Palatal fistula and syndromes associated with clcp part 1 by Dr. Amit Suryawanshi Oral & Maxillofacial Surgeon, Pune , India.

Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!

1. Palatal Fistula and Syndromes associated with CLCP Part - I Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeon Pune , India Contact details : Email ID - [email protected] Mobile No - 9405622455

2. The dictionary meaning of cleft is a crack, fissure, split or a gap. The zones affected by common orofacial clefts are as follows: Upper lip Alveolar ridge Hard palate Soft palate Nose (not so common) Eyes (not so common). INTRODUCTION

3. BIRTH DEFECTS Parents Family Members Patients Severe Psychological stress

4. Feeding problems Improper growth of face Delayed & Improper Speech Delayed or abnormal tooth eruption Ear infections & hearing problems Recurrent chest infections Social & Psychological problems EFFECTS ON CHILD

5. In India: (C.M.C. Vellore) 1:700 Racial variations: (By Gopalkrishnan : Dharwad Cleft Unit) American Black 0.21 - 0.41 Japanese 1.14 – 2.13 Caucasian 0.77 – 1.40 Indian 0.13 – 1.90 INCIDENCE

6. Clefts may be caused by hereditary Sex-linked recessive gene. Family history of cleft lip and palate (40%) Environmental Infections during pregnancy (viral) Nutrition deficiencies ( Folic acid) Anemia , seizures during pregnancy Harmful drug intake Excessive consumption of alcohol ETIOLOGY

7. Cleft Lip : Failure of fusion of medial nasal process and maxillary processes Cleft Palate : Failure of fusion of palatine processes of maxilla EMBRYOLOGY

8. INTERMAXILLARY SEGMENT – formed by Median nasal process fusion at deeper level . Composed of labial component upper jaw component PRIMARY PALATE portion of nasal septum DEVELOPMENT OF PALATE

9. DEVELOPMENT OF PALATE Palate develops from the primary palate & secondary palate Secondary palate derived from maxillary prominences Outgrowth of palatine shelves appear in sixth week & on each side of tongue

10. In 7 th week palatine shelves attain horizontal position & fuse with each other to form secondary palate Secondary palate fuse with nasal septum and posterior part of primary palate Bone extend from maxilla to ossify hard palate DEVELOPMENT OF PALATE

11. DEVELOPMENT OF PALATE Posterior part of palatine process do not get ossified and extend posteriorly to form soft palate The median palatine raphe indicates line of fusion of processes

12. Nasopalatine canal persists in median plane between premaxilla and secondary palate & represented in adult as incisive fossa . DEVELOPMENT OF PALATE

13. Incomplete cleft palate Unilateral complete cleft lip and palate Complete Cleft Palate Bilateral complete CLP TYPES OF CLEFT PALATE

14. Kernahan has simplified it representing various clefts in the form of Y. Anterior portion of Y depict the lip (1 and 4) Middle alveolus (2 and 5) Incisive foramina and the posterior portion (3 and 6) Posterior to the incisive foramen, the hard (7 and 8) and the soft (9) palate.

15. MUSCLES OF PALATE

16. Tensor veli palatini (TVP) Function-stiffens soft palate and opens eustachian tube Innervation -Cranial nerve V3 Levator veli palatini (LVP) Function-elevates soft palate in speech and swallowing Innervation -Cranial nerve IX and X

17. Uvula Fnction -elevates uvula Innervation -Cranial nerve IX and X Palatopharyngeus Function-narrow and seal nasal pharynx Innervation -Cranial nerve IX and X

18. Complete Cleft Palate : Palatal shelves fail to fuse The greater palatine foramen is located more anteriorly and laterally Gap in the soft palate does not always correspond to the gap of the hard palate A layer of the mucosa can extend and conceal a long underlying cleft in the bone structure The palatal aponeurosis is missing at the midline

19. Major muscles, levator veli palatini and palato pharyngeus do not join on the midline, fibres run parallel to the margins of the cleft Two halves of the uvula are converged towards one another There is a difference in the colour of the mucosa, oral mucosa is paler, nasal mucosa is redder

20. Cleft Palate Team Cleft Audiologist Orthodontics Cleft surgeon Social worker Psychologist 20 Assessment and Treatment of Cleft Palate.

21. Cleft Palate Team Cleft Audiologist Orthodontics Cleft surgeon Social worker Psychologist 21 Assessment and Treatment of Cleft Palate.

22. Preoperative Evaluation Pediatric evaluation Anesthetic evaluation Blood investigation Ear infection Malnutrition Anaemia Other congenital anomalies particularly cardiac. Milestones Chest x-ray Upper respiratory tract infection

23. Several Techniques- Trend is towards less scarring and less tension on palate Scarring of palate may cause impaired mid-facial growth(alveolar arch collapse, midface retrusion , malocclusion) Facial growth may be less affected if surgery is delayed until 18-24 months, but feeding, speech, socialization may suffer . Surgical Repair- Cleft Palate

24. Complications - Palatal Fistula

25. Introduction: Palatal defects are common complications seen after primary cleft palate repair. Small fistulas may be asymptomatic while large fistulas produce various symptoms. There are many methods proposed for closure of palatal defects.

26. Symptomatic fistula may cause : Regurgitation of food and fluid to the nasal cavity, Malodor Escape of air during speech resulting in hyper nasality Impaired suction Increased nasal discharge (Cleft palate journal, january 1978, vol. 15 No. 1 )

27. Most Common Site : Hard Palate ( most often at the junction of Hard & soft Palate) Incidence : 0% to 34% (Cohen SR, Kalinowaski J et al : Cleft palate fistula: A multivariate stastical analysis of prevalence, etiology & surgical management. Plast Reconstr Surg 87: 1041, 1991) 27

28. Causes of fistula formation: type of cleft, type of repair, wound tension, single-layer repair, infection and dead space deep to the mucoperiosteal flap (International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

29. Classification A. By Shultz 1. Pinpoint 2. Slit 3. Oval or Total dehiscence

30. B. Based on anatomical location by Smith: type I referred to bifid uvula; type II means fistula in the soft palate; type III means fistula at junction of the soft and hard palates; type IV means fistula in the hard palate;

31. type V indicates that the fistula at junction of the primary and secondary palates; type VI means lingual alveolar fistula; and type VII means labial alveolar fistula (International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

32. B. According to site : 1. Anterior 2. Middle 3. Posterior

33. C. ( According to size) 1. Small ( < 3mm ) 2. Medium ( 3-5mm) 3. Large ( > 5mm ) (Cohen SR, Kalinowaski J et al : Cleft palate fistula: A multivariate stastical analysis of prevalence, etiology & surgical management. Plast Reconstr Surg 87: 1041, 1991)

34. Causes of Fistula Improper Mobilization Tension Across the Suture Line Compromised Vascularity Flap Necrosis Infections dead space deep to the mucoperiosteal flap (International Journal of Pediatric Otorhinolaryngology 74 (2010) 1054–1057)

35. Closure of Palatal Fistula

36. Principals of fistula closure: Elevation of large palatal flaps based on the original incisions

37. Excision of the scarred margins of the fistula; No scar epithelium can be left traversing the fistula anywhere around its perimeter,

38. 3) Accurate tension free closure of the nasal & oral mucosa

39. 4 )Use of additional unscarred tissue to close anterior defects or large palatal defects; Mucobuccal flap & tongue flap are most useful;

40. 5) Bone graft when indicated; But it is not necessary for successful fistula closure.