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The role of primary surgery in the management of orofacial clefting

British Dental Journal volume 234, pages 859–866 (2023)Cite this article

Abstract

Primary cleft surgery refers to the planned surgical procedure(s) necessary to reconstruct an orofacial defect according to a specified protocol; in the context of a unilateral cleft lip and palate, this would include lip repair (with vomer flap closure of the hard palate), subsequent repair of the residual soft palate cleft and finally, the alveolar bone graft. This paper will provide an overview of the goals of primary surgical reconstruction, including the utility of pre-surgical orthopaedic techniques, including nasoalveolar moulding. The surgical methods of primary lip repair in both unilateral and bilateral clefts will be outlined and the concept of a primary rhinoplasty will be introduced. The principal techniques of cleft palate reconstruction will be delineated for a variety of cleft phenotypes. The final element of the primary reconstructive sequence is the alveolar bone graft using cancellous bone harvested from the iliac crest at approximately 8-10 years of age. The role of optimising oral hygiene prior to bone grafting cannot be over-emphasised and the utility of pre-surgical orthodontic arch expansion is also discussed. In the UK, bone graft outcomes are audited using the Kindelan score, which is evaluated from the six-month postoperative upper standard occlusal radiograph.

Key points

  • This paper covers the goals of primary cleft surgery, including the role of pre-surgical orthopaedics and nasoalveolar moulding.

  • Outlines the reconstructive options for a patient with a unilateral cleft lip and/or palate, including contemporary cleft lip repair techniques, vomerine flap closure of the hard palate, and the importance of alveolar bone grafting.

  • Discusses the primary surgery options for a patient with a bilateral cleft lip and/or palate, and summarises the methods of bilateral cleft lip repair.

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References

  1. Martin S V, Swan M C. An essential overview of orofacial clefting. Br Dent J 2023; 234: 937-942.

  2. Semb G, Brattström V, Mølsted K, Prahl-Andersen B, Shaw W C. The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 1: introduction and treatment experience. Cleft Palate Craniofac J 2005; 42: 64-68.

  3. Pandya A N, Boorman J G. Failure to thrive in babies with cleft lip and palate. Br J Plast Surg 2001; 54: 471-475.

  4. Butterworth S, Rivers C, Fullarton M et al. A Closer Look at Delayed Primary Cleft Surgery and Unrepaired Cleft Lip and/or Palate in 5 UK Cleft Centres. Cleft Palate Craniofac J 2022; 59: 724-731.

  5. Barillas I, Dec W, Warren S M, Cutting C B, Greyson B H. Nasoalveolar molding improves long-term nasal symmetry in complete unilateral cleft lip-cleft palate patients. Plast Reconstr Surg 2009; 123: 1002-1006.

  6. Greyson B H, Santiago P E, Brecht L E, Cutting C B. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J 1999; 36: 486-498.

  7. McNeil C K. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec (London) 1950; 70: 126-132.

  8. Berkowitz S. A comparison of treatment results in complete bilateral cleft lip and palate using a conservative approach versus Millard-Latham PSOT procedure. Semin Orthod 1996; 2: 169-184.

  9. Kornbluth M, Campbell R E, Daskalogiannakis J et al. Active Presurgical Infant Orthopedics for Unilateral Cleft Lip and Palate: Intercentre Outcome Comparison of Latham, Modified McNeil, and Nasoalveolar Molding, Cleft Palate Craniofac J 2018; 55: 639-648.

  10. Greyson B H, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 1993; 92: 1422-1423.

  11. Falola R A, Blough J T, Abraham J T, Brooke S M. Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction. Cleft Palate Craniofac J 2021; 58: 1500-1507.

  12. Fisher D M. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg 2005; 116: 61-71.

  13. El Magheraby M F, Ghozlan N A, Ashry M H, Abouarab M H, Farouk A. Comparative study between fisher anatomical subunit approximation technique and Millard rotation - advancement technique in unilateral cleft lip repair. Alexandria J Med 2021; 57: 92-102.

  14. Kwong J W, Cai L Z, Azad A D et al. Assessing the Fisher, Mohler, and Millard techniques of cleft lip repair surgery with eye-tracking technology. Ann Plast Surg 2019; DOI: 10.1097/SAP.0000000000001911.

  15. Patel T A, Patel K G. Comparison of the Fisher Anatomical Subunit and modified Millard Rotation-Advancement Cleft Lip Repairs. Plast Reconstr Surg 2019; DOI: 10.1097/PRS.0000000000005847.

  16. Suchyta M, Azad A, Patel A A, Khosla R K, Lorenz H P, Nazerali R S. Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques. Ann Plast Surg 2020; DOI: 10.1097/SAP.0000000000002389.

