Cleft palate is more common and can occur alone or in combination with cleft lip. Cleft palate not only causes soft tissue deformity, but most patients with cleft palate are also accompanied by varying degrees of bone tissue defects and deformities. They have physiological dysfunctions such as sucking, eating and speech that are far more serious than cleft lip. Due to jaw growth and development disorders, the middle part of the face often collapses. In severe cases, the face becomes a saucer shape, and the bite is misaligned (often with an underbite or an open bite). Therefore, the various physiological dysfunctions caused by cleft palate deformity, especially language dysfunction and dental disorders, have adverse effects on patients' daily life, study, and work; they can also easily cause psychological disorders in patients.

Edit the cause of this paragraph

The cause of cleft palate is not completely clear, but it is believed to be related to nutritional deficiencies in food during pregnancy, endocrine abnormalities, viral infections and genetic factors

< p>Edit this paragraph Clinical manifestations

So far, there is no unified classification method for cleft palate at home and abroad.

Usually cleft palate can be divided into four types:

① Cleft soft palate, not complicated by cleft lip;

② Cleft soft and hard palate, often complicated by unilateral incompleteness Cleft lip;

③ Unilateral complete cleft palate, starting from the uvula, to the incisor foramen, obliquely to the outside, to the lateral incisors. The alveolar processes on both sides are separated by mucosa, and are often complicated by unilateral cleft palate. Complete cleft lip;

④ Bilateral complete cleft palate, often coexisting with bilateral complete cleft lip. The cleft splits to both sides at the lateral incisors, and the lower end of the nasal septum is free.

Clinically, type 3 cleft palate is the most common, and type 4 is the least common.

Based on the degree and location of clefts in the bone, mucosa, and muscle layers of the hard palate and soft palate, the following clinical classification methods are often used:

(1) Cleft soft palate

Only the soft palate is cleft, sometimes only in the palatal lobe. Regardless of left or right, it is generally not accompanied by cleft lip. Clinically, it is more common in women.

(2) Incomplete cleft palate

Also known as partial cleft palate. A complete cleft of the soft palate is accompanied by a partial cleft of the hard palate; sometimes accompanied by a unilateral incomplete cleft lip, but the alveolar process is often intact. There is no distinction between left and right in this type.

(3) Unilateral complete cleft palate

The cleft is completely split from the palatine to the incisal foramen, and extends obliquely to the outside until it touches the alveolar process and is connected to the alveolar cleft; healthy The lateral cleft edge is connected to the nasal septum; sometimes the alveolar cleft disappears and only the cleft remains, sometimes the cleft is very wide; it is often accompanied by ipsilateral cleft lip.

(4) Bilateral complete cleft palate

Often occurs at the same time as bilateral cleft lip. The cleft is in the premaxilla, diagonally cleft on both sides, directly reaching the alveolar process; nasal septum , premaxillary process and anterior labial part are isolated in the center.

In addition to the above types, a few atypical conditions can also be seen: such as complete on one side and incomplete on one side; missing palatal lobes; submucosal clefts (cryptic clefts); partial clefts in the hard palate, etc.

In addition, some domestic units also have a commonly used classification method for cleft palate, which is to divide it into degree I, degree II, and degree III.

Because there is a gap between the oral cavity and the nasal cavity, cleft palate cannot form the necessary negative pressure in the mouth when sucking milk, resulting in difficulty in sucking milk, often leading to malnutrition, and prone to otitis media and respiratory infections. Newborns or infants with severe cleft palate often have sucking and swallowing dysfunction, resulting in nutritional disorders, choking and coughing when sucking milk, and aspiration pneumonia. In severe cases, it can cause articulation disorders, and children often have obvious open nasal sounds or unclear speech.

Edit this paragraph’s examination methods

Visual examination and finger palpation can detect the extent of the hard palate defect

Edit this paragraph’s treatment measures

Cleft palate Treatment is a complex process that requires the cooperation of experts from plastic surgery, orthodontics, voice training, psychiatry and psychology to achieve satisfactory results.

