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DOI: 10.1051/odfen/2011305 J Dentofacial Anom Orthod 2011;14:306� RODF / EDP Sciences

1

Received: 06-2011.Accepted: 08-2011.

Interventional calendarand protocol for cleft liftand palate repair at themaxillofacial and plasticsurgery department of theArmand Trousseau Children’s Hospital(AP-HP, Paris)

Arnaud PICARD, Eva GALLIANI, Veronique SOUPRE,

NatachaKADLUB,SophieCASSIER, GeorgianaCONSTANTINESCU,

Frederic ZAZURCA, Catherine TOMAT, Brigitte VI-FANE,

Chantal TRICHET-ZBINDEN, Cecile CHAPUIS-VANDENBOGAERDE,

Patrick A. DINER, Marie-Paule VAZQUEZ

ABSTRACT

Parents want their children’s’ faces, the most visible part of their bodies, onethat marks their identity throughout life, to be perfect. To satisfy thisunderstandably urgent desire, a high quality of primary treatment for cleft lipand palate is essential and must satisfy a double objective: restore normalmorphology and normal function. The functional, morphological, and estheticprognoses depend on the character of the defect, whether it stands alone or isassociated in a syndrome with other malformations. Important sequellae flowfrom the quality of the initial repair, as a consequence of the surgery and othertherapies as well as from the deformity itself.

Before the year 2000, the Maxillo-facial and Plastic Surgery Service at theArmand Trousseau Hospital of the Pierre and Marie Curie Faculty of Medicine

Address for correspondence

A. PICARDArmand-Trousseau Children’s Hospital,Maxillo-Facial and Plastic Surgery Service,26, avenue du Dr. Arnold Netter, 75571Paris Cedex [email protected]

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2011305

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adhered to the protocol that Malek had described, making an initialrepair of the soft palate at 3 months and then a cheiloplasty, withupper and lower triangles, and closure of the hard palate at 6months. Since then we have adopted the more functional approachthat Talmant described, integrating systematic nasal surgery and thetype of lip surgery that Millard suggested without leaving anyresidual exposed bone after closure of the osseous cleft. We thenperform gingivo-periosteal surgery with bone grafts on patientswhen they were between 4 and 6 years of age, after orthodontictherapy had been completed. This constitutes the last stage ofprimary treatment.

The therapeutic approach we have been using on our service,which has evolved of over the last 20 years, has come to define itsprincipal objective as integration of extensive rehabilitation into thevery first stages of our multi-disciplinary therapy so as to minimizethe establishment of faulty functioning of phonation, lipcompetence, and ventilation while avoiding any intervention thatwould have a harmful impact on facial growth. This multi-disciplinaryapproach, which integrates surgical evaluation and protocol, isindispensable and fully justifies treatment of patients with cleft lipand palate at accredited centers.

KEYWORDS

Cleft lip,

Cleft palate,

Bone graft,

Orthodontics,

Rhinoplasty.

1 – INTRODUCTION

Although all inter-disciplinary teamstreating labio-palatal clefts share thesame objectives, there is at presentno national or international consensuson what procedures to employ inseeking those goals nor on whatchronology should be used. In 2000,a Europe-wide inquiry on the subjectconfirmed this lack of agreementwhen it received 194 different proto-cols from 201 centers4.

The face, the most visible feature ofa human’s body, one that dotingparents dream will be perfect, marksa person’s identity throughout life.Medical management of facial defor-mities, like clefts, begins prenatallywhen ultrasound examinations dis-cern them. In these cases, the sur-geon’s first task is to break thedisquieting news to expectant parentsand help them prepare for the arrival

ARNAUD PICARD, EVA GALLIANI, VERONIQUE SOUPRE, NATACHA KADLUB, SOPHIE CASSIER, GEORGIANA CONSTANTINESCU, et al.

