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CLEFT LIP AND PALATE
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Jennifer E. Woerner, A. Omar Abubaker
CHAPTER 38
EMBRYOLOGY
1. Which processes merge to form the upper lip, anterior maxillary alveolus, the
nose, and the mouth?
The merger of the maxillary and medial nasal processes forms the upper lip and anterior maxillary
alveolus. The merger of maxillary and mandibular processes forms the mouth, whereas the merger of
the lateral nasal process forms the ala of the nose.
2. How does cleft lip develop?
Cleft lip develops from failure of fusion of the medial nasal process and the maxillary process.
3. At what time during gestation do cleft lip and/or palate occur?
The upper lip and premaxilla form at approximately 7 weeks’ gestation. Disruption around this time
results in clefting of the lip and/or alveolus. The palatal shelves fuse at approximately 12 weeks of
gestation. Disruption around this time results in clefting of the hard and/or soft palate.
4. Why are left-sided secondary or palatal clefts more common than right-sided
clefts?
Up to the seventh week of gestation, the two palatal shelves of the human embryo lie almost vertically.
As the neck straightens from its flexed position, the tongue drops posteriorly, and the shelves rotate
superiorly to the horizontal position; they fuse from anterior to posterior to form the palate by 12 weeks. In
rodents, the right palatal shelf reaches the horizontal position before the left one, leaving the left side susceptible to developmental interruption for a longer period than the right. It is believed that this sequence
of changes occurs in humans as well and may account for the higher incidence of left-sided clefts.
ANATOMY
5. What are the primary and secondary palates?
The primary palate comprises the lip, alveolar arch, and palate anterior to the incisive foramen (the
premaxilla). The secondary palate comprises the soft palate and hard palate posterior to the incisive
foramen. The primary and secondary palates are separated by the incisive foramen (Fig. 38-1).
6. Which orofacial muscles are anatomically abnormal in cleft lip and palate?
In cleft lip, the main muscle involved is the orbicularis oris muscle. In cleft palate, several muscles are
usually involved, depending on the extent of the cleft. In complete cleft palate, the levator veli palatini,
tensor veli palatini, uvular, palatopharyngeus, and palatoglossus muscles are involved (Fig. 38-2).
7. What is Passavant’s ridge?
Passavant’s ridge is a transverse ridge or a bulge produced by the forceful contraction of the superior
pharyngeal constrictor on the posterior pharynx opposite the arch of the atlas. This ridge is observed
during gagging and pronunciation of vowels. It is an important mechanism in velopharyngeal closure.
8. What is the blood supply to the palate?
The palate has an abundant blood supply that includes the greater and lesser palatine branches from
the descending palatine a. (branch of maxillary a.), palatine branch of the ascending pharyngeal a.
(branch of external carotid a.), ascending palatine branch of the facial a., and tonsillar branches of the
dorsalis linguae.
EPIDEMIOLOGY
9. What factors are known to cause cleft deformities?
Less than 40% of clefts of lip and palate are of genetic origin, and less than 20% of isolated cleft
palates are of genetic origin. Corticosteroids and diazepam taken during the first 8 weeks of pregnancy
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CHAPTER 38 CLEFT LIP AND PALATE 383
Incisive foramen
Palatine process
Lateral pterygoid
Vomer
Accessory m.
Uvulus m.
AB
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Premaxilla
of maxilla
Palatine bone
Major palatine
foramen
Hamulus
plate
Medial pterygoid
plate
Posterior nasal spine
Figure 38-1. Anatomy and divisions of the palate into primary and secondary palates. (From Randall P, LaRosa D: Cleft
palate. In McCarthy JG, editor: Plastic surgery, Philadelphia, 1990, Saunders.)
Aponeurosis
Hamulus
Tensor m.
Levator m.
