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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5805_Библиотеки_им_академика_М_И_Перельмана.pdf
7.1 Unilateral Cleft Lip andPalate
53
Fig. 7.5 Multiplanar imaging in unilateral CLP at 13+4
weeks (TVS)—correlation of defect in three orthogonal
planes, the reference dot is placed at the defect in parasag-
2
NB
ML
Fig. 7.6 TUI in Unilateral CLP at 13+4 weeks (TVS):
Intact maxillary line in parasagittal view on the non-cleft
side (section 1) and in midsagittal view (section 2),
whereas parasagittal view on the side of cleft (section 3)
M
ittal section in plane A.Simultaneous visualization of the
defect in axial section (plane B) and in coronal section
(plane C) (Video 7.2)
1
3
depicts defect in maxillary line (arrow)—this section corresponds to the dashed line. Nasal bone (NB), maxillary
line (ML) and mandible (M). (Video 7.3)
54
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
ML
b
A
*
M
M
c
Fig. 7.7 Unilateral CLP—utility of the three planes at
13weeks. (a) (TAS) Normal appearance of the maxillary
line (ML) in midsagittal view. (b) (TAS) lateralized defect
Two-dimensional and 3D images in a case of
unilateral CLP are shown in Fig.7.9. Once there
is a suspicion of cleft based on 2D markers, then
a volume acquisition in the sagittal plane is
recommended.
Figure 7.9e illustrates the rendered view of the
palate with ipped face technique which clearly
denes the type and extent of cleft [6]. The same
volume can also be used to render the face as
shown in Fig.7.9f.
Figure 7.10 is an illustration of the rendered
view of the face with the corresponding axial
view of under surface of the palate. Both multi-
planar imaging and rendered view clearly illustrate the defect in the alveolar arch and the
degree of cleft extension into the secondary pal-
in RNT (*) in coronal view. (c) (TVS) defect in the upper
lip and alveolar arch (arrow) in axial view. Apex (A) and
mandible (M)
ate (highlighted in green). Also, palatal shelf
separation can be appreciated in this view.
The two-dimensional markers in the sagittal,
axial, and coronal planes (a, b, and c) in unilateral
CLP are described in Fig.7.11. Figure7.11d is the
depiction of the unilateral cleft in the premaxilla
and the corresponding midsagittal and parasagittal views.
Note that in Fig.7.11e and f, the parasagittal section shows the complete absence of the
maxillary line as the cleft extends into the
entire secondary palate. Also, in the subtype
where the vomer is not fused with the palatal
shelf in the midline, the midsagittal section
shows an absent superimposed line sign as in
Fig.7.11f.
ab
cd
7.1 Unilateral Cleft Lip andPalate
A
ML
55
M
A
UL
M
N
UL
M
LL
M
e f
Fig. 7.8 Unilateral CLP conned to premaxilla (a)
13 weeks (TAS) midsagittal view intact maxillary line
(ML). (b) 13 weeks (TAS) coronal view intact base of
RNT. (c, d, e, and f) Follow-up at 19weeks (c) nose chin
view defect in the upper lip (arrow). (d) Intact base of
PMT. (e) axial view lateralized defect in the alveolar arch
(arrowhead). (f) Rendered view of the face. Mandible
(M), nose (N), upper lip (UL), lower lip (LL) and apex (A)
56
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
ab
NB
ML
M
c d
UL
N
*
UL
e
A
M
M
f
Fig. 7.9 Two-dimensional versus 3D image correlation
in unilateral CLP 12
(b) (TVS) Axial view arrow points to defect. (c) (TVS)
Nose chin view showing unilateral cleft lip (*) (d) (TAS)
Coronal view shows defect in the base of the RNT (arrow).
+4
weeks. (a) (TAS) Midsagittal view.
