Generally, cleft palate can be divided into four types:
① No cleft lip in soft palate;
② Soft and hard cleft palate, often complicated with unilateral incomplete cleft lip;
③ Unilateral complete cleft palate, from uvula to incisor foramen, obliquely to lateral incisor, with bilateral alveolar processes separated by mucosa, often accompanied by unilateral complete cleft lip;
④ Bilateral complete cleft palate often coexists with bilateral complete cleft lip. The fissure is open to both sides at the lateral incisor, and the lower end of the nasal septum is free.
Clinically, 3 kinds of cleft palate are the most common and 4 kinds are the least common.
According to the dehiscence degree and position of bone, mucosa and muscularis in hard palate and soft palate, the following classification methods are often used in clinic:
(1) Cleft palate
Only the soft palate is cracked, sometimes limited to the upper palate. No matter left or right, it is generally not accompanied by cleft lip, which is more common in women clinically.
(2) Incomplete cleft palate
Also known as partial cleft palate. Complete cleft of soft palate with partial hard cleft palate; Sometimes accompanied by unilateral incomplete cleft lip, but the alveolar process is often complete. This type is no different from the left.
(3) Unilateral complete cleft palate
The cleft is completely split from the maxilla to the incisor hole, reaching the alveolar process obliquely to the outside and connecting with the alveolar cleft; The cleft edge of the healthy side is connected with the nasal septum; Alveolar cracks sometimes disappear, leaving only cracks, and sometimes the cracks are very wide; Often accompanied by ipsilateral cleft lip.
(4) Bilateral complete cleft palate
It often occurs simultaneously with bilateral cleft lip, which is oblique to both sides of premolar and reaches alveolar process; The nasal septum, the anterior jaw process and the anterior lip are isolated in the central part.
In addition to the above, we can also see several atypical situations: for example, one side is complete and the other side is incomplete; Palatal lobe loss; Submucosal fissure (cryptofissure); Partial cleft of hard palate, etc.
In addition, some domestic units also have a commonly used classification of cleft palate, which is divided into I degree, II degree and III degree.
Cleft palate can not form the necessary negative pressure in the mouth when sucking milk, which often leads to malnutrition, otitis media and respiratory infection. Neonates or infants with severe cleft palate often have dysfunction of sucking and swallowing, which leads to malnutrition and coughing when sucking milk, and aspiration pneumonia occurs. Severe cases can cause dysphonia, and children often have obvious nasal opening or unclear pronunciation. The treatment of cleft palate is a complicated process, which requires the cooperation of experts such as oral and maxillofacial surgery, plastic surgery, orthodontics, voice training, psychiatry and psychology to achieve satisfactory results.
Principles of treatment
In terms of cleft palate operation time, we should try to complete cleft palate repair before the age of 2. For patients with fissure stenosis, it is best to complete cleft palate repair within one year after operation, without exposing or less exposing the hard palate bone surface. However, when the fracture is serious and a large area of exposed bone surface may be left after operation, the operation time can be delayed appropriately. For patients with cleft palate aged 5- 10, we performed posterior pharyngeal wall enlargement while repairing the cleft palate to help improve the velopharyngeal closure rate. For patients with cleft palate aged over 10, simultaneous velopharyngeal flap plasty can significantly improve the velopharyngeal closure rate of elderly patients, and children with cleft palate can be closely monitored. Repair of cleft palate can only be considered if there are feeding, hearing or voice problems.
In the choice of surgical methods for cleft palate, in principle, those surgical methods that can effectively restore the voice of cleft palate patients and have little effect on maxillary growth are selected. Our previous research showed that the use of plow bone flap to repair hard palate cleft palate can effectively reduce the cleft width of cleft palate, so that most patients can avoid or reduce the distance of making relaxation incision near the bilateral gingival margin and moving the palatal mucoperiosteal flap to the midline in cleft palate repair, and have no obvious effect on the early growth of maxilla. In the repair of cleft palate, Sommerlad levator palatini muscle reconstruction is mainly used, but also Lang's method (improved method), two-flap method (such as Bardach method) and reverse double Z method are used, and the following principles are followed for design and operation: strive to reconstruct the morphological structure of levator palatini muscle ring; Extend the length of soft palate as much as possible; Try to avoid or reduce surgery.
Surgical therapy
Surgical repair. After 2 years old, it is more suitable before 5 ~ 6 years old. Surgery can not only close cleft palate, but also provide correct conditions for children's pronunciation. Children should be trained in pronunciation after operation. The basic principle of cleft palate repair surgery is to prolong the soft palate, close the palate and pharynx, and restore normal swallowing and pronunciation functions. At present, the commonly used operations are: ① modified Langerhans operation; ② pear bone mucosal flap operation; ③ Operation of palatal flap of arterial island; ④ Retropharyngeal mucosal muscle flap transplantation.
Besides, this treatment usually takes several years to complete. Although due to the development of medicine, the therapeutic effect has been obviously improved. But the final effect is still not satisfactory.
Cleft palate repair is a key step in the treatment of cleft palate. However, the medical community still has different views on the choice of operation age. In the past, from the perspective of children's tolerance to surgery, doctors often advocated that 3-6 years old was the best age for surgery.
At present, many doctors believe that the safety of operation has been obviously improved due to the improvement of anesthesia technology, and suggest that the earlier the operation, the better, and no more than 2 years old at the latest. Early operation is very effective in improving postoperative pronunciation.
Children should eat liquid food within one week after operation and use semi-liquid food within three months.
After the operation, in order to improve the pronunciation, the child should be trained in pronunciation under the guidance of a doctor in order to form a correct pronunciation.
Children need to go to the orthodontics department for orthodontic treatment when they are teenagers.
In addition to surgical treatment, we should also pay attention to the following aspects: ① In order to avoid choking on milk, we can let the children sit still when feeding, or we can feed them with a dropper. Semi-liquid or solid food is easier to feed; ② Cleft palate is often complicated with tonsillitis and hyperplasia, otitis media and chronic nasopharyngitis. Antibiotics should be used in time.
The basic principle of cleft palate repair surgery is to use tissue flap near the crack to close the crack, prolong the soft palate, reset the dislocated tissue structure and restore the physiological function of the soft palate. In order to improve velopharyngeal closure, retropharyngeal tissue flap was used to increase the length of soft palate and lateral pharyngeal tissue flap to reduce the width of pharyngeal cavity.