Cleft Lip & Palate II

The incisive foramen is the anatomical landmark dividing primary and secondary clefts. Structures anterior are primary (lip, alveolus), posterior are secondary (hard and soft palate). This distinction is crucial for understanding developmental origins and classification.

This is a primary cleft involving only structures anterior to the incisive foramen (lip and alveolus). It's incomplete posteriorly as it doesn't extend into the palate. This type affects the primary palate only, formed from the fusion of medial nasal and maxillary processes.

The delay allows for adequate maxillary growth while balancing speech development needs. Earlier repair increases growth restriction risk, while later repair compromises speech development. 9-12 months represents optimal balance between growth and speech considerations. Current protocols prioritize this timing unless other factors intervene.

Approximately 90% of children with cleft palate experience chronic otitis media due to Eustachian tube dysfunction. This high prevalence necessitates early ENT involvement and often requires ventilation tubes. Regular audiological monitoring is essential.

The width of the cleft defect is the most reliable predictor. Wider clefts correlate with greater growth impairment due to more severe tissue deficiency and increased scarring from repairs. Initial cleft width better predicts outcomes than timing of repair or surgical technique alone.

Upright or semi-upright position (45° angle) reduces nasal regurgitation and aspiration risk. This position helps compensate for inadequate oral seal and promotes safer feeding. Special feeding devices like squeeze bottles or modified nipples may be needed.

The correct sequence is: medial nasal processes fuse with maxillary processes (weeks 4-7). Failure results in cleft lip. The intermaxillary segment forms from merged medial nasal processes. Lateral nasal processes contribute to nasal walls but not lip formation. Understanding this sequence helps explain unilateral vs bilateral cleft patterns.

The lateral incisor in the cleft area is most affected due to its position at the cleft site. Common findings include: missing lateral incisor (35-60% cases), supernumerary teeth, or malformed laterals. Canines and central incisors are less frequently affected. This impacts early treatment planning and space management.

The "Rule of 10s" is commonly used: 10 weeks of age, 10 pounds weight, and hemoglobin of 10 g/dL. This timing allows for adequate weight gain and tissue maturity while minimizing social impact. Earlier surgery increases anesthetic risks, while later surgery may affect bonding and feeding.

Veau Type II describes isolated complete cleft of secondary palate (soft and hard). Type I is soft palate only, Type III includes unilateral complete lip and palate, Type IV is bilateral complete. This classification helps standardize treatment protocols and communication.

Palatal shelf elevation and fusion occurs during weeks 7-12. Specifically, the secondary palate develops from the maxillary processes, with shelves elevating during week 7 and fusion completing by week 12. Maternal folate deficiency during this period increases cleft risk. Primary palate forms earlier, around weeks 4-6.

Columella lengthening and nasal tip elevation are key indicators of NAM success. These changes reduce the severity of nasal deformity and improve surgical outcomes. While alveolar approximation is important, nasal symmetry has greater impact on long-term aesthetic outcomes.

Initial orthodontic evaluation should occur at birth for NAM (Nasoalveolar Molding) consideration, with active treatment planning starting around age 5-6 years for mixed dentition management. Early evaluation allows for growth monitoring and timely intervention. Primary dentition issues can be addressed as they arise.

Prevention of middle ear effusion and potential hearing loss due to Eustachian tube dysfunction. The abnormal insertion of palatal muscles affects Eustachian tube function. Early intervention prevents chronic complications and supports normal speech development.

Left side is affected in approximately 70% of unilateral cleft cases. This left-sided predominance is thought to be related to embryonic vascular development patterns. Right-sided and bilateral clefts are less common. Understanding this helps in epidemiological studies and surgical planning.