Figure 38-2. Musculature of the A, normal soft palate and B, cleft soft palate. Note that in the normal musculature, the
elevator muscles are oriented transversely and insert in the midpalate. In the cleft palate, the musculature is disrupted and
the muscles are oriented more longitudinally, inserting on the posterior edge of the palatal bone and along the bony edges
of the cleft. (From Randall P, LaRosa D: Cleft palate. In McCarthy JG, editor: Plastic surgery, Philadelphia, 1990, Saunders.)
Aponeurosis
Hamulus
Tensor m.
Levator m.
are also believed to be etiologic factors. Viral infections, lack of certain vitamins, and other factors
during the first trimester of pregnancy are suspected as well.
10. What is the incidence of cleft lip with or without cleft palate in the general population? In different ethnic groups?
The incidence of cleft lip worldwide is approximately 1 in every 700 to 800 live births. Incidence is
highest in the Japanese, about 2.1 to 3.2 in every 1000 births. In Caucasians, incidence is 1.4 in every
1000 births; in Africans, it is 0.3 to 0.43 in every 1000 births.
The incidence of isolated cleft palate in general is 1:2000.
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11. When is a cleft palate associated with a cleft lip?
The most frequent combination is a unilateral cleft of the lip and palate, which is seen more often in
boys than girls, and predominantly on the left side. The hereditary incidence in these patients is fairly
high. The next most common cleft is isolated cleft palate, which is seen more frequently in girls; the
hereditary incidence in these patients is fairly low. Bifid uvula has an incidence of about 2%, but most
cases are asymptomatic. However, as many as 20% of patients with bifid uvula have some degree of
velopharyngeal incompetence (VPI).
12. What is the familial risk for developing cleft palate?
Family Makeup Risk of CL/P Risk of CP
One affected sibling or parent 4% 2.5%
Two affect siblings 9% 1%
One sibling and one parent 16% 15%
13. Is prenatal ultrasound useful in diagnosing cleft deformity?
Successful imaging of the face is usually not possible till approximately 15 weeks’ gestation. The lip
is most easily visualized in the coronal plane. Identification of isolated cleft palate may be more challenging, but it is easiest to visualize in the axial plane.
14. What is the importance of auditory screening in this population?
The same muscles that elevate the soft palate also help to tense and open the eustachian tube to
equalize the middle ear; therefore, children born with cleft palate are at risk for eustachian tube
dysfunction and chronic middle ear effusions because these muscles do not function appropriately.
It is recommended that all children undergo a newborn hearing screen. If they do not pass, they will
have this exam repeated by an audiologist and have a follow-up with an ENT to check for middle ear
effusions. It is recommended that this be completed before 6 months of age.
15. What are the currently available feeding aids for cleft patients?
There are multiple specialty feeders for cleft children. The Mead Johnson is a low-cost compressible
bottle that allows the caregiver to squeeze the milk into the infant’s mouth as he or she is sucking. The
Pigeon Nipple has a faster flow and can often be used by older infants on any bottle. The nipple itself
is compressed against the hard palate and does not require sucking to dispel milk. The Haberman
feeder is a more expensive bottle that is good for children who are small or premature. It contains a
one-way valve that keeps milk in a soft chamber and nipple. The chamber can then be pumped to
dispel milk into the infant’s mouth. The flow can be adjusted by rotating the nipple.
When bottle feeding cleft infants, it is important to remember they swallow more air when sucking
than non-cleft infants; therefore, it is important to feed them upright at a 45 degree angle and burp
them frequently.
CLASSIFICATION
16. How can clefts be classified?
Clefts can be described as complete or incomplete, and prepalatal (cleft of the primary palate) or
palatal (cleft of the secondary palate). Prepalatal can be further divided into unilateral or bilateral;
each may be further subdivided into involving one-third, two-thirds, or all (complete cleft) of the lip.
Similarly, palatal clefts may be described as involving one-third, two-thirds, or all of the soft palate
and one-third, two-thirds, or all of the hard palate, extending up to the incisive foramen (Fig. 38-3).