(e) (TVS) Flipped face view showing the extent of cleft
into the secondary palate arrow points to defect. (f) (TVS)
Rendered view of the face. Nasal bone (NB), maxillary
line (ML), nose (N), upper lip (UL), apex (A), mandible
(M)
7.2 Bilateral Cleft Lip andPalate
a
b
57
Fig. 7.10 Rendered view of the face and the corresponding intraoral surface of the palate in two cases of unilateral
CLP (13 weeks TVS). (a) Case 1 (b) Case 2, the cleft
7.2 Bilateral Cleft Lip andPalate
The bilateral cleft lip and palate may be complete
or incomplete. In cases of complete bilateral
CLP, both the nasal chambers communicate
with the oral cavity. The palatal processes are
divided into two equal parts, with the nasal
septum in midline. The nasal septum is rmly
attached to the base of the skull, and it is fairly
mobile at the vomeropremaxillary junction in
cases of bilateral CLP.
In rst trimester the soft tissue development
is minimal, and the routine nose chin view seen
in mid trimester does not serve as the initial
diagnostic clue. The initial clue is obtained by
looking at the bony landmarks of the palate.
Figure 7.12 illustrates the bilateral paramedian
labial defect in 3D reconstructed image using
VCI at 12weeks.
Actually, bilateral CLP is identied in the rst
trimester by the presence of premaxillary protrusion and the maxillary gap in the sagittal view,
which serves as the initial clue (Fig.7.13a) [10,
11]. The axial view (Fig. 7.13b) demonstrates
extension into the palate is highlighted in green. Arrow
points to defect
discontinuity of the alveolar arch with vomer
seen in the midline.
The coronal section shows a defect in the base
of the retronasal triangle (Fig. 7.13c) [8]. Note
that there is an absent superimposed line sign in
midsagittal section, which depicts the involvement of the secondary palate [12]. Figure7.13d is
a rendered image of the face depicting bilateral
CLP.
Figure 7.14 is an example of bilateral CLP
with an intact secondary palate. The midsagittal
section shows the maxillary gap and premaxillary protrusion; note that the posterior aspect of
the maxillary line appears bid (Fig.7.14a).
The axial view of the palate depicts bilateral
paramedian clefts in Fig.7.14b, c shows an intact
base of the retronasal triangle. Note that vomer
bone is not visualized in the axial view of the
palate.
Compare Fig.7.13b with 7.14b to assess for
involvement of the secondary palate in bilateral
CLP. In Fig.7.13b the nasal septum is seen in the
midline, which shows that the secondary palate is
58
ab
PARASAGITTAL
d
e
f
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
c
SAGITTAL
AXIAL
MIDSAGITTAL
MIDSAGITTAL
PM
VB
CORONAL
PARASAGITTAL
PARASAGITTAL
MIDSAGITTAL
Fig. 7.11 Line diagram illustrating the 2D markers in
unilateral CLP. (a) Midsagittal section. (b) Axial section.
(c) Retronasal triangle view. (d) Unilateral cleft involving
decient, whereas in Fig.7.14b the vomer is not
seen in the midline.
Figure 7.15 illustrates bilateral CLP with an
intact secondary palate in multiplanar imaging
with VCI.Figure7.15a shows the superimposed
line sign, which indicates an intact secondary
palate. The base of the retronasal triangle is
intact in the coronal plane (Fig.7.15b).
premaxilla. (e) Unilateral cleft with unilateral extension
into the secondary palate. (f) Unilateral cleft with bilateral
extension into the secondary palate
Figure 7.15c illustrates the bilateral cleft
involving the premaxilla in the axial plane. Note
that the vomer bone is not visible in the midline
in the rendered view of the palate.
The midsagittal view is often misleading in
bilateral CLP involving the secondary palate, as
the vomer in the midline is mistaken for an
intact palate (Fig. 7.16a). Three-dimensional
7.2 Bilateral Cleft Lip andPalate
M
*
*
LL
Fig. 7.12 Bilateral cleft lip at 12weeks: Nose chin view,
bilateral paramedian defect (*), median process (M) and
lower lip (LL)
multiplanar imaging shows that the vomer is
visualized in a slightly superior plane, and the
defect caudal to the premaxillary protrusion is
shown in Fig.7.16b.
