior maxillary expansion. If nasal breathing is necessary for an adequate facial growth, 25 years of experience showed us that it was very difficult to erase the cortical imprint of an early oral breathing pattern. So it is essential to establish a normal nasal breathing mode at the initial surgery. When the initial surgery is efficient and/or the secondary repair is successful, the final esthetic rhinoplasty, when indicated, is just performed for the sake of harmonization, with a classic internal approach and a few refinements.     

Velopharyngeal sequels in labial-alveolar-velopalatine clefts. Pharyngoplasty by pharynx Lipostructure

Advancing the posterior pharyngeal wall is a classic technique to treat velopharyngeal insufficiency. Injection of autologous fat behind the posterior pharyngeal mucosa according to the Coleman Lipostructure technique is a recent development. The authors report their experience in six cases using this modification. The preoperative work-up was performed by a speech therapist with a physical examination and measurement of the nasal air loss was performed using an aerophonometer. Fat was harvested either on the abdominal wall or on a buttock and then centrifuged. Fat injection was performed using a curved blunt cannula under the mucosa of the lateral and posterior pharyngeal walls. Injecting fat is an autologous graft of fat tissue: after a postoperative period of three months, the volume of fat becomes permanently stable. In five out of the six patients who presented moderate velopharyngeal insufficiency, speech improvement was significant. The single failure was a patient with bilateral cleft lip and palate sequels after previous pharyngoplasty using the Orticochea procedure. Treatment of moderate velopharyngeal insufficiency using fat injection is an efficient method. The advantages are its innocuousness and that scaring of the pharynx is avoided.     

A functional approach in the primary treatment of labial-alveolar-velopalatine clefts for a minimum of sequels

Is the poor potential of growth an ineluctable consequence of mesodermal deficiency? Should we agree with the idea that all protocols are equivalent? Actually, these opinions reflect the empiricism of previous generations. We must now become rational and develop a project without compromise to achieve good functions at primary surgery. 'The normal structures are present on either side of the cleft, only modified by the fact of the cleft...' Victor Veau's hypothesis is the conclusion of rigorous anatomical and embryological research. Our current knowledge of the pathological anatomy allows for a better restoration of the normal anatomy. Anatomy is nothing if it is not functional. Every thing should be done to control the healing process to allow the best expression and interaction of the various functions, especially for those concerning nasal ventilation and masticatory efficiency. To correct the deformity, the cleft surgeon must perform a wide subperiosteal and subperichondrial elevation and must learn the skills of this accurate work to preserve the integrity of very fragile structures. The primary treatment must take into account a rational and uncompromising selection of the age of the first operation, of the successive procedures, and their chronology to benefit from the growth spurt of the maxilla, and to avoid the worse scars resulting from secondary epithelialization. Finally, if nasal breathing is the most important function concerning facial growth, it is essential to restore this normal function at the time of the first operation. The oral breathing pattern set at the time of the first operation leaves a cortical imprint that is very difficult to erase, even after clearing the nasal airways. The results of the functional approach we have used in the last decade are particularly consistent and very convincing. In this ambitious and demanding program, the patient comes first; we decrease the burden for him and his family, and give them the benefit of a good social life before school age.     

Velopharyngeal sequels in labial-alveolar-velopalatine clefts. Veloplasty and pharyngoplasty using an inferior or superior pedicle pharyngeal flap

Velopharyngeal insufficiency remains a sequel of labial-alveolar-velopalatine clefts. It may occur despite a good quality primary repair. A surgical management must be considered as soon as speech therapy is no longer efficient or before any irreversible compensatory speech pattern appears. Thus, surgery should be decided on after consultation between the surgeon and the speech pathologist or speech therapist, when considering that speech therapy has failed. Several surgical techniques are discussed: intravelar veloplasty, Furlow double-opposing Z-plasty, pharyngoplasty using an inferior or superior pedicle flap. Superior pedicle flap surgery is currently the most commonly used technique. For the past twenty years we have used this technique as described by Petit and modified by Malek, because of the excellent speech results. The drawbacks are known and can be contained by a preventive management.     

Sequels of labial-alveolar-velopalatine clefts observed in charity missions. Analysis and management

A lot of children with cleft lip and palate are not operated in the developing world, due to a lack of surgeons, hospitals, or simply because the condition is not considered as a priority. Charity missions give the opportunity to repair these malformations. Non-operated cleft lip and palate are the first problem, but our surgery may cause growth disturbances and sometimes a second operation is needed, more difficult than the first one in mission conditions. Repairing a cleft palate needs to be adapted to the type of cleft but also to the age of the child, a velopalatine pharyngoplasty can be performed in some cases.     