A cleft can also be classified as a submucosal cleft palate or a bifid uvula (see questions 18 and 19).
17. What is the difference between a complete and incomplete cleft of the lip?
A complete cleft lip is a cleft of the entire lip and the underlying premaxilla, or alveolar arch. An incom-
plete cleft lip involves only the lip.
18. What is a submucous cleft?
A submucous cleft is a deficiency in the musculature of the palate due to failure of the levator muscle
fibers to fuse completely in the midline. However, clinically, the palate looks intact because the overlying oral and nasal mucous membranes are present. A submucous cleft is characterized by a bifid
uvula, loss of the posterior nasal spine, and a bluish midline streak on the soft palate due to muscular
diastases. A notch may be present in the posterior hard palate.
CHAPTER 38 CLEFT LIP AND PALATE 385
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Nose
1
Nasal floor
5
2
3
Figure 38-3. Millard’s modified classification of Kernahan’s and Elsahy’s classification of cleft lip and palate. The small
circle indicates the incisive foramen. (Modified from Randall P: Cleft palate. In Smith JW, Aston SJ, editors: Grabb and
Smith’s plastic surgery, ed 4, Boston, 1991, Little, Brown.)
This type of cleft usually leads to difficulties with speech and to VPI because the muscles of the
soft palate are unable to function normally. A congenital absence of the muscularis uvulae may also
occur (with or without a bifid uvula) and is often associated with palatal incompetence.
19. What is a bifid uvula?
A bifid uvula is a variation of cleft palate seen in 2% of the normal US population. It may be associated
with palatal incompetence, and patients should be followed for possible speech problems.
Lip
Alveolus
Hard
4
Hard
palate
10
Soft
11
palate
palate
9
6
7
8
CLEFT LIP REPAIR
20. What are the criteria for timing of cleft lip repair?
Surgical repair of cleft lip is generally carried out at 10 to 14 weeks of age. However, traditionally,
the time of repair of cleft lip often is based on the Rule of Tens. According to this rule, cleft lip
can be closed when the infant is ≥10 weeks old, the hemoglobin is ≥10 g/dL, and the child’s weight
is ≥10 lb.
21. What is Simonart’s band?
Often defined as the soft tissue band between the margins of the cleft lip, nostril, or alveolar cleft
when a complete skeletal cleft of the alveolus is also present. Most of these soft tissue adhesions are
located at the base of the nostril. They often help maintain nasal form and decrease the dimensions of
the soft tissue cleft and segmental displacement, possibly aiding in primary lip repair.
22. What is the lip adhesion procedure?
Lip adhesion is reserved for very wide clefts in which primary closure may not be possible. It is usu-
ally carried out at 3 to 4 months of age with the definitive repair planned for 6 to 12 months of age.
Advantages include narrowing of a wide cleft and alignment of the alveolar arches. Disadvantages
include an additional anesthetic and possibility of increased scar tissue formation.
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23. What are some of the techniques for cleft lip repair?
These techniques are the lip adhesion procedure, the Millard rotation advancement flap, the Tennison
Randall triangular flap, and the Delaire.
24. What is the Millard rotation advancement flap?
The Millard rotation advancement flap is a modified Z-plasty technique placed at the top of the cleft
so that the point of greatest tension is placed at the base of the nares. It is the most popular method
of cleft lip repair. It is used for complete, incomplete, and wide cleft repairs and is ideal for closing
incomplete or narrow clefts. The technique involves downward rotation of the philtrum of the lip as a
flap into normal symmetric position, while the lateral lip segment is advanced across the cleft and into
the space behind the central lip. The final scar from the suture line closely recreates the philtrum of
the lip on the cleft side (Fig. 38-4).
