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 Table of Contents  
CME ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 184-188

Cleft Palate: Part I – Historical perspective and anatomical basis


1 Department of Plastic and Reconstructive Surgery, King Georges Medical College, Lucknow, Uttar Pradesh, India
2 Consultant, Durgapur Cleft Centre, Operation Smile, Siliguri, West Bengal, India

Date of Submission03-Apr-2022
Date of Acceptance26-Apr-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Neelam Chauhan
Assistant Professor, Department of Plastic and Reconstructive Surgery, King Georges Medical College, Lucknow, U.P
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_9_22

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  Abstract 


Cleft palate is a developmental craniofacial anomaly with multiple aspects. With time, the understanding of its anatomy and its pathophysiology evolved leading to simultaneous improvement in surgical techniques. The timing of its surgical as well as nonsurgical management has great importance in determining the functional outcome. The priorities in its management and the techniques are quite well understood now though some difference of opinion still exists. In these series of articles, we aim to discuss its various aspects in detail, beginning with an emphasis on its history and anatomy.

Keywords: Anatomy, cleft palate, history


How to cite this article:
Chauhan N, Sadhu P. Cleft Palate: Part I – Historical perspective and anatomical basis. J Cleft Lip Palate Craniofac Anomal 2022;9:184-8

How to cite this URL:
Chauhan N, Sadhu P. Cleft Palate: Part I – Historical perspective and anatomical basis. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Dec 8];9:184-8. Available from: https://www.jclpca.org/text.asp?2022/9/2/184/354299




  Introduction Top


Cleft lip and palate is one of the most common developmental craniofacial anomalies characterized by failure of fusion of palate and lip leading to an obvious facial deformity. Cleft palate has both functional and psychological aspects. It affects the patient at many stages of life, starting from difficulty in alimentation and nasal regurgitation, malnutrition,  Eustachian tube More Details malfunction and deafness to difficulty in speech, malocclusion, and facial developmental changes.

The understanding of the various aspects of cleft palate such as its anatomy, need for surgery, timing, surgical technique, and velopharyngeal insufficiency has gradually improved over time. Certain techniques stood the test of time whereas some faded over the years. The topic in itself is too wide, but, in this series of articles, we aim to compile the evolution and management of cleft palate.


  History of Cleft Palate Repair Top


The history of cleft surgeries dates back to the fourth century when a Chinese surgeon repaired cleft lip,[1] however, there was no mention of cleft palate. A common belief in those times that cleft palate was syphilitic in origin and also the fear of pain and bleeding probably retarded any development in this regard till the 16th century. Franco was the first to describe cleft palate in 1556.[2] It was in 1564 that Pare described the term “obturateur” for plates of gold and silver to occlude the cleft palate. Pierre Fauchard (1678–1761) in his book “Le Chirurgien Dentiste” described several different obturators to close the cleft palate defect.[3] By the 18th century, obturators became quite common in use and newer designs incorporating wings and sponge padding and clasps to fix on to the teeth were developed.

In 1766, Le Monnier described a cleft palate operation in which the margins of the gap were freshened to cause an inflammation which would stimulate healing.[4] The 19th century marked the introduction of anesthesia techniques and also the beginning of cleft palate closure. Von graefe in 1816[5] and Roux in 1819 did successful cleft soft palate closure. Roux published his work in 1825 where he described his technique of simple suture closure of surgically freshened cleft edges as “Staphyloraphie.”[6] Dorrance[7] described the development of cleft palate surgery and believed that premature removal of stitches was the cause of frequent failures of the various operative techniques, as Alcock[8] removed the stitches on the 4th day and Mayo[9] on the 3rd day after operation.

Dieffenbach in 1826 expanded the concept to achieve soft and hard palate closure and described the separation of hard palate mucosa from bone in order to close the cleft palate and also later employed lateral osteotomies to achieve palatal closure. His technique of palatoplasty included the use of twisting silver and lead sutures passed through hard palate by drilling holes to bring the bony cleft edges together.[10] His concept was further emphasized by Von Langenbeck who described the subperiosteal undermining and mucoperiosteal flaps in his bipedicle technique[11] which marked a great advance in cleft palate surgery. In 1843, John Pancoast described the necessity of joining the muscles when doing palate surgery,[12] and Fergusson[13] advised relieving the muscle tension by using relaxing incisions with scissors in the neighborhood of the Eustachian tube.

