CLEFT LIP AND PALATE PART 3 - SURGICAL.pptx

Various surgical procedures performed for cleft lip and cleft palate

1. DR. GENOEY GEORGE CLEFT LIP AND PALATE (SURGICAL) PART 3

2. CONTENTS Introduction Cleft Lip Repair Cleft palate Repair Velo pharyngeal Insufficiency Alveolar Bone Grafting Types Of Graft Complications Pre surgical orthodontics Post surgical Orthodontics Advancements Conclusion References

3. LIP REPAIR INTRODUCTION Cleft lip repair is a surgical procedure that may be approached with a wide array of different techniques. The ultimate goal of cleft lip repair is to restore the sphincter function of the orbicularis oris muscle and obtain a cosmetically favourable outcome for the developing child.

4. ANATOMY During the sixth to seventh weeks of embryonic development, the bilateral maxillary prominences grow medially towards the medial nasal prominences, and fusion occurs, leading to the formation of the upper lip In unilateral cleft lip, The columella will be found on the noncleft side. These anatomical abnormalities lead to nasal tip deviation towards the noncleft side with nasal septum deviation towards the noncleft side and a laterally, inferiorly, and posteriorly displaced alar base on the cleft side . In bilateral cleft lip , lack of orbicularis oris muscle in the prolabial segment causes anterior premaxillary protrusion. This causes columellar skin to be deficient, leading to a shortened, almost absent, columella . These findings lead to a broad nasal tip with laterally displaced alae.

5. TIMING Although some have proposed surgical correction of the cleft lip as early as 48 hours after birth, surgical repair is generally performed following the rule of 10s, which states that: S urgery should be performed at 10 weeks of age, Patient weighs 10 lbs haemoglobin is at 10 g/ dL . Repair between 2 to 3 months of age allows the patient to be adequately evaluated for other congenital anomalies

6. TECHNIQUES OF LIP REPAIR UNILATERAL CLEFT LIP BILATERAL CLEFT LIP Millard’s rotational advancement Straight line closure Modifications Columella lengthening Millard II Millard repair Skoog’s Technique Tennison-Randall triangular flap Mohler’s Technique Other techniques : Tennison-Randall Triangular flap Bauer Method Delaire’s Functional lip closure Manchester method Skoog method Wynn method

7. STRAIGHT LINE REPAIR Historically, the first cleft lip repairs relied on freshening the edges of the cleft and suturing them together. These have been largely replaced by various Z- plasty -based techniques. Rose Thompson repair: Straight-line repair that can be used for minor clefts with lip length nearly equal on both sides of cleft . Fusiform excision with straight-line closure.

8. Indications : Still used for mild forms of cleft lip Lengthening effect achieved Advantages Straightforward Disadvantages Minimal lengthening is obtained Destroys important landmarks STRAIGHT LINE REPAIR

9. MILLIARD ROTATION-ADVANCEMENT Ralph Millard developed the rotation-advancement technique by operating the children with cleft lip during his military service in the Korean War The rotation advancement repair of the unilateral cleft lip deformity was described by Millard Introduced in 1957 Most widely used procedure for unilateral cleft lip repair

10. MARKINGS 1 . Center /low point cupids bow 2 . Peak of bow on NCS 3. Peak of bow on medial side of cleft 4 , Alar base, NCS 5 . Columellar base, NCS 6 , Commissure, NCS 7 . Commissure, deft side 8. Peak cupids bow lateral side of cleft 9. Superior extent of advancement flap 10. Alar base, cleft side Point x: Back-cut point

11. ADVANTAGES The main advantage of this technique is its flexibility and application. The rotation advancement technique relies on a "cut as you go" strategy that allows continuous modifications during the design and execution of the repair . Another advantage is that the suture line approximates a new philtral column. The aesthetic philtral subunit is not violated, and this tends to create a scar that is more camouflaged. Minimal tissue is discarded during the rotation advancement technique, and this tends to put less tension on the closure. Lip often short due to under rotated lip Tension across repair of wide clefts May have constricted nostril on side of repair DISADVANTAGES

12. TENNISON-RANDAL TRIANGULAR FLAP   Tennison - Z plasty Tennison (1952) -frustrated by straight-line scar contraction. He preserves the cupid’s bow and places it in normal position He inserted a wedge from the lateral lip into the lower portion of the medial lip, and achieved good results - and called it ‘ stencil method ’ - came to be known as the Tennison triangular flap technique.