CLEFT PALATE REPAIR
25. What is the timing for cleft palate repair?
In most centers, repair of the cleft palate is carried out when the child is 10 to 18 months of age, the
age at which articulate speech skills are beginning to develop. In contrast, some centers prefer repair
to be delayed until 18 to 24 months of age, after eruption of the first molars. The differences in timing
of cleft palate repair are mostly based on different opinions regarding the balance between needs for
normal speech versus normal palate growth and occlusion.
26. What are the goals of successful cleft palate repairs?
• Separationofthenasalandoralcavitiesthroughclosureofbothmucosalsurfaces
• Constructionofawater-tightvelopharyngealvalve
• Preservationoffacialgrowth
• Gooddevelopmentofaestheticdentitionandfunctionalocclusion
27. What are some of the techniques for cleft palate repair?
These techniques are the von Langenbeck, Furlow palatoplasty, V-Y pushback, and Wardhill-Kilner.
28. What is the von Langenbeck operation?
The von Langenbeck operation involves long, relaxing incisions laterally, with elevation of large
mucoperiosteal flaps from the hard palate, which is bipedicled anteriorly and posteriorly. The cleft
margins of both the hard and soft palates are approximated at the midline. The levator muscles are
completely detached from their abnormal bony insertion, and the soft palate musculature is repaired
in the midline. A palatal lengthening procedure is not included in this operation (Fig. 38-5).
29. What is a vomer flap?
This procedure consists of elevation of a wide, superiorly based flap of nasal mucosa from the vomer
to close the hard palate. In bilateral clefts, vomer flaps can be obtained from each side of the vomer.
This technique avoids the need for elevating large mucoperiosteal flaps from the hard palate and the
potential risk of resultant maxillary growth disturbances.
30. What are the most common postoperative complications of cleft palate?
Hypernasal speech is the most common complication following cleft palate repair, occurring in up to
30% of patients. Oral-nasal fistulas are the second most common complication and occur in 10% to
21% of cleft repairs. These fistulas typically occur at either end of the hard palate (i.e., at the anterior
alveolus or at the junction of the soft and hard palate).
31. What are the major sequelae of an unrepaired cleft palate?
The problems associated with an unrepaired cleft palate are numerous, and they begin at birth and
continue for the patient’s lifetime:
• Aninabilitytobuildupsuctionandnasalregurgitation
• Pooreustachiantubefunction,whichmayleadtouidinthemiddleearspaceandinclination
toward recurrent otitis media
• Breathingproblems,particularlyifthechinisshortandthetonguefallsbackward,causinginspira-
tory obstruction, as in Pierre Robin sequence
• Speechproblems,includinghypernasalitywithvowelsoundsanddistortionofthepressureconsonants
• Adjacentteethangledintothecleftandpossiblymalformedorabsent,ifthealveolarridgeisinvolved
• Dentalcariesandseveremalocclusion
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5
4
2
C
X
A
3
1
D
B
8
C
A
D
B
6
A
7
B
C
C
A
C
Figure 38-4. Rotation advancement cleft lip repair (Millard, 1958, 1976). A, An incision is made at right angles to the
vermilion borders into the medial edge of the cleft lip at a point corresponding to the potential height of Cupid’s bow on
the cleft side (3). From this point superiorly, the cleft-edge vermilion is trimmed. The full-thickness incision is then carried
upward following the curvature and position of the philtrum on the normal side until it reaches the base of the columella.