The 20th century brought along greater knowledge about the anatomy of these defects and helped in further refinement of the surgical techniques. It was understood by then that a short and immobile palate affected the speech capability of the patient, hence palatal lengthening was needed. Veau in 1931 described single pedicle mucoperiosteal flaps based on greater palatine artery and also highlighted the need for palatal lengthening. Wardill and Kilner later modified their procedures to achieve palatal lengthening.

This era also showed concerns regarding the contraction of raw areas post palatal lengthening. Hence, a number of surgical techniques were described such as use of skin graft by Dorrance and Bransfield, nasal flaps by Cronin, and buccal mucosal flaps by Kaplan. In 1944, Dr. Schweckendiek advocated the use of a two-stage cleft palate closure in which the soft palate was closed early (4–6 months), and hard palate closure was delayed until 4–5 years later (sometimes even at age 14–15 years). The reason behind this was to improve velopharyngeal function during the initial speech development and to cause less facial growth retardation by closing the hard palate after the cleft narrows with facial growth.[14]

By the 1960s, the abnormal palatal musculature became the center of interest and it was Kriens who described the muscular reconstruction of disoriented levator and tensor veli palatini muscles in the procedure known as intravelar veloplasty. Later, Furlow developed the double-reversing Z-plasty palatoplasty to achieve muscular reconstruction. The 20th century also marked the beginning of alveolar bone grafting. During 1950–1960, primary and secondary bone grafting was practiced by many surgeons. Simultaneously, there was also development of fixed and mobile prosthesis to correct the malaligned alveolar segments.


  Evolution of Surgical Techniques Top


  • von Langenbeck's bipedicle flap technique[15] – Described by Bernard von Langenbeck in 1861, as bipedicle mucoperiosteal flaps for the repair of the hard palate region. The technique also involves the use of relaxing lateral incisions. However, this technique had poor speech outcome due to inadequate retropositioning
  • Veau-Wardill-Kilner pushback technique[15] – Described in 1937, it is a V-Y procedure which retroposes the whole mucoperiosteal flap and the soft palate, thus giving palatal lengthening. However, its drawback is the extensive raw area anteriorly and laterally along the alveolar margin with exposed bare membranous bone which heals by secondary intention and causes shortening of the palate leading to velopharyngeal incompetence, alveolar arch deformity, and dental malalignment. It also has a higher incidence of fistula formation
  • Bardach's two-flap technique – It is a modification of the von Langenbeck technique whereby bipedicle flap is changed to single pedicle based on greater palatine artery
  • Intravelar veloplasty- In 1968 Braithwaite first described the dissection of the Levator Palati during cleft palate repair. He described the release of the muscle from its abnormal attachment at the posterior border of the hard palate, and also dissecting the muscle free from nasal and oral mucosa. Once the muscle is dissected, it is posteriorly repositioned and then sutured with that of the opposite side for the reconstruction of the Levator sling
  • Furlow double-opposing Z-plasty – It was described in the 1980s by Furlow. It is a double-reverse Z-plasty for the oral and nasal surfaces of the soft palate which helps in palatal lengthening
  • Two-stage palatal repair[15] – Unrepaired cleft patients have better maxillary relationship and development as early palatal surgical intervention causes maxillary hypoplasia. Hence, many surgeons performed palate repair in two stages – early soft palate (4–6 months) and late hard palate repair (4–5 years). This delay reduced the cleft width in the hard palate making it easy to close and also reduced the maxillary hypoplasia. However, the speech result was compromised. Hence this technique is not preferred
  • Hole in one repair[15] – It is a one-stage cleft lip and palate repair. It is preferred in developing countries where repeated hospitalization is a drawback. This is performed in children above 10 months of age
  • Raw area-free palatoplasty[15] – It is also two-flap palatoplasty in which the palatal lengthening is performed by the nasal mucosa back-cut, and the raw area is covered with a local flap like the vomer flap or the buccal mucosal flap. Lateral incisions on the oral side are also closed to avoid any raw area. Hence, secondary deformities and shortening of the palate are less likely to occur
  • Alveolar extension palatoplasty[15] – It is a recent technique in which the entire lingual gingivoperiosteal tissue is incorporated into the mucoperiosteal flap which lengthens and widens the flap to cover the larger defect