Specificity of prosthetic dental rehabilitation in cleft lip and palate sequels

The same techniques are used for dental rehabilitation in cleft patients and non-cleft patients. The clinical state for cleft edentulous patients ranges from one missing tooth to maxillary loss. For cleft patients, several surgical procedures may have been performed to close the cleft lip and/or palate, so the patient will not always agree to a new surgical procedure for preprosthetic management. The main difference to take into account is the dental occlusion stability. If previous management of the cleft patient did not provide normal occlusion, dental rehabilitation is the alternative. We describe implant-supported prosthesis; implant stabilized prosthesis, bridge, and maxillofacial prosthesis.     

Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. In this article the authors analyze the impact of primary surgery on the maxillary growth failure and discuss on how to prevent this complication.     

Labial sequels after uni- and bilateral cleft lip repair

Children born with labial-alveolar-velopalatine clefts must be managed by multidisciplinary teams in order to decrease the frequency and the importance of sequels, by implementing a true therapeutic strategy. It is indeed easier to avoid a secondary deformation than to correct it. Labial sequels are often associated to nasal sequels, and are managed in a single surgical intervention, with total revision of the cheilorhinoplasty. Some less important labial deformities can be corrected without total and simultaneous revision of the lip-nose complex. The goal of correction is functional and aesthetic, and the choice of the moment depends mainly on the psychological impact of the deformation for the child, and his motivation for reoperation.     

Maxillary sequels in labial-alveolar-velopalatine clefts. The role of orthognathic surgery

Maxillary hypoplasia is a common sequel in cleft lip and palate deformities. After primary surgery to close lip and palate, patients routinely need extensive treatment particularly orthodontic management. With this type of approach, maxillary hypoplasia is less frequent and severe and subsequent orthognathic surgery is efficient in most cases. Without the proper management maxillary hypoplasia may be severe and patients will need a modified management and specific revision. At the end of maxillar growth, the first aim of treatment is to achieve continuity of the maxillary arch with gingivoperiosteoplasty. The transversal insufficiency can then be treated by distraction osteogenesis. Orthodontic treatment should leave place for missing teeth.     

Growth defects of fibular flaps in children

BACKGROUND: Mandibular reconstruction with fibula free flap is a challenge in pediatric patients because of the size of the bone and absence of growth without epiphyseal transplantation. CASE REPORT: We report 2 cases of free fibula flap in children for mandibular reconstruction. The 2 patients presented with growth insufficiency of the bone graft after few years of evolution. DISCUSSION: Growth insufficiency was treated with different surgical procedures which were discussed We review the consequences on growth after fibula free flap and the specific indications to achieve epiphyseal fibular growth in children.     

Dehiscence of the greater palatine nerve. A risk factor in inferior turbinectomy?

Inferior turbinectomy, often combined with septal surgery, is frequently performed in the surgical treatment of nasal obstruction. A patient with post-operative greater palatine anaesthesia occurring after this procedure prompted a study of the anatomy of the greater palatine nerve in the region of the inferior turbinate. Sixty-four lateral nasal walls were examined in cadavers. A dehiscence rate of 22% was noted, and in an additional 55% there was only a minimal bony covering to the nerve. Dehiscences occurred exclusively in the inferior meatus, anterior to the posterior bony end of the inferior turbinate. The narrow antero-posterior extent of the dehiscence, the hard dense lateral nasal wall bone and the lateral position of the nerve in the canal help to protect the nerve from surgical trauma during turbinate surgery.     

Medial cleft of the tongue, the lower lip and the mandible

INTRODUCTION: The oro-facial clefts are very frequent congenital malformations, with many clinical forms. We report an exceptional case of median cleft of the tongue, the lower lip and the mandible. CASE REPORT: Our patient was a new born, admitted in our unit for major facial malformation with swallowing disorder. The patient presented a particular form of cleft no 30 in Tessier's classification, which associated two hemi-tongues, two hemi-lower lips and two hemi-mandibles. Surgery was performed early because of the swallowing disorder. Cosmetic and functional results were positive, with 18 month follow-up. DISCUSSION: With a review of the literature, we describe this pathology, its embryologic origin, its different clinical forms and its treatment.