2 Picard A., Galliani E., et al. Interventional calendar and protocol for cleft lift and palate repair at the maxillofacialand plastic surgery department of the Armand Trousseau Children’s Hospital (AP-HP, Paris)

of their very special child. Adequatepreparation for these future parents onthe fundamentals of the treatmenttheir newborn will have to receivewill, without any doubt, reduce theanguish they will have to endure and,also, will ameliorate the psychologicaldistress the child itself will ultimatelybe subjected to.

It is essential that treating teamsoffer a high quality of initial treatment

for patients with labio-palatal clefts. Byproviding patients with reconstructionof cutaneo-mucosal, muscular, andcartilaginous structures surgeons willrestore functional activity, proper mor-phology, and acceptable esthetics forthem. The quality of this rehabilitationwill also greatly affect the nature oflater sequellae that are most oftencaused by some surgical lapse ratherthan by the original malformation.

2 – TREATMENT PROTOCOL

Even though we continue to em-phasize our objective of minimizingsequellae by diligently restoring thefunctions of phonation, mastication,and ventilation, and avoiding anyprocedure that could have a deleter-ious effect on growth, we havemodified our therapeutic approachover the past 10 years. We haveadopted the functional proceduresthat Talmant6,7 described.

2 – 1 – Prenatal management

The diagnosis of a labio-palatal cleftis most often made in a prenatalmorphological ultrasound examinationduring the second trimester of preg-nancy. We then discuss it at ourMultidisciplinary Prenatal DiagnosticCenter, evaluating any available sup-plementary radiological and geneticrecords searching for possible asso-ciated anomalies. In a consultationwith the surgeon our group confirmsthe diagnosis and establishes a prog-nosis for the deformity. Then, in a pre-natal appointment, using ultrasounddocuments, we explain the various

dimensions of the deformity to theprospective parents describing whatthe surgical and later over-all manage-ment of the newborn will be. Next,parents have a meeting with a nurseworking in our service who will tellthem what type of feeding and post-operative care their child will need andalso what future procedures will beundertaken. To help them understandthe situation better, they will thenhave an opportunity to observe an-other child who is being successfullytreated for a similar problem.

2 – 2 – Surgical treatment

• The first step: repair of the soft

palate, the lip, and the nose (fig. 1and 2)We perform this first surgical pro-

cedure after the infant reaches theage of 3 months. We reconstruct thesoft palate in accordance with theveloplasty technique that Kriens firstdescribed in 1967, which Sommerlad5

later renewed and improved.

INTERVENTIONAL CALENDAR AND PROTOCOL FOR CLEFT LIFT AND PALATE REPAIR AT THE MAXILLOFACIAL AND PLASTIC SURGERY DEPARTMENT OF THE ARMAND TROUSSEAU CHILDREN’S HOSPITAL

J Dentofacial Anom Orthod 2011;14:306 3

Figures 1 a to cA left side unilateral cleft. The deformity before surgery (a) and 1 year later after combined cheiloplasty and rhino-septoplasty (b). We plan the procedure in accordance with a modified Millard technique (c).

Figures 2 a to dBilateral labio-palatal cleft. Pre-operative views (a, b) and post-operative views (c, d).



We incorporate an anatomicallycorrect unilateral or bilateral cheilo-plasty in this procedure using a mod-ified Millard technique. At the sametime we perform a rhino-septoplastyto reposition the alar cartilage and thenasal septum that are always deviatedon the side opposite the cleft in itsanterior sector. Here, muscle repair isessential because it will restore propersymmetry to the lips and give goodposture to the tip of the nose. We affixnasal retainers, made on site by theProsthetic Laboratory of our Service,in place with a trans-septal suture. Wereplace them with removable bi-nasalretainers, also prepared on site, thatare worn for a total duration of fourmonths.

After completion of the surgery,which lasts from 3 and a half hoursto 5 hours, depending on the type ofcleft, newborns are admitted to thePost-Intervention Observation Room

where they are carefully watched, andgiven intravenous morphine analgesiaand antibiotic and cortisone therapy.They are fed, beginning on the day ofthe operation by syringe or bottlespoon for three weeks to remove thepossibility of trauma to the newlyjoined soft palate that bottle-feedingcould cause. We use no splints or armor other kinds of restraints on thesechildren recovering from their firstoperation placing them instead indecubitus dorsal with head slightlyraised so they have free movementand can suck a thumb or a pacifier.