13. TENNISON-RANDAL TRIANGULAR FLAP  This repair technique is conceptually similar to the rotation advancement repair. The primary difference is that the rotation backcut in the noncleft segment is performed more inferiorly, closer to the vermilion border . Similarly the advancement segment on the cleft side is designed to occur inferiorly near the vermilion cutaneous border .

14. ADVANTAGES They are used to close wide clefts without having to perform lip adhesion or presurgical tissue manipulation. The operation is done on strictly geometric methods of mathematical principles and measurements , leaving not much room for errors in judgment. Therefore , many experts consider the triangular flap technique to be well suited for experienced surgeons. zigzag scar prevents scar contracture and lip shortening leading to a vermilion notch that can be sometimes observed in the rotation advancement technique. Minimal soft tissue dissection Preservation of cupids bow

15. DISADVANTAGES Difficulty in modifying the repair or performing secondary revision at a later stage due to the zigzag scars. Late vertical lengthening may occur. SKOOG REPAIR Consists of two Zplasties . Violates Cupid's bow and the philtral dimple

16. DELAIRE’S FUNCTIONAL LIP CLOSURE Does not make use of flaps – accurate reconstruction of the 3 rings of muscles of the Lip and nose Creates a highly symmetric nose and a functional lip NASO-LABIAL/UPPER RING : Transverses nasi , levator labii superiorisalequi nasi , levator labii superioris , zygomaticus minor and the levatoranguli oris . BILABIAL/MIDDLE RING : Represents oral sphincter, consisting of theupper and lower lip orbicularis oris muscle. LABIO-MENTAL/LOWER RING : Lower ring has an incomplete circumference and consists of orbicularis inferior, triangularis labiiand quadrates labii inferioris . Brusati , Roberto & Mannucci , N. & Mommaerts , Maurice. (2006). The Delaire philosophy of cleft lip and palate repair. Maxillofacial Surgery. 1027-1047.

17. The integrity of the first ring is fundamental for sustaining and allowing normal functioning of the other two. The lower ring acts by remodelling the dento alveolar complex and chin portion of the mandible vertically and transversely. DRAWBACKS Straight-line scar and inability to achieve adequate lengthening of the lip, resulting in a notching.

18. BILATERAL CLEFT LIP REPAIR Achieve symmetrical result Reconstruction of vermillion & white roll Muscle repair - allow upper lip to function as a single unit Reconstruction of gingival-labial sulcus Form medial tubercle & vermillion-cutaneous ridge from lateral lip tissue (in caseswhere the prolabium is deficient) Primary improvement of columellar length and nasal tip projection Proper philtral size and shape

19. MANCHESTER REPAIR: For less severe bilateral deformities in which the prolabium has adequate white roll and vermillion →these structures are preserved in the repair (in contrast with Millard, Mulliken , etc. which discard this tissue Advantages C omparatively straightforward L ess tension on repair decreased chance of tight upper lip Disadvantages whistle-notch deformity if used in cases with deficient prolabial vermillion

20. MILLARD TECHNIQUE Advantages • Good result even when prolabial white roll and vermillion are deficient Disadvantages • Rectangular columella without a normal-appearing • Sharp columella -labial angle • Abnormally elongated nostrils • Columellar over-elongation • Downward drift of the columellar base • Requires multiple procedures

21. MILLARD TECHNIQUE Variations of this technique are widely used ( mulliken ) • Repair brought lateral vermillion flaps under the prolabium , avoiding the whistle notch deformity of some earlier repairs • Restores orbicularis continuity deep to the prolabium • Uses forked flaps derived from the prolabial parings to lengthen the columella ; these are banked in the alar bases until they are required

22. MULLIKEN TECHNIQUE Many similarities with millard repair, but : • Emphasized importance of how the repaired lip will grow over time • Advocated lengthening the columella by repositioning the alar cartilages rather than deriving tissue from prolabial forked. Advantages • Good result even when prolabial white roll and vermillion are deficient • Good scar position - hidden in philtral columns • Addressed nasal deformity with repositioning of cartilage elements rather than with external flaps → less external scarring • Avoids characteristic prolabial wideness of bilateral cleft lip repairs Disadvantages • Can get tight upper lip

23. POSTOPERATIVE CARE A. Orders Arm restraints for 3 weeks to prevent disruption of repair. Specialized nipple/bottle to decrease sucking effort when bottle-feeding . Breast-feeding is controversial; based on surgeon preference. B. Leave Steri -Strips in place over the incision for reinforcement. C. Follow up in 1 week for suture removal if nonabsorbable skin sutures were used.

