Cleft palate is a condition in which the two plates of the skull that form the hard palate or the muscles that form the soft palate are not completely joined. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide.
Cleft palate can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). They can be unilateral or bilateral.
Incomplete cleft palate
Unilateral complete cleft lip and palate
Bilateral complete cleft lip and palate
Surgical Anatomy of a normal and cleft palate
The palate is the roof of the mouth. The palate has to be seen as two distinctive units:
The hard palate—This is the front part of the palate and is made of bone and is hard.
The hard palate is essential for normal facial growth, facial aesthetics, and dental development. Focus here is cleft palate closure with a type of surgery without excessive scarring. Surgical scarring is proven to result during growth in retardation of the development of the upper jaw with abnormal dentition and a dish-in face.
The soft palate— This is the back part of the palate and is made of muscles and does not contain bone hence is soft.
The soft palate is the unit that enables normal speech since the soft palate is the housing of the speech muscles. So focus of the soft patalte surgery is speech, which is of paramount importance. Normal speech, above all, is to be seen as an absolute priority.
On the back are the soft palate muscles in a normal (left) and cleft (right) palate. On the front you see the bones of the hard palate.
Both the hard and soft palate are covered by a mucous membrane.
Soft and Hard palate, covered by mucosa.
In certain cases, the mucous membrane may appear intact, but the bones and/or muscles beneath it may not be appropriately fused in the midline. Despite its almost normal surface appearance, the underlying changes still can create functional problems, particularly for speech. This type of cleft palate is known as a submucous cleft palate.
Timing of the cleft palate surgery
The timing of cleft palate surgery is based upon considerations of speech development and the inhibition of subsequent growth by surgical scarring. Some surgeons repair the palate in two stages. The two-stage technique closes the soft palate at the time of earlier cleft lip repair followed by hard palate repair at a later date. However, most surgeons repair both the hard and soft palates together in a single stage between the ages of 9 and 18 months.
We tend more and more to use a new technique that enables us to close
the whole palate in 1 operation without causing a lot of scarring on the hard palate.
We advocate an earlier repair, stating that feeding, speech and socialization are improved if the surgery is performed by the 1st year of life, and that facial growth problems can be minimized with less traumatic palate repairs. We think that surgical correction of a cleft palate should be accomplished when patients are younger than 1 year, before significant speech development occurs. The potential benefits of an intact velum as a child begins to speak are believed to outweigh the possible complications of early closure, namely later collapse of the maxillary arch with a resultant crossbite.
Similar to a lip adhesion for a wide cleft lip, a 2-stage approach may still be useful when the cleft palate is particularly wide.
Cleft palate surgery
The surgery involves making a number of incisions in the palate and using the tissue and muscle present in the roof of the mouth and joining these together to close the cleft in three layers, namely the roof of the mouth, the floor of the nose and the muscle in between. Like the lip repair, there are a number of different techniques the surgeon can use.
Repair of the soft palate is accomplished by reattaching the muscles as anatomically as possible to form a functional muscle sling. This reconstruction of the muscular sling is called an intravelar veloplasty. The soft palate is further lengthened by placing a flap from the inside of the cheek in between the hard palate and the soft palate, thus minimizing the risk of persistent velopharyngeal inadequacy.
The soft palate is further lengthened by placing cheekflaps in between the hard palate and the soft palate, thus minimizing the risk of persistent velopharyngeal inadequacy.
Repair of the hard palate is accomplished, not by moving the palatal bones, but rather by reattaching the mucosal coverings of the bone in two layers (nasal and oral). With the use of a second mucosal cheek flap to partly bridge the oral layer of the hard palate cleft we minimize the amount of tension and scarring.
With the use of a second mucosal cheek flap to partly bridge the oral layer of the hard palate cleft we minimize the amount of tension and scarring.
The inside of the cheeks where the flaps have been taken normally heals without problems.
After The Surgery For Cleft Palate
Pain—Cleft palate surgery is usually more involved and can cause more discomfort and pain for the child than cleft lip surgery. Your child's health care provider may order pain medicine to help with this. As a result of the pain and the location of the surgery, your child may not eat and drink as usual. An intravenous (IV) catheter will be used to help give your child fluids until he/she can drink adequately.
Stitches—Your child will have stitches on the palate where the cleft was repaired. The stitches will dissolve after several weeks and they do not have to be taken out by the health care provider.
Blood—After cleft palate surgery there may be some bloody drainage coming from the nose and mouth that will lessen over the first day.
Swelling—There will be some swelling at the surgery site, which will diminish substantially in a week.
Nasal congestion—Many infants show signs of nasal congestion after cleft palate surgery. These signs may include nasal snorting, mouth breathing, and decreased appetite. Your child's physician may prescribe medication to relieve the nasal congestion.
Antibiotics—Your child will be on antibiotics to prevent infection during surgery.
Hospitalisation—Your child may be in the hospital for one to three days, depending on your child's general condition and capability to drink.
Complications of cleft palate surgery
In about 10% of cleft palate surgery the center of the repair does not heal, leaving a hole (fistula) through which there may be excess leakage. This hole usually needs to be closed surgically at a later stage (between 3 and 10 years of age).