• Second surgical operation: clos-

ing the osseous cleft (fig. 3)Patients are scheduled for this

second operation when they are about12 months old and the hard palatebone gap has had time to closeappreciably spontaneously after thelip and soft palate repair.

Figures 3 a and bThe appearance of the hard palate cleft at 12 months after the spontaneous shrinking of the gap that follows repair ofthe soft palate and lip at 3 months. Surgeons can now close the osseous defect without leaving any scar zone in thereunited palate.



Thanks to this spontaneous im-provement, surgeons can alwaysclose the remaining hard palate gapin two planes by sliding the nasalmucosa and the palatal fibromucosatogether without leaving any denudedosseous zones. This is importantbecause studies have clearly shownthat if secondary scar tissue finds aplace to form it can interfere withproper maxillary growth1. We closethe osseous gap right up to theretroalveolar zone, leaving the alveolarcleft itself untouched, free of anysurgical intervention at that time.

• Third surgical operation: gingivo-

periosteoplasty combined with

bone graft (fig. 4)We close the alveolar cleft, which

has been spared any scar tissueformation, when patients are 4 to 6years old in the third and last primarycleft surgical procedure. It is under-taken after completion of orthodonticpreparation that consisted of correc-tion of the position of the retrudedsmall alveolar fragment and, notably,repositioning of the canine throughexpansion provided either by a ce-mented or splint-born palatal expanderor, earlier on younger patients, by aquad’helix cemented to temporarymolars. Orthodontists decide whichtype of appliance is best suited to thespecial needs of the individual pa-tient’s malocclusion. After orthodon-tists have achieved an intercaninedistance of about 32 to 35 mm fortheir patients they put a removablequad’helix in place that is worn untilthe surgical intervention begins.

Surgeons routinely place a graft ofspongy iliac bone in position whenthey perform gingivoperiostoplasties.In our procedures, the mucosa, which

is free of scar tissue, is of high qualitymaking it possible for us assure a full,impermeable seal of both the oral andthe nasal cavities. The graft must beplaced vertically along the maxilla tothe level of the piriform aperture butno higher. Surgeons should raise themucoperiosteal flap generously sothat it can cover the graft freely,without tension and accomplish thesub-periosteal dissection prudently toavoid harming any permanent toothbuds that may lie in nearby corticalbone.

When the surgery is complete thequad’helix is returned to its positionand left in place to serve as a retainerfor 3 to 6 months.

Orthodontists prepare the teeth ofpatients with bilateral clefts in thesame way they treat patients withunilateral clefts. We do the surgery intwo stages 2 to 6 months apart so asto avoid harming circulation in themucosa of the premaxilla.

2 – 3 – Associated and follow-uptreatment for cleftpatients

For functional issues:

• ENT

It is important for ENT specialists toexamine cleft palate patients at theage of nine months and then at leastonce a year systematically becausethey are at high risk for developingserious chronic otitis.

• Speech-language pathology

Speech therapists on our service,provide early ‘‘logopedic guidance’’ in



Figures 4 a to ga and b: intraoral frontal and palatal views of the cleft before surgery. A quadhelix has opened up an intercaninedistance of 32 to 35 mm.c to e: intraoral views of the gingivo-periosteal surgery combined with placement of a graft of spongy iliac bone. Theclosed nasal and palatal planes (c), the graft in place (d), and the sutured mucoperiosteal flap (e).f and g: occlusal X-ray films showing the lateral incisor bud emerging in the graft.



three sessions to children of the sameage with similar deformities and theirparents. The meetings, which takeplace when patients are 12 to 16months old, 18 to 26 months old,and 28 to 36 months old, are designedto acquaint parents with the impor-tance of the ‘‘pre-phonation’’ phase, atime when it is possible to make agame of at home exercises that im-prove velo-pharyngeal competence.This approach also emphasizes forparents the critical role that carefulauditory surveillance will play for theirchildren.