24. CLEFT PALATE REPAIR TIMING Age o f surgery (6-14 months) TECHNIQUES Bardach Two Flap Von Langenbeck Furlows Delaire Sommerlads Morphofunctional

25. CLEFT PALATE REPAIR BARDACH The design of the flap entirely depends on the greater palatine nuerovascular pedicle and it provides versatility to cover the cleft. A modification of von Langenbeck's technique by extending the lateral alveolar relaxing incisions to the edge of the cleft. ADVANTAGES Complete closure of entire palate in one stage Creation of physiological soft palate muscle sling and a layered closure. DISADVANTAGES Does not provide additional length to the repaired palate to allow normal speech production Bardach J. Two-flap palatoplasty : Bardach's technique. Operative techniques in plastic and reconstructive surgery. 1995 Nov 1;2(4):211-4.

26. CLEFT PALATE REPAIR VON LANGENBECK The Vonlangenbeck technique is almost similar to bardach palatoplasty but preserves the anterior pedicle for increased blood supply to the flaps. It is used in isolated cleft cases. ADVANTAGES Easy to perform Requires less dissection Results in decreased raw area of palate DISADVANTAGES Cannot be used in wider and complete clefts. Failure to provide additional palatal length Rossell -Perry P. Flap Necrosis after Palatoplasty in Patients with Cleft Palate. Biomed Res Int. 2015;2015:516375. doi : 10.1155/2015/516375. Epub 2015 Jul 26. PMID: 26273624; PMCID: PMC4529936.

27. CLEFT PALATE REPAIR VEAU-WARDILL-KILNER PUSHBACK PALATOPLASTY VEAU-WARDILL-KILNER PUSHBACK PALATOPLASTY is used for the incomplete clefts of hard and soft palate ADVANTAGES Lengthening of palate Repositioning the Levator muscle in a favorable position DISADVANTAGES Adversely affects midfacial growth of the cleft palate patients because of scar tissue anteriorly. Higher rate of fistula in complete cleft palate than other techniques because it provides single nasal mucosal layer anteriorly Agrawal K. Cleft palate repair and variations. Indian Journal of Plastic Surgery. 2009 Oct;42(S 01):S102-9.

28. CLEFT PALATE REPAIR FURLOW Alternating the reverse z plasties of the nasal and oral flaps and repositioning the levator veli palatini muscle within the posteriorly mobilized flaps. Effective for primary closure of submucous cleft palate and secondary correction of marginal velopharyngeal insuffieciency ADVANTAGES No need to raise large muccoperiosteal flaps from the hard palate The soft palate can be lengthened (Good speech Outcome) DISADVANTAGES Non anatomical palatal closure Ignores musculus Uvulae Difficult to close wider clefts Larger raw areas need to be covered with buccal flap Leow AM, Lo LJ. Palatoplasty : evolution and controversies. Chang Gung Med J. 2008 Jul 1;31(4):335-45.

29. CLEFT PALATE REPAIR SOMMERLAD Radicular retropositioning of velar musculature and tensor tenotomy using a operating microscope to allow accurate levator muscle reconstruction ADVANTAGES Non tension closure in wider palates Good speech Outcomes DISADVANTAGES Reccurent ear infections due to tensor tenotomy High fistula rates due to radical muscle relieving from the nasal area Loss of tautness of soft palate Sommerlad BC. A technique for cleft palate repair. Plastic and reconstructive surgery. 2003 Nov 1;112(6):1542-8.

30. CLEFT PALATE REPAIR MORPHOFUNCTIONAL TWO FLAP TECHNIQUE WITH OPTIMAL MUSCLE DISSECTION Gosla Reddy, S. (2017). Morphofunctional palatoplasty : evidence based recommendations. International Journal of Oral and Maxillofacial Surgery Medial and Lateral incisions to expose the soft palate musculature and mobilize the hard palate flaps.