Video 7.4 illustrates the palate in bilateral
CLP involving the premaxilla alone. Fluid in the
oral cavity outlines the hard palate and soft palate. Video 7.5 depicts the nasal septum (vomer)
seen in the midline in case of complete bilateral
CLP, and the parasagittal section shows the complete absence of the maxillary line.
Cleft involving the secondary palate is better
depicted with TUI as there is a complete absence
of a maxillary line in the parasagittal view
(Fig. 7.17a). In case of bilateral CLP involving
the premaxilla alone, sagittal sections in TUI
show the interrupted maxillary line in all the sections (Fig.7.17b). The proximal portion is formed
by the premaxillary protrusion, and the distal
portion by the secondary palate.
Note that in Fig.7.17a section 2, the posterior
portion of the maxillary line appears as a single
line and the absent superimposed line sign
denotes cleft involving the secondary palate.
59
Figure7.17b section 2, the presence of superimposed line sign denotes that the secondary palate
is intact.
Figure 7.18 illustrates the premaxillary protrusion in two cases of bilateral CLP.Note the correlation of the facial prole in 3D rendered
images with postnatal face; the PMP is evident as
early as 12 to 13weeks of gestation.
Most often, the midsagittal view shows the
maxillary gap and the premaxillary protrusion
(PMP), however in some cases, the maxillary
gap may not be present [12]. Figure 7.19 is a
case of bilateral CLP in which the maxillary gap
is not evident in the midsagittal section
(Fig.7.19a), but seen in the parasagittal section
(Fig.7.19b).
Further, the axial plane depicts the bilateral
paramedian defect (Fig.7.19c), and absent base
in the RNT view is seen in Fig.7.19d. Video.7.6
illustrates the midsagittal prole with a very subtle maxillary gap in the case of bilateral CLP.
Figure 7.20 illustrates that the midsagittal prole can be misleading in some cases of bilateral
CLP. The premaxilla and the vomer bone
together form the maxillary line in bilateral
CLP, and the maxillary gap is not evident
(Fig. 7.20a). However, note that the superimposed line sign is absent, and only a single line
is present.
The parasagittal view (Fig.7.20b), axial view
(Fig. 7.20c), omni view technique (Fig. 7.20d)
conrms the defect. Rendered view of the face
clearly depicts the bilateral cleft lip (Figs.7.19e
and 7.20e).
Figure 7.21 illustrates the interpretation of the
superimposed line sign and maxillary gap in
cases of bilateral CLP.Complete bilateral CLP
can present with an intact maxillary line
(Fig.7.21b), absent superimposed line sign gives
a clue in the midsagittal view.
The presence of maxillary gap and absent
superimposed line sign indicates complete bilateral CLP (Fig. 7.21c), whereas the presence of
maxillary gap and presence of superimposed line
sign indicates incomplete bilateral CLP
(Fig.7.21d).
Figure 7.22 illustrates the follow-up of a case
presenting with the maxillary gap at 12weeks of
60
cd
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
NB
PM
V
T
M
A
b
*
MM
Fig. 7.13 Complete bilateral CLP at 12+4 weeks (a)
(TVS) Midsagittal view demonstrating the presence of a
maxillary gap (arrowhead), the premaxillary protrusion
(arrow) and the presence of a single line in the posterior
aspect of the maxillary line. Nasal bone (NB), Vomer (V),
gestation (Fig.7.22a). The axial (Fig.7.22b) and
coronal view (Fig. 7.22c) can be evaluated to
show the evidence of bilateral CLP at this period
of gestation.
Follow-up scan at 15 weeks illustrates the
marked premaxillary protrusion (Fig.7.22 d, e)
and the axial view Fig. 7.22f clearly illustrates
bilateral CLP. Postnatal image correlation is
shown in Fig.7.22g, h, and i.