When patients are 3 years old,speech pathologists make an auditoryassessment, associated with a naso-metric sensitivity and specificity eva-luation that determine whetherpatients will simply continue with thebreathing exercises they had beentaught or will require more intensivespeech therapy at home. Their pro-gress is then evaluated annually.

• Orthodontics

Cleft palate patients often requireinterceptive orthodontic treatment tocorrect incisor malpositions as well asprotrusions, retrusions, or cross bites.The permanent central incisor on theborder of the cleft is often rotated -sometimes by as much as 90� – andinclined palatally enough to irritate andscar labial mucosa. It is at risk of beingtraumatized but severe rotations ofunerupted teeth visible on panoramicX-rays sometimes correct themselvesspontaneously during eruption. Bycorrecting irregular teeth with a remo-vable or a multi-band appliance, ortho-dontists can sometimes re-establishthe anterior locking necessary forharmonious maxi l lo-mandibulargrowth. In their treatments, orthodon-

tists must be careful to keep toothroots fully surrounded by basal bonebecause any weakening of periodontalsupport can make the quality of theultimate prognosis doubtful. The multi-disciplinary treatment team mustmaintain especially vigilant supervi-sion of patients with syndromic formsof clefts that are accompanied bymultiple congenital absences of teeth.The collaborative team should discussthe problems of these patients whorequire case-by-case adaptions oftreatment protocols.

• Surgery

Surgeons who are members of themulti-disciplinary team coordinatetreatment of cleft palate patients fromthe prenatal period to the end of thegrowth period. Their first responsibilityis to insure that the initial reparativeoperation produces optimal morpholo-gical and functional results with well-formed labio-nasal and velar musclebands, fully installed nasal breathing,and maxillary arch continuity that willencourage permanent teeth to eruptin good position, and eventually estab-lish a correct canine lock.

Depending on the wishes of thepatient, the team will determinewhether secondary operations areneeded to deal with lip or cutaneousscarring. A rhinoplasty associated witha new septoplasty may be indicated torepair a nasal deformity insufficientlycorrected by the initial surgery. Thesurgeon follows the same protocolthat guided the first procedure seek-ing the objective of restoring theanatomy of the cartilages. Patientswill again wear a conformer after thesecondary rhino-septoplasty. Achiev-ing good function for patients is crucialand requires ongoing collaborative



communication between speech lan-guage therapists, orthodontists, andsurgeons all working to prevent anyinterferences with correct growth andfunction such as encroachment ofpossible compensatory phenomenaas well poor speech production thatappointments with the speech lan-guage therapist can forestall. Sur-geons wi l l ascer ta in whetheradditional operations on the soft pa-late or pharynx are required to makesure students with treated clefts arenot handicapped in their school work.

2 – 4 – Surgical management ofarrested skeletal growth

We perform intermediate surgery ofmaxillary distraction with a techniquemost of whose components we de-veloped at our Center using a hybrid,internal distractor with double boneand dental anchorage2,3. Indicationsfor distraction therapy most oftenarise for patients with syndromicclefts not accompanied by a short,hypoplastic lip. Clinical syndromeforms of clefts, like the Van DerWoude syndrome, are classically ac-companied by multiple agenesies ofteeth and also frequently demonstrateover-all hypoplasia of the maxilla. Earlyosseous distraction of the upper jawhas the objective of establishing prop-er articulation with the mandible,which is usually normal size, so thatthe engagement of the two jaws willstimulate the maxilla to follow thenormal growth pattern of its inferiorfellow. Maxillary distraction also facil-itates orthodontic alignment of themaxillary teeth with creation and

maintenance of adequate space forunerupted teeth. And, finally, maxillarydistraction improves facial appearanceby correcting the position and bulk ofthe upper lip, all of which make iteasier for cleft palate patients tointegrate themselves in their lives atschool and play. When there is adiscrepancy greater than 10 mmbetween maxilla and mandible webelieve intermediary maxillary distrac-tion is indicated.