31. CLEFT PALATE REPAIR MORPHOFUNCTIONAL SOFT PALATE MUSCLE DISSECTION Gosla Reddy, S. (2017). Morphofunctional palatoplasty : evidence based recommendations. International Journal of Oral and Maxillofacial Surgery Optimal muscle dissection Dissection only of Levator muscle bundle ( Levator Myoplasty ) Tensor tendon is not dissected

32. CLEFT PALATE REPAIR MORPHOFUNCTIONAL Gosla Reddy, S. (2017). Morphofunctional palatoplasty : evidence based recommendations. International Journal of Oral and Maxillofacial Surgery

33. CLEFT PALATE REPAIR MORPHOFUNCTIONAL Gosla Reddy, S. (2017). Morphofunctional palatoplasty : evidence based recommendations. International Journal of Oral and Maxillofacial Surgery Postoperative antibiotic dressing for 5 days Postoperative feeding: Clean, Clear and filtered fluids for 1 month. Plenty of oral fluids. Parent counselling.

34. VELOPHARYNGEAL INSUFFICIENCY Inadequate closure of the soft palate during speech to the posterior pharynx during speech, resulting in air leak up to the nasopharynx LINDSEY AND DAVIS 1995 Velopharyngeal Insufficiency : Inability to achieve complete closure of the velopharyngeal apparatus during speech Velopharyngeal Incompetence : Imperfect closure of velopharyngeal apparatus caused by nueromuscular dysfunction(Impaired motor programming of velopharynx . Velopharyngeal Inadequacy : Imperfect closure of velopharyngeal apparatus caused by tissue defect

35. ASSESMENT OF VELOPHARYNGEAL INSUFFICIENCY Speech evaluation by well trained speech pathologist Pressure flow measurements Nasopharyngeal Endoscopy Videoflouroscopy

36. CORRECTION OF VPI Secondary Palatoplasty aims at correcting velopharyngeal inadequacy 5% to 36% patients who have undergone primary palatoplasty have persisting VPI SURGERIES VELOPHARYNGEAL NARROWING PALATAL LENGTHENING V-Y PUSHBACK INTRAVELAR VELOPLASTY DOUBLE OPPOSING Z PLASTY SPHINCTER PALATOPLASTY PHARYNGEAL FLAP SUPERIORLY PLACED INFERIORLY PLACED Dorf DS, Curtin JW. Early cleft palate repair and speech outcome. Plastic and reconstructive surgery. 1982 Jul 1;70(1):74-9.

37. INTERVELAR VELOPLASTY A triangular flap is designed comprising new epithelial tissue which will be turned over. Using a single hook, the oral mucosa and gland layer is separated from the muscle layer. Dissection of the greater palatine nerve-vessel bundle. The anterior palatal flap is raised by a curved elevator. The closure of the nasal mucosa and muscle is completed.

38. CORRECTION OF VPI This Study conducted to determine the effectiveness of a modified secondary Furlow Zplasty in improving VPI Reddy RR, Reddy SG, Banala B, Bronkhorst E, Kummer AW, Kuijpers-Jagtman AM, Bergé SJ. Use of a modified Furlow Z- plasty as a secondary cleft palate repair procedure to reduce velopharyngeal insufficiency. International Journal of Oral and Maxillofacial Surgery. 2016 Feb 1;45(2):170-6.

39. TONGUE FLAP Guerrero-Santos and Altamirano , were the first to report on the use of tongue flaps for palatal defect closure. The tongue flap is easy and reproducible with excellent esthetical and functional results. Advantages The use of adjacent tissue, the excellent blood supply and the low morbidity in donor site. Disadvantage In some cases the attachment of the flap can be lost due to traction.