Treatment Principles

In terms of the timing of cleft palate surgery, try to complete the cleft palate repair before the age of 2 years. For patients whose cleft is narrow and the exposed bony surface of the hard palate can be left unexposed or less exposed after surgery, it is better to complete cleft palate surgery within one year of age. When the fissure is severe and a large area of ??exposed bone surface may be left after the operation, the operation time can be appropriately delayed. For cleft palate patients aged 5 to 10 years old, we perform Huaxi posterior pharyngeal wall augmentation surgery at the same time as cleft palate surgery to help improve the velopharyngeal closure rate. For cleft palate patients older than 10 years old, we perform cleft palate surgery at the same time as cleft palate surgery. West China's velopharyngeal muscle flap pharyngoplasty can significantly improve the velopharyngeal closure rate in older patients. Children with cleft palate can be closely monitored. Cleft palate repair should only be considered when feeding, hearing or speech problems occur.

In the selection of cleft palate surgical methods, in principle, those surgical methods that can effectively restore the speech of cleft palate patients and have minimal impact on the growth of the maxillary bone should be selected. Our existing research has shown that the vomer bone flap repair method for cleft hard palate performed at the same time as cleft lip repair can effectively reduce the cleft width of the cleft palate, allowing most patients to avoid or reduce the work done on both sides near the gingival margin during cleft palate repair. The distance of the relaxing incision and the movement of the palatal mucoperiosteal flap toward the midline did not have a significant impact on the early growth of the maxilla.

In cleft palate repair, Sommerlad's levator veli palatini muscle reconstruction method is mainly used, and Lang's method (modified method), two-flap method (such as Bardach method) and reverse double Z (Furlow method) method are also used, and the following principles are followed. Carry out design and operation: strive to reconstruct the morphological structure of the levator veli palatini ring; extend the length of the soft palate as much as possible; try to avoid or reduce surgery

Surgical treatment

Surgical reconstruction. It is more suitable after 2 years old and before 5 to 6 years old. Surgery not only closes the cleft in the palate, but also provides the correct conditions for the child's pronunciation. Children should receive pronunciation training after surgery. The basic principle of cleft palate repair surgery is to lengthen the soft palate, close the velopharynx, and restore normal swallowing and pronunciation functions. At present, the more commonly used surgeries include: ① modified Lang's surgery; ② pear bone mucosal flap surgery; ③ arterial island palatal flap surgery; ④ posterior pharyngeal wall mucosal muscle flap transplantation surgery.

Moreover, this treatment often takes many years to complete. Although due to the development of medicine, treatment effects have been significantly improved. But the final effect is still unsatisfactory so far.

Cleft palate plastic surgery is a key step in the treatment of cleft palate. However, there are still different opinions in the medical community regarding the selection of age for surgery. In the past, doctors mostly advocated that the best age for surgery is 3-6 years old, considering whether the child can tolerate surgery.

At present, many doctors believe that due to improvements in anesthesia technology, the safety of surgery has been significantly improved, and propose that the earlier the surgery, the better, and it should not be older than 2 years old at the latest. Early surgery is very effective in improving postoperative speech.

Children should eat liquid food within one week after surgery and semi-liquid food within three months.

After surgery, in order to improve pronunciation, children should undergo pronunciation training under the guidance of doctors in order to develop correct pronunciation.

After the children reach their teens, they still need to go to the orthodontics department for orthodontic treatment.

In addition to surgical treatment, the following aspects should be noted: ① In order to avoid choking, the child can sit in a sitting position when feeding, or use a dropper to feed. It is easier to feed semi-liquid or solid food than liquid; ② Cleft palate is often If combined with tonsillitis and proliferative body hypertrophy, otitis media, chronic nasopharyngitis, etc., antibiotics should be applied promptly.

The basic principle of cleft palate surgery is to use tissue flaps adjacent to the cleft to close the cleft, extend the soft palate, and reset the misplaced tissue structure to restore the physiological function of the soft palate; to use posterior pharyngeal wall tissue flaps to increase the length of the soft palate. , using the pharyngeal side tissue flap to reduce the width of the pharyngeal cavity to improve velopharyngeal closure.