The incision is cut to preserve as much muscle as possible on the flap. Without crossing into the normal philtrum, the incision curves under the base of the columella and extends toward the normal side as far as is necessary to rotate Cupid’s
bow (flap A) into a normal horizontal plane. A small back-cut (X) directed obliquely downward facilitates this rotation. B, A
hook is used to exert upward traction on the cleftside alar rim. This results in a defect at the base of the cleftside columella
to be filled with flap C. An incision is made into the membranous septum following the posterior border of flap C. This flap
is subsequently undermined and advanced into position to balance the columella. The medial aspect of flap C is tailored
and sewn into the superior aspect of the defect created by the downward rotation of flap A. C, Flap B is then developed to
preserve as much muscle on the flap as possible. The vermilion is trimmed by making an incision at a right angle to the
vermilion border at a point (8) at which the vermilion becomes attenuated to preserve the length of the lateral element
when sutured to the medial element (flap A). The distance between this point (8) and the ipsilateral oral commissure (7)
corresponds to the distance between the apex of Cupid’s bow (2) and the oral commissure on the non-cleft side (6). The
incision is carried up along the vermilion border to include the most superomedial usable lip tissue and then curved laterally around the alar base. Once this is completed, and through an incision in the upper gingivobuccal sulcus, the lateral
element is then dissected from the maxilla. At the same time, the cleftside alar base (flap D) is released from its pyriform
aperture attachment. The orbicularis oris muscle bundles are then carefully dissected, freeing them subcutaneously and
submucosally so that when approximated across the cleft, the orientation of their fibers will be changed from a nearvertical direction to the normal horizontal direction. Flap B is then advanced medially and sewn into the defect created by
the downward rotation of flap A, and the lip is closed in three layers: muscle, skin, and mucosa. Flap D is then advanced
medially to close the nostril floor. A portion of this flap may be deepithelialized and sewn to the base of the nasal septum
anteriorly with a permanent suture as a unilateral alar cinch. D, The completed repair. (From Perry RJ, Loré JM Jr: Cleft lip
and palate. In Loré JM, Medina JE, editors: An atlas of head and neck surgery, ed 4, Philadelphia, 2005, Saunders.)
D
B
D
B
A
D
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Figure 38-5. The von Langenbeck operation. A, Flap design. B, The relaxing incisions. C, Elevation of the mucoperiosteal
flap. D, Closure of the nasal mucosa and closure of the oral mucosa. (From Randall P, LaRosa D: Cleft palate. In McCarthy
JG, editor: Plastic surgery, Philadelphia, 1990, Saunders.)
VELOPHARYNGEAL INSUFFICIENCY
32. What is VPI?
VPI is a confusing term used to describe resonance disorders due to structural abnormalities (velo-
pharyngeal insufficiency), neurologic disorders (velopharyngeal incompetence), or functional issues
(velopharyngeal mislearning). During speech production, the velum is elevated and the pharyngeal wall
moves to close the nasopharynx off from the oropharynx to produce oral speech sounds. When there is a
deficiency in this mechanism, hypernasality, nasal emissions, or compensatory mechanisms can result.
33. How is VPI being diagnosed?
No single technique has been found to be ideal for the diagnosis of VPI. Diagnosis is usually based
on a combination of perceptual assessments by a speech language pathologist, visualization of the
mechanism during function via direct techniques such as nasopharyngoscopy and videofluoroscopy,
and data collected from indirect techniques such a nasometry. This includes a formal speechlanguage evaluation.
34. Which muscles are the most important in achieving VP closure?
The levator palatini muscles contribute the most to VP closure by pulling the middle third of the soft
palate superiorly and posteriorly to produce firm contact with the posterior pharyngeal wall at about
the level of the adenoidal pad. Other muscles that contribute to VP closure include the paired palatopharyngeus muscles, which pull the soft palate posteriorly; the muscularis uvulae, which cause the
uvula to thicken centrally with contraction; and the superior pharyngeal constrictors, which move the
lateral pharyngeal walls medially or the posterior pharyngeal wall anteriorly with contraction.
35. How is VPI managed?
Speech therapy usually begins with parental counseling when the child is 6 months old, and individual
child therapy should begin when the child is about age 4 or when the definitive diagnosis is made.
Dental prosthesis may also be helpful. About 20% to 25% of VPI cases require surgery. Surgical methods include secondary palatal lengthening, pharyngeal augmentation using soft tissue or implants,
and pharyngeal flaps. Such flaps convert the incompetent nasopharynx into two lateral ports and are
most successful in patients with good lateral pharyngeal wall motion.