40. BUCCAL MYOMUCOSAL FLAP BMMF is a vascular and dependable flap. Vascular supply of the flap is consistent and profuse. It is effective in reducing/eliminating hypernasality in patients with cleft palate and velopharyngeal insufficiency Advantages Flap congestion is occasional and necrosis is rare. It tolerates stretching, folding, and twisting. Disadvantage Fibrosis. Secondary healing. Parotid duct orifice injury

41. COMPLICATIONS PRE OPERATIVE Otitis Media Aspiration Pnumonia Nutritional Deficiency INTRA OPERATIVE Blood Loss Damage to the Pedicle IMMEDIATE POST OPERATIVE Bleeding Airway Obstruction Wound dehiscence/infection Hanging palate Erosion of corner of mouth LATE POST OPERATIVE Fistula formation Velopharyngeal Insufficiency Maxillary Hypoplasia Reccurent Ear Infections

42. ALVEOLAR BONE GRAFTING Usually done at the time of lip repair TIMING - 0-2.5 years usually at the time of lip repair Disadvantage P oor maxillary growth N egative effects on anterior and inferior growth of maxilla inadequate contour of bone graft higher propensity for cross bites PRIMARY ABG

43. U sually done in childhood before the eruption of permanent incisors Early surgery is not evaluated as thoroughly as late surgery Boyne indicated this when permanent central and lateral incisors appear to be developing in such a direction that it may erupt abnormally into the cleft resulting in inadequate tooth position or severe malposition jeopardized bone support because of anatomy of tooth eruption . SECONDARY ALVEOLAR BONE GRAFTING ADVANTAGES: classic time for alveolar grafting H igh percentage of good results Allows eruption of canine H ealthy teeth on either side of cleft Minimal impact on facial growth A llows for orthodontic alignment EARLY SECONDARY ABG Boyne PJ. Use of marrow-cancellous bone grafts in maxillary alveolar and palatal clefts. Journal of dental research. 1974 Jul;53(4):821-4.

44. DISADVANTAGE central and lateral incisors must have erupted carries increased risk of periodontal bone loss and root resorption . Posnick mentions that waiting allows maximum transverse growth of maxilla to occur before bone grafting . 95 % of anteroposterior and transverse growth of maxilla is completed by the age of 8yrs . It is done after the eruption of canine It has got lower incidence of successful grafts due to Poor oral hygiene and decreased blood supply or altered oral flora in older children. Hall HD, Posnick JC. Early results of secondary bone grafts in 106 alveolar clefts. Journal of Oral and Maxillofacial Surgery. 1983 May 1;41(5):289-94. LATE SECONDARY ALVEOLAR BONE GRAFTING

45. TIMIMNG Primary ABG : 0-2.5 years usually at the time of lip repair Early secondary ABG : 2-5 years before the eruption of permanent incisors Secondary ABG : 6-13years before the eruption of permanent canines Late secondary ABG : >13 years after the eruption of permanent canines TYPES OF GRAFT AUTOGENOUS GRAFT ALLOGENOUS GRAFT ALLOPLASTIC GRAFT

46. RELEVANCE TO ALVEOLAR CLEFT Various factors affecting in decision making process : choosing an appropriate donor site for alveolar cleft size of the cleft volume of bone needed whether teeth will erupt through graft material health of donor site healing potential of the patient Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H.Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

47. ILIAC BONE Gold standard, Easy access & high success rates R apid bone formation and calcification ( large supply of pleuripotent / osteogenic cells ) Earlier cortico -cancellous blocks were used but lately only cancellous bone is harvested using cylindrical punch with minimal incision. H igh content of osteogenic cells Rapid revascularization of graft ( 3 weeks ) While choosing the anteromedial approach care should be taken to preserve the attachment of tensor fascia lata - Anterior Illiac Crest For Larger Quantities of bone - Posterior Illiac Crest Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

48. ILIAC BONE CREST ADVANTAGES A dequate quantity, easily condensed and placed proven successful results little donor site morbidity two team approach DISADVANTAGES Q uestionable effects on growth possible gait disturbance post operative hematoma D onor site morbidity Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

49. TIBIAL BONE CREST Johanson and Ohlsson , Drachter 1941 – facial clefts medial, slightly curved incision with excellent exposure of the tibial shafts. Large supply of cancellous bone is available. Cosmetically the post operative incision appears to be quite acceptable. ADVANTAGES A dequate volume Q uality similar to iliaccrest P redictable results Two team approach DISADVANTAGES concern with ambulation Epiphyseal injury Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