The basic surgical operations of palatoplasty are as follows:

① Incision: Make an incision on the palatal mucosa 1 to 2 mm away from the edge of the gingival groove, and cut backward from the lateral incisors to The maxillary tubercle bends outward and rearward until it reaches the outside of the lingual and palatine arch. It should not exceed the outside of the pterygomandibular ligament to avoid exposing the buccal fat pad. The incision in the hard palate should be as deep as the bone surface of the palatine bone, and care should be taken not to damage the descending palatine vessel nerve bundle.

② Peel off the mucoperiosteal flap: Use a peeler to quickly and accurately lift the mucoperiosteal flap of the hard palate from the bone surface until it reaches the edge of the cleft. During dissection, blood should be sucked out in time to make the surgical field clear, and saline gauze should be used to compress and stop bleeding at any time to reduce intraoperative bleeding.

③ Dissect the edge of the cleft: Use a No. 11 sharp blade to carefully dissect the tissue at the edge of the cleft from the front to the end of the uvula. Because the tissue at the edge of the soft palate, especially the uvula, is very fragile, it is easy to cause Tear, be careful when cutting open.

④ Break off the wing hook: At the posterior end of the lateral incision, above the maxillary tubercle, touch the position of the wing hook, use a stripper to break off the wing hook or use an osteotome to cut off the wing hook, so that the tensor veli palatini muscle can Losing the original tension, the palatal flap tissues on both sides can relax.

⑤ Peel off the vascular and nerve bundles: Lift the mucoperiosteal flap, expose the greater palatine foramen on both sides, incise the periosteum along both sides of the vascular and nerve bundles, and carefully free the vascular and nerve bundles by 1 to 2 cm. Remove its hold on the soft palate.

⑥Separate the nasal mucosa: Insert the curved stripper along the nasal side of the hard palate, widely separate the nasal mucosa on both sides, and relax it so that it can be sutured in the center.

⑦ Cut off the palatal aponeurosis: Pull the mucoperiosteal flap laterally and posteriorly to expose the palatal aponeurosis at the junction of the soft and hard palate, and then cut off the palatal aponeurosis along the posterior edge of the palatine bone. Then decide whether to cut off the nasal mucosa based on the size of the crack and the degree of relaxation required. This can fully free the soft palate and nasal mucosa.

⑧Suture and wound treatment: suture the palatal mucoperiosteal flaps on both sides and the soft palate relative to each other in the midline. When suturing, first suture the nasal mucosa from front to back, then suture the soft palate muscle layer from the uvula forward, and finally suture the oral mucosa. After suturing is completed, stuff iodoform gauze into the loose incisions on both sides to prevent postoperative bleeding and protect the wound, and to reduce tissue tension to facilitate wound healing. Be careful not to over-pack to prevent the loose incision wound from everting. However, the wing hook should be packed tightly to prevent the loose incision wound edge from everting. However, the pterygoid hook should be packed tightly to prevent pterygoid process displacement or wound bleeding.

Postoperative care

After cleft palate surgery, it is advisable to make the child bend his knees, lie on his side, or head sideways or head down to facilitate the flow of blood or saliva from the mouth. Children with weak muscles may have their tongue fall back when they are asleep, which affects breathing. An oral airway can be placed; oxygen can be given if necessary.

The endotracheal intubation can be removed only after the child wakes up. Four hours after the child is fully awake, the child can be fed a small amount of sugar water and observed for half an hour. If there is no vomiting, the child can be given liquid food.

Children should take liquid food within 2 to 3 weeks after surgery, and then change to semi-liquid food, and can take regular food after 1 month.

It is strictly forbidden for children to cry loudly or put fingers or toys into their mouth after surgery to prevent the wound from dehiscing.

In order to prevent wound infection, children's mouths should be cleaned every day, children should be encouraged to drink more water, and antibiotics should be routinely used for 3 to 5 days after surgery.