ALVEOLAR CLEFT BONE GRAFTING
36. What are the goals of ACBG?
• Closureoforonasalstulas
• Givecontinuitytomaxillaryarch
• Providesupporttoalaoncleftsidebyrecreatingpiriformrim
• Provideboneforeruptionofpermanentteeth
• Facilitateorthodonticmovementofteeth
• Improvelipsupport
• Createpatentnasalairway
37. What is the ideal age for alveolar cleft repair?
Most studies indicate that the bone graft should be placed before the eruption of the permanent
canine and when the canine root is one-fourth to one-half or one-half to two-thirds developed. Root
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resorption and graft failure are common when bone grafts are placed after eruption of the canine.
Traditionally, bone grafts are placed at ages 9 to 11, although early grafting at ages 5 to 7 is becoming
more popular. Orthodontic treatment to stimulate growth and tooth eruption should be instituted within
3 months before bone graft. Orthodontic expansion of the maxillary arch after grafting instead of
before grafting, at approximately ages 7 to 12, has also been advocated.
38. When should the cleft site be orthodontically expanded prior to grafting?
The maxillary segments should be expanded prior to bone grafting to correct posterior and/or anterior
cross-bites. Care should be taken to avoid orthodontic movement or rotation of teeth near the cleft
site that may have questionable bony support.
39. Which is the ideal bone for alveolar cleft repair?
Particulate bone with cancellous marrow is the best choice for grafting an alveolar cleft because its
osteoinduction and osteoconduction qualities are most predictable.
ORTHOGNATHIC SURGERY FOR CLEFT PATIENTS
40. What are the most common skeletal jaw deformities in the cleft palate patient?
The skeletal deformities associated with cleft lip and palate vary but generally include one or more
of the following: midface deficiency, maxillary transverse deficiency, Class III skeletal and occlusal
deformity, and prognathic mandible.
41. What is the ideal age for cleft orthognathic surgery?
The ideal age for cleft orthognathic surgery is similar to that of children without cleft lip and palate.
Ideally, it should be performed upon completion of facial growth, which is age 14 to 16 in girls and
16 to 18 in boys. Orthognathic surgery can be accomplished earlier for psychosocial considerations,
improvement of sleep apnea, or in children with large anterior-posterior deficiencies, with the knowledge that they may require an additional procedure at a later date due to relapse.
42. What incision modifications should be considered during cleft orthognathic surgery?
In unilateral cleft lip and palate, a typical Le Fort I, circumvestibular incision can be made during
orthognathic surgery. In the bilateral cleft lip and palate patient, it is important to leave the mucosa
from canine to canine anteriorly intact to maintain the blood supply to the maxilla. To complete
the osteotomy, incisions are made from the distal of the canine to the mesial of the first premolar. Subperiosteal dissection is then completed and the osteotomies are made through these two
windows. To use the nasal-septal osteotome, a small stab incision is made in the midline at the height
of the vestibule and the osteotome is inserted.
43. What are generally safe guidelines for maxillary advancement versus distraction
osteogenesis?
Le Fort I advancement can usually be accomplished in patients with cleft palate requiring ≤6 mm of
advancement, though up to 10 mm may be indicated in some cases. One must consider the number or
previous palatal surgeries and the amount of scarring present. Advancements greater than 6 to 10 mm
are generally best treated with distraction osteogenesis.
44. What are the complications specific to cleft orthognathic surgery?
When considering either orthognathic surgery or distraction osteogenesis in patients with cleft palate,
one must understand the risks of the patient developing VPI. All patients must be informed that the
risk of developing hypernasal speech following surgery is common in the cleft population. In most
cases, this resolves without intervention in 6 to 12 months, and the speech will return to its preoperative quality. If after 12 months it does not resolve, patients may require a pharyngeal flap to improve
their quality of speech.
