Definition & Overview

Cleft palate reconstruction is the surgical procedure to repair a congenital condition in which the roof of the mouth failed to fuse completely.

Cleft palate is a common deformity affecting one in a thousand children and may involve either the soft or hard palate or both. Some patients with cleft palate also have associated syndromes affecting the limbs, heart, and other parts of the body. The causes of this condition are not completely known, though it is recognised to be genetically influenced and affects more males than females. Cleft palate can be diagnosed even before birth with the use of ultrasound and can occur with or without cleft lip.

Reconstructing the cleft palate is a complex procedure, involving several medical specialists and practitioners to provide specialised care to improve the patient’s overall quality of life. If left untreated, this condition adversely impacts the child’s feeding habits, speech production, teeth growth, and maxillofacial growth.

Who Should Undergo and Expected Results

Paediatric patients with cleft palates typically start to undergo reconstructive surgery before they turn a year old. However, infants who are also diagnosed with heart diseaseor compromised breathing are generally treated for these conditions before they are allowed to undergo cleft palate reconstruction. In some cases where a submucous cleft is present, the physician may advise to defer the procedure until the child is four years old.

Timing is considered an important factor in achieving excellent outcomes. The child has to be old enough to tolerate surgery but at the same time, young enough that the condition does not have significant impacts on its growth and speech development just yet.

There are some cases in which the physician may not be able to diagnose cleft palate immediately after the birth of the child. This is especially true for patients with partial clefts of the soft palate, which is characterised by difficulty in feeding, nasal reflux of food and liquids, and hypernasal speech. Older children diagnosed with cleft palate are still eligible to undergo cleft palate reconstruction.

Though complex, recent advancements in cleft palate reconstruction have significantly improved its success rate. Most patients resume normal activities after several weeks while the external scars in the upper lip and below the nose fade over time.

How is the Procedure Performed?

There are varied techniques for surgically repairing the cleft palate. These include the von Langenbeck technique, the Bardach Two-flap palatoplasty, one-stage cleft lip and palate repair, Vomer flap, the buccal myomucosal flap, among others.

Cleft palate reconstruction is performed in a hospital setting under sedation. Despite the varied techniques, the procedure typically involves making incisions on the sides of the cleft and using the soft tissue taken from the sides to rebuild the palate. The flaps are used to reposition the hard and soft palate. Sutures are then used to join the flaps at the midline of the roof of the mouth. The reconstruction process does not only address the closing of affected part but may also involve the alignment of the upper jaw, positioning the teeth, and repairing nearby parts such as the ears. In most cases, a part of the hard palate is left open to allow growth of the affected part and its nearby facial structures such as the mouth and jaw.

If the cleft palate extends into the anterior part of the mouth, alveolar bone grafting may be performed with bone graft taken from ribs or hips.

Patients may experience postoperative pain, which can be managed with mild analgesics. Utmost care is taken to make sure that the patient’s airway is not blocked. Injury to the surgical site is also prevented among younger patients with the use of arm restraints. Patients often have to undergo several therapy modalities to improve their speech, dental, and hearing development. Also, diet has to be restricted to liquid and soft food to allow repair of the palate. Further surgeries, such as rhinoplasty and palatal expansion may be required to complete the reconstructive process.

Possible Risks and Complications

Risks and complications of cleft palate reconstruction are the following:

  • Surgical risks, which include adverse reaction to anaesthesia, bleeding, and infection of the surgical site
  • Postoperative complications, which include nasal congestion and bloody drainage from the mouth and nose
  • Swelling and bruising of the surgical site
  • Respiratory distress, which could prove fatal if not addressed immediately
  • Wound dehiscence resulting from excessive wound tension and poor tissue quality
  • The development of oronasal fistula in the surgical site
  • The development of chronic otitis media
  • Maxillary growth restriction, which is manifested in narrower dental arch or decreased interior and posterior dimensions of the palate



References:

  • Hanes LA, Murphy A, Hatchette JE, et al. Chronic Otitis Media with Effusion Is Associated with Increased Risk of Secondary Speech Surgery. Plast Reconstr Surg. 2015 Aug. 136 (2):343-9.

  • Lee YH, Liao YF. Hard palate-repair technique and facial growth in patients with cleft lip and palate: a systematic review. Br J Oral Maxillofac Surg. 2013 Sep 14.

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