50. RIB BONE CREST An eccentrically placed H shaped rib strut is wedged into the cleft with the more prominent portion facing the labial side to elevate the depression caused by cleft. A solid piece of rib can be used for linear separation at the ends exposing the cancellous part of the bone . The rib can be broken into many small chips and packed into the cleft ADVANTAGES for infants two team approach DISADVANTAGES D onor site morbidity unpredictable results Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

51. MANDIBULAR SYMPHYSIS Bosker & Von Dijt – Mandibular symphysis Low morbidity LIMITATIONS Limited volume increased percentage of impacted canines(increased cortical content) loss of unerupted permanent teeth early mixed dentition N ecrosis of the pulp, or devitalisation of teeth; Injury to the mental nerve ADVANTAGES E mbryonic origin and earlier vascularization less resorption No external scar DISADVANTAGES L imited amount of bone I nability to remove bone graft simultaneously with preparation of recipient site . Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H. Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670

52. PRE SURGICAL ORTHODONTICS 2 orthodontic considerations integrate with timing of alveolar cleft grafting C orrection of cross bites A lignment of anterior teeth cross bite due to narrowed transverse dimension of maxilla (maxillary expansion performed before grafting) when graft is performed before expansion (3 months should elapse before expansion) B ilateral cleft with a pre-maxilla (maxilla must be expanded first before distalizaton of pre-maxilla to ensure proper space) It better not to begin teeth alignment before grafting as movement of teeth adjacent to cleft may result in root exposure through this alveolar bone in this area. F ull revascularization of cancellous bone takes place in 3 weeks

53. PREPARATION OF CLEFT ALVEOLUS Five Principles in approaching the cleft alveolus : Wide exposure and appropriate Flap design. Reconstruction of Nasal floor closing the oro nasal fistula Adequate graft material harvest. Adequate packing of the defect with cancellous bone Watertight closure of bone graft with gingival mucoperiosteal flaps. Bajaj AK, Wongworawat AA, Punjabi A. Management of alveolar clefts. J Craniofac Surg. 2003 Nov;14(6):840-6 ..

54. SECONDARY ALVEOLAR BONE GRAFTING PROCEEDURE

55. SECONDARY ALVEOLAR BONE GRAFTING Vemagiri CT, Damera S, Pamidi VR, Pampana SG. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. International Journal of Clinical Pediatric Dentistry. 2022 Dec 17;15(4):472-4.

56. SECONDARY ALVEOLAR BONE GRAFTING Vemagiri CT, Damera S, Pamidi VR, Pampana SG. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. International Journal of Clinical Pediatric Dentistry. 2022 Dec 17;15(4):472-4.

57. SECONDARY ALVEOLAR BONE GRAFTING Vemagiri CT, Damera S, Pamidi VR, Pampana SG. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. International Journal of Clinical Pediatric Dentistry. 2022 Dec 17;15(4):472-4.

58. TYPES OF TISSUE FLAPS USED FOR BONE GRAFTS LOCAL FLAPS Local flaps obtained from the labial alveolar ridge and rotated in a hinge like fashion based either medially or laterally towards the palate exposing the alveolar clefts. The labial defect is then closed with any of the labial flaps which can be rotated from the medial or lateral side.

59. TYPES OF TISSUE FLAPS USED FOR BONE GRAFTS DISTANT FLAPS Distant flaps ( one stage vomer ) used for the closure of wider alveolar clefts. It was used by Stellmach and Schrudde It is easily elevated and transferred in one stage directly anteriorly to meet oncoming flap from the labial side. Bilateral vomer flaps used in bilateral clefts are formed in two stages with intervals of two or three months as simulatenous denudation and elevation of two vomer flaps jeopardize the blood supply to vomer

60. COMPLICATIONS Infection Wound dehiscence Loss of intact of graft Incomplete closure of oronasal fistula

61. POST SURGICAL ORTHODONTICS 3 months after the bone graft procedure, depending on the radiographic image of the area orthodontic treatment is restarted to correct the position of the permanent teeth . The pattern of eruption of the maxillary central incisor follows the pattern of alveolar development in the cleft subjects. Dental alignments are possible if the alveolar cleft is grafted Correction of malpositioned teeth - fixed / Semi-fixed or fully bonded appliance permitting adjacent teeth to migrate or orthodontically move into the grafted bone . C anine brought into the space of the lateral incisor moving the tooth through the alveolar bone graft and reshaped into a lateral incisor and residual spaces closed with fully fixed bonded appliance.