CLEFT RHINOPLASTY
45. What are the common features of unilateral cleft nasal deformities?
• Nasalseptum:convexonanddeviatedtowardthecleftside
• Nasaltip:deviatedtowardthenon-cleftside,depresseddomewithpoortipsupport
• Lowerlateralcartilageonthecleftsidemaybeweak,smaller,ormisshapen;anglebetweenmedial
and lateral crura is excessively obtuse on the cleft side
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• Pyriformaperture:webbingofthesofttissuepresentonthecleftside
• Nostril:horizontallyorientedonthecleftsideandmayhaveasymmetry
• Columellamaybeshorteronthecleftsideandcommonlydeviatedtowardthenon-cleftside
• Nasolabialstulamaybepresent
• Hypertrophyoftheturbinateonthecleftside
• Poorsupportofthealaonthecleftsideduetocleftingofalveolusifpresent
46. What are the common features of bilateral cleft nasal deformities?
• Broadandbidnasaltip
• Displacementofalarcartilagesinferiorlywithhoodingofthenostril
• Widehorizontalnostrils
• Mayhaveshorteningofthecolumella
47. What is the timing of cleft rhinoplasty?
Some of the cleft nasal deformities are addressed at the time of primary cleft lip repair including
correction of the flared ala, correction of the nasal-septal deviation, and improvement of nostril
symmetry. Some surgeons advocate correction of tip deformities with various techniques at the time
of primary lip repair, but this can be controversial due to the possibility of adverse effects on nasal
growth. A formal open or closed rhinoplasty is usually reserved for the completion of facial growth,
consolidation of the maxillary arch, and correction of maxillary hypoplasia.
48. What is the traditional sequence of treatment for cleft lip and palate?
• Atbirth,thecleftlipandpalateteamevaluatesthechild.
• At10weeksold,thecleftlipisrepaired.
• Atage1year,thechildisreevaluatedbythecleftlipandpalateteam.
• At12to18months,thesoftandhardpalatesarerepaired.
• At5to8years,interceptiveorthodonticsareused.
• At5to7years,thepharyngealap(ifnecessary)isdone.
• At7to8years,maxillaryexpansionisdone,ifneeded.
• At9to11years,alveolarcleftbonegraftingisperformed.
• At12to13years,comprehensiveorthodonticsareinitiated.
• At14to16years,orthognathicsurgeryandnasalsurgeryaredone,ifneeded.
BiBliography
American Cleft Palate-Craniofacial Association: Parameters for evaluation and treatment of patients with cleft lip or palate
and other craniofacial anomalies. In Philips BJ, Warren DW, editors: The cleft palate and craniofacial team, Chapel Hill, NC,
1993, American Cleft Palate Association.
Grabb WC, Rosenstein SW, Bzoch KR, editors: Cleft lip and palate: surgical, dental, and speech aspects, Boston, 1971,
Little, Brown.
Hendrick DA: Cleft lip and palate. In Jafek BW, Stark AK, editors: ENT secrets, Philadelphia, 1996, Hanley & Belfus.
Johnson MC, Bronsky PT, Millicorsky G: Embryogenesis of cleft lip and palate. In McCarthy JG, editor: Plastic surgery,
Philadelphia, 1990, Saunders.
Kernahan DA: The striped Y—a symbolic classification for cleft lip and palate, Plast Reconstr Surg 47:469–470, 1971.
Millard Jr DR, Latham RA: Improved primary surgical and dental treatment of clefts, Plast Reconstr Surg 86:856–871,
1990.
Millard Jr DR: Combining the Von Langenbeck and the Wardill-Kilner operations in certain clefts of the palate, Cleft Palate J
29:85–86, 1992.
Millard Jr DR: Cleft lip. In Weinzweig J, editor: Plastic surgery secrets, Philadelphia, 1996, Hanley & Belfus.
Natsume N, Kawai T: Incidence of cleft lip and palate in 39,696 Japanese babies born in 1983, Int J Oral Maxillofac Surg
15:565–568, 1986.