  17. Millard D R Jr. A radical rotation in single harelip. Am J Surg 1958; 95: 318-322.

  18. Millard D R Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J 1964; 12: 246-252.

  19. Mohler L R. Unilateral cleft lip repair. Plast Reconstr Surg 1987; 80: 511-517.

  20. Manchester W M. The repair of bilateral cleft lip and palate. Br J Surg 1965; 52: 878-882.

  21. Millard D R Jr. Closure of bilateral cleft lip and elongation of columella by two operations in infancy. Plast Reconstr Surg 1971; 47: 324-331.

  22. Mulliken J B. Repair of bilateral complete cleft lip and nasal deformity-state of the art. Cleft Palate Craniofac J 2000; 37: 342-347.

  23. Tajima S, Maruyama M. Reverse-U incision for secondary repair of cleft lip nose. Plast Reconstr Surg 1977; 60: 256-261.

  24. McComb H K, Coghlan B A. Primary repair of the unilateral cleft lip nose: completion of a longitudinal study. Cleft Palate Craniofac J 1996; 33: 23-31.

  25. Fisher D M, Sommerlad B C. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg 2011; DOI: 10.1097/PRS.0b013e3182268e1b.

  26. Hill C, Martin S. Rationale of Cleft Palate Repair. In Fayyaz G Q (eds) Surgical Atlas of Cleft Palate and Palatal Fistulae. Singapore: Springer, 2022.

  27. Hathaway R, Daskalogiannakis J, Mercado A et al. The Americleft study: an inter-centre study of treatment outcomes for patients with unilateral cleft lip and palate part 2. Dental arch relationships. Cleft Palate Craniofac J 2011; 48: 244-251.

  28. Good P M, Mulliken J B, Padwa B L. Frequency of Le Fort I osteotomy after repaired cleft lip and palate or cleft palate. Cleft Palate Craniofac J 2007; 44: 396-401.

  29. Schweckendiek W, Doz P. Primary veloplasty: long-term results without maxillary deformity. a twenty-five year report. Cleft Palate J 1978; 15: 268-274.

  30. Bardach J, Morris H L, Olin W H. Late results of primary veloplasty: the Marburg Project. Plast Reconstr Surg 1984; 73: 207-218.

  31. Van Aalst J A, Kolappa K K, Sadove M. MOC-PS CME article: Nonsyndromic cleft palate. Plast Reconstr Surg 2008; 121: 1-14.

  32. Hay N, Patel B, Haria P, Sommerlad B. Maxillary Growth in Cleft Lip and Palate Patients, With and Without Vomerine Flap Closure of the Hard Palate at the Time of Lip Repair: A Retrospective Analysis of Prospectively Collected Nonrandomized Data, With 10-Year Cephalometric Outcomes. Cleft Palate Craniofac J 2018; 55: 1205-1210.

  33. Kriens O B. An anatomical approach to veloplasty. Plast Reconstr Surg 1969; 43: 29-41.

  34. Sommerlad B C. A technique for cleft palate repair. Plast Reconstr Surg 2003; 112: 1542-1548.

  35. Furlow L T Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 1986; 78: 724-738.

  36. Furlow L T. Cleft palate repair by double opposing z-plasty. Oper Tech Plast Reconstr Surg 1995; 2: 223-232.

  37. Kindelan J D, Nashed R R, Bromige M R. Radiographic assessment of secondary autogenous alveolar bone grafting in cleft lip and palate patients. Cleft Palate Craniofac J 1997; 34: 195-198.

  38. Rossell-Perry P. Unilateral Cleft Lip Repair. In Rossell-Perry P (ed) Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair. Cham: Springer, 2020.

  39. Rossell-Perry P. Bilateral Cleft Lip Repair. In Rossell-Perry P (ed) Atlas of Operative Techniques in Primary Cleft Lip and Palate Repair. Cham: Springer, 2020)

  40. Kaufman Y, Buchanan E P, Wolfswinkel E M, Weathers W M, Stal S. Cleft Nasal Deformity and Rhinoplasty. Semin Plast Surg 2012; 26: 184-190.

  41. Berkowitz S. Lip and Palate Surgery. In Berkowitz S (ed) Cleft Lip and Palate. Berlin: Springer, 2006.

  42. Coots B K. Alveolar bone grafting: past, present, and new horizons. Semin Plast Surg 2012; 26: 178-183.

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Authors and Affiliations

  1. Cleft Fellow, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom

    Serena V. Martin

  2. Consultant Cleft and Maxillofacial Surgeon, Alder Hey Childrens Hospital and Aintree University Hospital, Liverpool, L14 5AB, United Kingdom

    Simon Van Eeden

  3. Consultant Cleft and Plastic Surgeon, Spires Cleft Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom

    Marc C. Swan

Authors
  1. Serena V. Martin
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  2. Simon Van Eeden
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  3. Marc C. Swan
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All three authors contributed to the concept, content and preparation of this manuscript.

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Correspondence to Marc C. Swan.

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The authors declare no conflicts of interest.

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Martin, S., Van Eeden, S. & Swan, M. The role of primary surgery in the management of orofacial clefting. Br Dent J 234, 859–866 (2023). https://doi.org/10.1038/s41415-023-6002-7

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