Pay close attention to postoperative bleeding. On the day of surgery, if there is blood in the saliva but no obvious bleeding or bleeding points, no special treatment is required. Hemostatic drugs can be given throughout the body. When there is a blood clot in the mouth, attention should be paid to checking the bleeding point. If there is a small amount of bleeding but no obvious bleeding point, apply local gauze compression to stop the bleeding. If there is an obvious bleeding point, it should be sutured to stop the bleeding. If the bleeding is large, you should go back to the operating room for exploration and complete hemostasis.

If the child cries hoarsely, it means there is edema in the larynx. He should be treated with hormones in time and his breathing should be closely observed.

The iodoform gauze packed in the loose incisions on both sides will be removed 8 to 10 days after the operation, and the sutures will be removed 2 weeks after the operation. If the thread ends are infected, they can be removed in advance. If the child does not cooperate, the sutures may not be removed and allowed to fall off on their own.

Feeding knowledge

The reason why it is more difficult to feed children with cleft lip and palate than ordinary children

Reason 1: Due to the cleft lip and palate of the child, the mouth and nose are connected , a complete closed structure cannot be formed in the oral cavity and the negative pressure required for effective sucking cannot be generated.

Reason 2: Due to changes in the distribution and attachment of the labial and palatine muscles, muscle development and tension are insufficient. Causes tongue retraction; at the same time, the tongue is overdeveloped, and the tongue cannot be lifted up to effectively wrap the nipple during sucking.

Reason 3: Due to the shortening or inability of the soft palate to lift, the soft palate function is incomplete, which affects sucking and swallowing.

Effective feeding methods

Method 1: Pay attention to body position: (1) Take a sitting position or a 45゜ corner hug position. Do not lie down to avoid choking;

(2) Adopt face-to-face feeding to facilitate observation.

(3) Use prone position so that the nasal cavity is above the mouth to avoid choking.

Method 2: When the child sucks milk, block the cleft lip with your fingers to help the lip close.

Method 3: Choose a plastic bottle with a cross opening, because the cross-shaped opening will open only when it is pressed, so the child will not choke.

Method 4: Use squeeze feeding, that is, buy a squeezable bottle or syringe or dropper for feeding.

Method 5: Train the functions of the cheek and tongue by blowing up balloons, sucking pacifiers or massaging muscles.

Method 6: Place the pacifier in a non-cracked area to avoid excessive local irritation.

Method 7: Early orthodontic treatment, such as wearing a Hotz appliance made of soft and hard resin materials, covering the entire alveolar ridge and hard and soft palate, creating negative pressure in the oral cavity and improving Tongue movement can significantly improve feeding.

The significance of using spoon feeding after surgery

Reason 1: Sucking on a pacifier after surgery will cause excessive local tension in the wound, resulting in incomplete wound healing.

Reason 2: The wound is painful after surgery, and the child is unwilling to suck on the pacifier, resulting in insufficient food.

Method 1: Use a flat-bottomed spoon rather than a deep-bottomed spoon, and avoid metal products.

Method 2: Start with a small amount of food and gradually increase it.

Things to note after surgery

(1) Do not feed hot food.

(2) After feeding, you should drink a small amount of warm water to clean your mouth.

(3) Avoid irritation from residue and hard food.

(4) Keep the wound clean and dry.

(5) Avoid excessive crying, scratching, and collision with the wound site.

Psychotherapy

Due to the growth and development of patients with cleft lip and palate, psychosocial assessments should be conducted periodically on patients and their families as much as possible. Usually performed by a surgeon or nurse with knowledge of the psychology of cleft lip and palate. During the assessment, fill out the "Psychological Scale for Cleft Lip and Palate Patients of West China Stomatological Hospital" to identify each child's cognitive development, self-evaluation, personality development, interpersonal relationships, social and psychological development and other issues. When a child is found to have the above problems, he or she should receive professional developmental/cognitive assessment, guidance, counseling or other necessary help.

When children grow up, provide them with knowledge about cleft lip and palate deformities, and allow and encourage them to become active participants in the treatment plan. Inform the child's caregiver that they should be aware of the child's understanding of treatment discussions and should strive to let the child know as much as possible about the treatment plan.