Randall P, LaRosa D: Cleft palate. In McCarthy JG, editor: Plastic surgery, Philadelphia, 1990, Saunders.
Randall P, LaRosa D: Cleft palate. In Weinzweig J, editor: Plastic surgery secrets, Philadelphia, 1996, Hanley & Belfus.
Randall P: Cleft palate. In Smith JW, Aston SJ, editors: Grabb and Smith’s plastic surgery, ed 4, Boston, 1991, Little, Brown.
ORTHOGNATHIC SURGERY
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David M. Alfi, Ariel Farahi, A. Omar Abubaker, Bashar M. Rajab
1. What does the clinical workup of orthognathic surgery consist of?
The clinical workup for orthognathic surgery should consist of photographic records, diagnostic casts,
interocclusal records, facebow transfer, radiographic examination, and facial measurements. In addition, a
thorough medical history and physical examination must be completed. At the minimum, the photographic
records should capture the patient’s frontal view (with lips relaxed and smiling) and the patient’s right
profile view in repose. The radiographic examination should include a lateral cephalogram, posterioranterior (PA) cephalogram, and panoramic radiograph with lips relaxed and teeth in centric relation (CR).
The diagnostic casts should be mounted on an anatomic, fully adjustable articulator, and in CR. With the
recent availability of cone beam computer tomography (CBCT), its use in orthognathic surgery ranges from
generating a lateral cephalogram, PA cephalogram, and panoramic radiograph to being used to assess a
posterior airway and, when obtained with a gyroscope, can be used to digitally simulate the surgery.
2. How is the facial examination of a patient performed?
The facial examination of a patient is the most important stage of the surgical planning and is
performed with the patient in the natural head position (NHP). The NHP orients the patient’s head to
a position that is most natural to the observer. In cephalometry, the NHP is approximated by rotating
the S–N line down 6 degrees. The facial examination can be divided into three components: the upper
third, middle third, and the lower third of the face.
In evaluating the lower third of the face, the lips are evaluated for static and dynamic symmetry.
There is usually a 0.5-5 mm upper tooth show at rest in adults, with females showing more than
males and both genders decreasing tooth show with age. In addition, the upper lip length (22 mm) is
equal to roughly 30% of the lower third of the face (22 mm + 3 mm + 45 mm) (Fig. 39-1).
3. How are skeletal age and deceleration of growth determined?
Skeletal age is determined by a hand–wrist radiograph. Deceleration of growth is determined by serial
cephalometric films.
4. What is the significance of cervical vertebral maturation in relation to planning
orthognathic surgery?
Cervical vertebral maturation can be seen on a single lateral cephalometric radiograph. There are six
stages of cervical vertebral maturation. The peak of mandibular and craniofacial growth corresponds
to the peak in statural height growth, which corresponds to stages three and four of cervical vertebral
maturation. As cervical vertebra mature through the six stages, they develop a concavity on the
inferior border and assume a more rectangular shape (Fig. 39-2).
5. What is the role of cephalometric evaluation in pre-surgical treatment planning?
The facial skeleton can been quantified and measured by using cephalometric analysis. However,
orthognathic treatment planning must depend largely on clinical findings. The use of cephalometrics
should support or dispute the clinical impression, similar to the way laboratory blood studies support
the medical examination and decision making. Some insurance companies may also base their determinations on cephalometric parameters.
6. What are the most commonly used analyses and what they are used for?
The Steiner, the Downs analysis, and the McNamara analysis are the commonly used bony cephalo-
metric analyses. The Steiner analysis is useful for evaluating the upper and lower incisor position relative to the anterior cranium. The Downs analysis is used to determine the facial angle that describes
the relative anteroposterior (AP) relationship of the mandible to the cranium. The McNamara analysis
is used to compare the incisor relationship to basal bone.
7. What are the most common soft tissue facial measurements?
1. Facial contour angle
2. Lower lip length
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CHAPTER 39
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