Moreover, bilateral clefts of lip and palate
exhibit wide separation of the palatal shelves in
some cases, whereas others exhibit very minimal
Tongue (T), Premaxilla (PM) and Mandible (M) (b) (TVS)
Axial view demonstrating bilateral cleft in the alveolar
arch (arrows). (c) (TAS) coronal view shows defect in the
base of RNT (arrows), Apex (A). (d) (TVS) Rendered
view of face illustrating the premaxillary protrusion (*)
separation. Figure7.23a is a collection of the rendered view of the palate showing varying degrees
of palatal shelf separation. In Fig.7.23b and c the
correlation of rendered view of the face with the
corresponding palate is illustrated.
The line diagram Fig.7.24 clearly illustrates
the correlation of maxillary gap, premaxillary
protrusion, and superimposed line sign in the
interpretation of bilateral cleft lip and palate. The
salient features in sagittal, axial, and coronal
planes in bilateral CLP is illustrated in a, b, and c,
respectively.
7.2 Bilateral Cleft Lip andPalate
61
a
NB
V
P
M
c
A
b
d
Fig. 7.14 Bilateral CLP with intact secondary palate 13+3
weeks. (a) (TVS) Midsagittal section showing premaxillary protrusion (arrow), maxillary gap (arrowhead), nasal
bone (NB), mandible (M), vomer (V) and palate (P). (b)
Figure 7.24d summarizes the ndings in midsagittal and parasagittal views in bilateral CLP with
intact secondary palate. Note that the superimposed
line sign is present in midsagittal section, and the
maxillary line is interrupted in parasagittal sections.
Figure 7.24e depicts the appearance of midsagittal and parasagittal sections in complete
bilateral CLP.Note that there is absent superimposed line sign in the midsagittal section and
complete absence of the maxillary line in parasagittal sections.
(TAS) Axial section arrows points to bilateral paramedian
defect in alveolar arch. (c) (TVS) Coronal section shows
intact base of RNT (arrow), apex (A). (d) (TVS) Rendered
image of the face
In bilateral CLP, the presence of the maxil-
lary gap is dependent on the degree of premaxillary protrusion. The vomeropremaxillary
junction tends to elongate to various degrees
in bilateral CLP, and most often, when there is
no maxillary gap, the premaxillary protrusion
tends to be subtle. Note in (Fig.7.25a) the pala-
tal shelves are seen apart from the premaxilla,
whereas in (Fig.7.25b) the palatal shelves are
in close proximity to the vomeropremaxillary
junction.
62
7 Protocol forDiagnosing Type andExtent ofaCleft inFirst Trimester
a
V
P
b
c
P
Fig. 7.15 3D imaging in bilateral CLP with intact secondary palate 13
presence of superimposed line along with maxillary gap
(arrowhead). Premaxillary protrusion (arrow), Vomer (V),
+3
weeks (TVS) (a) Midsagittal view
7.3 Median Cleft Lip andPalate
Midline clefts arise due to incomplete merging of
the medial nasal prominences that form the intermaxillary segment. Most often, median cleft is
associated with other system malformations and
is a part of genetic syndromes. In mediolateral
cleft type, there is a lateralized defect involving
the premaxilla and has a midline extension into
the secondary palate.
In median CLP, there is an absence of premaxillary portion and secondary palate in the mid-
Palate (P). (b) Intact base of RNT (arrow). (c) Axial view
intact secondary palate (P) and bilateral paramedian cleft
involving premaxilla (arrows)
line. Hence, the proximal segment is absent,
and the vomer forms the distal segment leading
to shortening of the maxillary line (Fig.7.26a).
A midline defect is seen in the alveolar arch in
axial view (Fig.7.26b) and the secondary palate,
which forms the base of the retronasal triangle is
decient in all sections in median CLP
(Fig.7.26c) [8, 9].
Figure 7.27a is a sagittal section showing
shortening of the maxillary line, and Fig.7.27b
shows a narrow midline defect in the alveolar
arch in the axial view. Figure7.27c illustrates a
defect in the base of the retronasal triangle. The