But this procedure does not meanthat orthognathic surgery will not beneeded at the termination of thegrowth period. What it does effec-tively is bolster cleft palate patients’self esteem at a critical juncture intheir lives and limit the extent of themaxillary advancement required in thesecondary, post growth surgery thusreducing the risk of relapse caused bythe shrinking traction of soft tissuescarring. This progressive maxillaryadvancement also limits velo-pharyn-geal decompensation tied to the ad-vancement of the soft palate.

Orthodontists and oral surgeonsjointly make the decision on whatsurgical correction will be required atthe end of the growth period. On ourservice we stress the importance ofmaintaining the harmonious size andshape of the maxillary arch and ofpreserving space for unerupted upperlateral incisors so that implants can beplaced where, and when, indicated.Orthodontists must also prepare thetwo arches so that a stable post-operative occlusion will be estab-lished, giving maximum protectionagainst development of any futureantero-posterior discrepancy.



3 – CONCLUSION

We have derived the interventionalcalendar that we use on our servicefrom the one Talmant described7. Thisso-called functional approach we be-lieve is a perfectly logical and effectiveone because using it we can reducethe assault that scar formation levels

on trouble-free growth of the maxilla.This calendar also has the objective ofpromoting the nasal breathing that wenow fully understand plays an impor-tant role in the growth and balance ofthe middle third of the face.

REFERENCES

1. Benateau H, Diner PA, Soubeyr and E, Vazquez MP, Picard A. Les sequelles maxillairesdans les fentes labioalveolopalatovelaires. Rev Stomatol Chir Maxillofac 2007;108:297–300.

2. Picard A, Diner PA, Labbe D, Nicolas J, Tomat C, Seigneuric JB, Vazquez MP, BenateauH. Les sequelles maxillaires dans les fentes labioalveoloplatovelaires. Place de ladistraction osteogenique. Rev Stomatol Chir Maxillofac 2007;108:313–20.

3. Picard A, Diner PA, Galliani E, Tomat C, Vazquez MR, Carls FP. Five years experiencewith a new intraoral maxillary distraction device (RID). Br J Oral Maxillofac Surg. 2010Dec 8.

4. Shaw WC, Semb G, Nelson P, Brattstrom V, Mølsted K, PrahlAndersen B, Gundlach KK.The Eurocleft project 19962000: overview. J Craniomaxillofac Surg 2001;29(3):131–40.

5. Sommerlad BC, Henley M, Birch M, Harland K, Moiemen N, Boorman JG. Cleft palatererepair – a clinical and radiographic study of 32 consecutive cases. Br J Plast Surg1994;47(6):406–10.

6. Talmant JC. Current trends in the treatment of bilateral cleft lip and palate. In: PreciousDavis S, Cleft Lip and Palate: A physiological approach. Oral and Maxillofac Surg ClinNorth Am 2000;12:421–41.

7. Talmant JC, Talmant JC, Lumineau JP. Une approche fonctionnelle lors du traitementprimaire des fentes labioalveolopalatovelaires pour le minimum de sequelles. RevStomatol Chir Maxillofac 2007;108(4):255–63.

Appointments– A. Picard, E. Galliani, V. Soupre, N. Kadlub, S. Cassier, G. Constantinescu, F. Zazurca, C.

Tomat, Vi-Fane, C. Trichet-Zbinden, C. Chapuis-Vandenbogaerde, P.A. Diner, M.-P.VazquezAP-HP, Armand-Trousseau Children’s Hospital, Maxillo-facial Surgery and Plasticsurgery Service; Referral Center for Rare Deformities off the Face and the Oral Cavity

– A. Picard, N. Kadlub, S. Cassier, M.P. Vazquez; Pierre and Marie Curie-Paris 6, UFR deMedicine Pierre and Marie Curie, Paris, F-75005.



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