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9
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Cleft Lip and Palate
Surgery
ALVEOLAR BONE GRAFT (ABG) SUCCESS
USING BERGLAND SCALE
e following classication includes radiographic criteria that
compare the occlusal level of interdental bone with that of the
normal side (following canine eruption).
1. Normal
2. More than 75% of contralateral height
3. More than 50%
4. Less than 50%
ABG SUCCESS GRADING BY KINDELAN
e following classication is a four-point radiographic scale
that assesses the degree of bony ll in the cle 4–6 months aer
the operation; the added advantage of this is that it does not
depend upon canine eruption.
1. >75% bony inll
2. 50–75% bony inll
3. <50% bony inll
4. No bony bridge
DOI: 10.1201/9781003156895-9 73
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MODIFIED KRIENS’ LAHSAL (RECOMMENDED
BY ROYAL COLLEGE OFSURGEONS, 2005)
e following classication is used to describe cle types and for
comparison between locations. It is a palindrome representing
the anatomic structures, proceeding from the patient’s right side
to le side. Acapital letter indicates that anatomic feature has
completely cleed, a lowercase letter means an incomplete cle
and an asterisk (*) indicates a minimal clef. Aperiod (.) indicates that the anatomic feature has developed normally.
●
Lip (L) (right)
●
Alveolus (A) (right)
●
Hard palate (H)
●
So palate (S)
●
Alveolus (A) (le)
●
Lip (L) (le)
VEAU CLASSIFICATION
is classication scores cle palate on the basis of the anatomic
disruption of the primary and secondary palates.
●
Class 1 – incomplete and limited to so palate (midline cle),
intact hard palate
●
Class 2 – involves both hard and so palate (midline cle)
●
Class 3 – complete cle, unilateral
●
Class 4 – complete cle, bilateral
KERNAHAN AND ELSAHY CLASSIFICATION
(MODIFIED BY MILLARD)
e following classication describes the common types of cle
lip/palate, complete unilateral, isolated posterior or the unusual
cle deformities.
●
Nasal oor – 1/5
●
Lip – 2/6
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●
Alveolus – 3/7
●
Primary hard palate – 4/8
●
Secondary hard palate – 9 and 10
●
So palate – 11
NYBERG CLASSIFICATION OF ANTENATAL
ULTRASOUND CLEFT FINDINGS
e following USS classication is one that correlates very
well with the severity of the defect, with outcomes divided into
ve types.
1. Lip
2. Unilateral cle lip and palate (UCLP)
3. Bilateral cle lip and palate (BCLP)
4. Median lip
5. Cles with amniotic banding of limbs and body wall
SPEECH TESTING STANDARDS FOR CLEFT
TREATMENT
From the Great Ormond Street Speech Assessment (GOSPASS).
●
Tested at 18 months, 3years, 5years, 10years (and before/
aer any treatments)
●
By 5½ years old (up to 11years), 50% should have normal
speech
●
erefore, only 50% need speech therapy, 30% maximum
should need speech surgery (re-repair)/superior based pharyngeal ap if no AP closure/sphincter pharyngoplasty
●
Orticochea pharyngoplasty more functional than Hynes
pharyngoplasty technique if posterior pharyngeal walls do
not move in
●
Investigated with videouoroscopy (VF), breoptic endoscopic evaluation of swallowing (FEES)
●
If surgery contraindicated, then management will include
palatal li appliance/speech bulb
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76 Classifications and Lists in Oral and Maxillofacial Surgery
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TIMING OF CLEFT TREATMENT IN THE UK
e following list highlights the target time for surgical intervention
for the various types of surgery required in cle lip and palate care.
●
Lip – 3–5 months
●
Palate – 6–9 months
●
Pharyngeal ap/speech surgery – 3–5years
●
ABG – 9–11years (canine root one-half to two-thirds formed)
●
Orthodontics – 12years of age
●
Orthognathic – 16/18years of age (F/M)
FURTHER READING
Britton L, Albery L, Bowden M, Harding-Bell A, Phippen G, Sell
D. Across-sectional cohort study of speech in five-year-olds
with cleft palate ± lip to support development of national
audit standards: Benchmarking speech standards in the
United Kingdom. Cleft Palate Craniofac J. 2014;51(4):431–51.
Kindelan JD, Nashed RR, Bromige MR. Radiographic assessment
of secondary autogenous alveolar bone grafting in cleft lip
and palate patients. Cleft Palate Craniofac J. 1997;34:195–8.
Kriens O. Lahshal: Aconcise documentation system for cleft lip,
alveolus, and palate diagnoses. In: Kriens O, ed., What is a
cleft lip and palate?: Amultidisciplinary update. New York:
Thieme Medical Publishers; 1989: 30–34.
Nyberg DA, Sickler GK, Hegge FN, Kramer DJ, Kropp RJ. Fetal
cleft lip with and without cleft palate: US classification and
correlation with outcome. Radiology. 1995;195(3):677–84.
Rawashdeh MA. Morbidity of iliac crest donor site following
open bone harvesting in cleft lip and palate patients. Int J
Oral Maxillofac Surg. 2008;37(3):223–7.
Shaw W, Semb G, Lohmander A, etal. Timing of Primary Surgery
for cleft palate (TOPS): Protocol for a randomised trial of palate surgery at 6 months versus 12 months of age. BMJ Open.
2019;9:e029780.