62. RECENT ADVANCES AUTOGENEOUS BONY SUBSTITUTES R educe morbidity Not necessary to harvest autogenous bone, R educe the cost of rehabilitating patients with clefts. LIMITATIONS U npredictability in resorption / amount of bone formed

63. RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN (RHBMP ). rhBMP-2 is effective in the regeneration of alveolar bone and associated periodontal attachment apparatus It promotes the differentiation of pluripotential cells into bone forming cells that lay down new host bone in the site of the defect ( osteoinduction ) Remodelling equilibrium prevents loss of bone through resorption However , it requires a suitable carrier for its clinical applications in human conditions to prevent rapid diffusion of the protein

64. RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN (RHBMP ). Scalzone A, Flores-Mir C, Carozza D, d’Apuzzo F, Grassia V, Perillo L. Secondary alveolar bone grafting using autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and meta-analysis. Progress in Orthodontics. 2019 Dec;20:1-0.

65. RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN (RHBMP ). Scalzone A, Flores-Mir C, Carozza D, d’Apuzzo F, Grassia V, Perillo L. Secondary alveolar bone grafting using autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and meta-analysis. Progress in Orthodontics. 2019 Dec;20:1-0. Autologous bone and rh-BMP2 graft showed a similar effectiveness in maxillary alveolar reconstruction patients with unilateral cleft lip and palate with rh-BMP2 graft showed a relative shorter length of hospital stay

66. CONCLUSION The primary aim in CLP is to educate parents and future mothers and fathers. Cleft lip and palate are both birth defects that affect different structure and function such as speech difficulty, aesthetic, eating, nutrition etc. Patients with oro ‑facial cleft deformity needs to be treated at right time and at right age to achieve functional and aesthetic well‑being . Treatment involves a number of specialists who decide the best treatment plan depending on the site of defect and age of the infant The multidisciplinary approach towards this problem will lead to a steady improvement in its end results.

67. REFERENCES Brusati , Roberto & Mannucci , N. & Mommaerts , Maurice. (2006). The Delaire philosophy of cleft lip and palate repair. Maxillofacial Surgery. 1027-1047. Bardach J. Two-flap palatoplasty : Bardach's technique. Operative techniques in plastic and reconstructive surgery. 1995 Nov 1;2(4):211-4. Leow AM, Lo LJ. Palatoplasty : evolution and controversies. Chang Gung Med J. 2008 Jul 1;31(4):335-45 . Agrawal K. Cleft palate repair and variations. Indian Journal of Plastic Surgery. 2009 Oct;42(S 01):S102-9 . Sommerlad BC. A technique for cleft palate repair. Plastic and reconstructive surgery. 2003 Nov 1;112(6):1542-8. Gosla Reddy, S. (2017). Morphofunctional palatoplasty : evidence based recommendations. International Journal of Oral and Maxillofacial Surgery Reddy RR, Reddy SG, Banala B, Bronkhorst E, Kummer AW, Kuijpers-Jagtman AM, Bergé SJ. Use of a modified Furlow Z- plasty as a secondary cleft palate repair procedure to reduce velopharyngeal insufficiency. International Journal of Oral and Maxillofacial Surgery. 2016 Feb 1;45(2):170-6. Hall HD, Posnick JC. Early results of secondary bone grafts in 106 alveolar clefts. Journal of Oral and Maxillofacial Surgery. 1983 May 1;41(5):289-94.

68. REFERENCES Secondary Alveolar Bone Grafting: the Dilemma of Donor Site Selection and Morbidity M.A. Rawashdeh , H.Telfah / British Journal of Oral and Maxillofacial Surgery 46 (2008) 665–670 Vemagiri CT, Damera S, Pamidi VR, Pampana SG. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. International Journal of Clinical Pediatric Dentistry. 2022 Dec 17;15(4):472-4. Bajaj AK, Wongworawat AA, Punjabi A. Management of alveolar clefts. J Craniofac Surg. 2003 Nov;14(6):840-6 . Vemagiri CT, Damera S, Pamidi VR, Pampana SG. Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report. International Journal of Clinical Pediatric Dentistry. 2022 Dec 17;15(4):472-4.