Subramanyam D. An insight of the cleft. Lip and palate in pediat-
ric dentistry—a review. J Dent Oral Biol. 2020;5(2).
Veau V. Division palatine. Paris: Masson& Cie; 1931.
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Craniofacial Surgery
ACROCEPHALOSYNDACTYLY AND OTHER
SYNDROMIC CRANIOSYNOSTOSES
e following information highlights the types of syndromes
that may occur in a patient presenting with craniosynostoses. It
allows a surgeon to assess for signs found elsewhere in the body
to provide holistic care for the patient.
1. Apert (autosomal dominant)
2. Crouzon (autosomal dominant)
3. Saethre-Chotzen (autosomal dominant)
4. Pfeier (autosomal dominant)
5. Carpenter (autosomal dominant)
DOI: 10.1201/9781003156895-10 77
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BARROW CLASSIFICATION FOR CAROTID
CAVERNOUS FISTULAE
The following classification divides caroticocavernous fistulas into direct (A) or indirect (B–D). Indirect fistulae are further subdivided according to whether the supply is from the
internal carotid artery, the external carotid artery or both
vessels.
A. Direct connection between intracavernous internal carotid
and cavernous sinus (high ow, high pressure)
B. Dural shunt between intracavernous branches of internal
carotid and sinus (lower ow, lower pressure)
C. Dural shunt between external carotid branches (middle men-
ingeal) and sinus (lower ow, lower pressure)
D. Combination of B and C
BIOLOGIC CLASSIFICATION OF VASCULAR
ANOMALIES
e following highlights the types of vascular anomalies and
lesions, as well as provides common lesions to consider.
●
Haemangioma
●
Congenital
– Rapidly involuting congenital haemangioma (RICH)
– Non-involuting congenital haemangioma (NICH)
●
Infantile
●
Angiosarcoma
●
Vascular malformation
●
Low ow
– Capillary
– Lymphatic/lymphovenous
– Venous
●
High ow
– Arterial
– Arteriovenous
– Arteriovenous stula
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CLASSIFICATION OF CHERUBISM
e following classication describes a rare, hereditary, autosomal-dominant, benign lesion of childhood oen presenting as
bilateral painless swellings of the mandible and maxilla as well
as syndromes associated with the presentation.
1. Rami
2. All mandible except condyles
3. Maxilla AND mandible
Syndromes with cherubism:
●
Raman – epileptic
●
Jae-Campanacci – café au lait with hypogonadism
●
Noonan-like – short, hypertelorism, wide neck, cryptorchidism, heart defect, low ears, down-slanting palpebral
fissures
CURACAO DIAGNOSTIC CRITERIA
FOR HEREDITARY HAEMORRHAGIC
TELANGIECTASIA (HHT)
e following criteria are used for the diagnosis of hereditary
haemorrhagic telangiectasia (HHT). HHT is an inherited
genetic disorder that aects blood vessels, which can oen present as bleeding.
Need three out of the following:
●
Family history
●
Recurrent spontaneous epistaxis
●
Arteriovenous malformation (AVM) diagnosis
●
Telangiectasia
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DIAGNOSTIC CRITERIA FOR GORLIN
SYNDROME
e following criteria are used to aid in the diagnosis of a rare
condition called Gorlin syndrome, which predisposes individuals to develop basal skin cancers. It is caused by an autosomaldominant mutation in the PTCH1 gene.
Two major or one major plus two minor criteria:
●
Major
●
Calcied falx (seen in 50%)
●
OKC
●
ree BCCs (or a single one before age 20)
●
ree palmar/plantar pits
●
Bid ribs (or fused/splayed)
●
First-degree relative with Gorlin’s
●
Minor
●
Macrocephaly
●
Bridging of sella (with hypertelorism and frontoparietal
bossing)
●
Cle lip and palate (CLP)/other congenital malformations
●
Pectus/Sprengel’s deformity (one scapula higher than
the other)
●
Flame naevus
●
Ovarian broma/medulloblastoma
EYE MEASUREMENTS
e following measurements aid in planning for both aesthetic
and reconstructive craniofacial surgery.
●
Intercanthal=30–31mm
●
Interpupillary=60–62mm
●
Interorbital=25mm in women, 28mm in men
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TESSIER’S CLASSIFICATION OF HYPERTELORISM
e following classication is used for rare craniofacial cles.
It denotes the position of the cle process in a schematic based
around the orbit. Hypertelorism refers to the increased distance
between the bony orbits.
●
First degree=30–34mm
●
Second degree=35–39mm
●
ird degree=40mm or more
MUNRO’S CLASSIFICATION OF
HYPERTELORISM
e followi ng system classies hy pertelori sm by the shape of the orbit.
A. Parallel medial orbits
B. Wider anteriorly
C. Wider halfway back
D. Wider posteriorly
MARX CLASSIFICATION OF MICROTIA
e following grading system is used to classify the severity of
microtia, which is a congenital hypoplastic malformation of the
pinna; it can range from a fully formed auricle to an absent auricle/lobule in its most severe form.
1. Slightly smaller auricle (2 standard deviations below normal)
but subunits all present
2. Slightly smaller auricle (2 standard deviations below normal)
and the subunits are severely underdeveloped or absent
3. Only a small piece of cartilage is present in the superior remnant of the ear and the lobule is rotated anterosuperiorly
4. No auricle or lobule (anotia)
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