  Anatomy of Cleft Palate Top


Based on embryology, the bony portion of the palate [Figure 1] is divided into primary and secondary palates limited by the incisive foramen. The primary palate or prepalatal structures lie anterior to incisive foramen and comprise premaxilla, alveolus, and lip. The premaxilla comprises the nasal spine and the incisors. The secondary palate includes structures posterior to the incisive foramen, which are paired maxilla, palatine bones, and pterygoid plates.
Figure 1: Normal bony anatomy of palate (After Millard, D.R., Jr.: Cleft craft. Vols III. Boston, Little, Brown and Company, 1980, following p19)

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The maxilla on its superior surface has a bony groove that holds the nasal cartilaginous septum anteriorly and vomer posteriorly. Palatine bone forms the posterior edge of hard palate and contains the major and minor palatine foramen through which passes the neurovascular structures of the palate. The palatine bone also articulates with the medial pterygoid plate of sphenopterygoid bone. Through this medial pterygoid plate projects the pterygoid hamulus which acts as pulley for tensor veli palatini tendon.

Muscles of palate [Figure 2] comprise levator veli palatini, tensor veli palatini, musculus uvulae, palatopharyngeus, and palatoglossus. Levator veli palatini originates from the undersurface of temporal bone and medial part of cartilaginous portion of Eustachian tube. It inserts into the palatal aponeurosis in the mid-portion of soft palate. The tensor veli palatini originates lateral to the levator muscle from the base of medial pterygoid plate, spina angularis of sphenoid bone, and lateral part of cartilaginous part of Eustachian tube. It passes around the pterygoid hamulus where some of its fibers insert, but most of them become tendinous and turn around the hamulus and insert into the anterior part of palatine aponeurosis of soft palate and laterally into palatine bone.
Figure 2: Normal musculature of palate (After Millard, D.R., Jr.: Cleft Craft. Vols III. Boston, Little, Brown and Company, 1980, following p37)

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The palatopharyngeus muscle comprises three parts. The palatine part passes from the thyroid cartilage and adjacent part of pharyngeal wall and passes laterally, downward, and posteriorly in the posterior edge of the soft palate and into the posterior tonsillar pillar.

The pterygopharyngeal part arises from the posterior and lateral part of pharynx and inserts into the hamulus and palatine aponeurosis. The salpingopharyngeal part inserts into the cartilaginous portion of Eustachian tube.

The palatoglossus arises from the transverse bundles of tongue and passes through the palatoglossal arch to insert into the muscles of soft palate. Musculus uvulae arise from palatine aponeurosis and posterior nasal spine and reach to the tip of uvulae.

Levator veli palatini, superior pharyngeal constrictor, and musculus uvulae contribute the most to velopharyngeal function. The levator veli palatini pulls the velum superiorly and posteriorly to oppose the velum against the posterior pharyngeal wall. The medial movement of the pharyngeal wall, attributed to superior pharyngeal constrictor, adds in the opposition of the velum against the posterior pharyngeal wall to form the competent sphincter. The uvulae muscle acts by increasing the bulk of the velum during muscular contraction.

In patients with cleft palate, the cleft may vary from a narrow slit to horseshoe-shaped configuration. It may involve the secondary palate only or may involve primary and secondary palates. It may be complete or incomplete. Another important alteration in these patients is the abnormal insertion of the muscles. Normally, the muscles come in the midline in a transverse fashion and insert in the middle one-third of the soft palate. However, in cleft palate, the muscle bundles lie longitudinally and insert at substitute points along the posterior edge of palatine bone close to the cleft and also along the cleft margin [Figure 3]. This abnormal insertion of palatal muscles also causes retardation of their growth. The palatoglossus and palatopharyngeus muscles insert along the posterior edge of hard palate at an acute angle and few fibers may insert along the cleft margin as well. The levator veli palatini reaches along the edge of cleft palate and fuses with the tensor muscle anteriorly and uvulae and palatopharyngeus posteriorly. The tensor veli palatini also fails to develop and function fully and also causes hypoplasia of palatine aponeurosis. The detachment of these abnormal insertions and joining the muscles of the two halves in the midline is an important principle in cleft palate surgery.
Figure 3: Muscle anatomy in cleft palate (After Millard, D.R., Jr.: Cleft Craft. Vols III. Boston, Little, Brown and Company, 1980, following p37)

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The submucous cleft comprises a bifid uvula, abnormal orientation of levator veli palatini in the form of a converging ridge with thin mucosa in between, known as zona pellucida, and a notch in the posterior border of bony palate.

This abnormal muscular arrangement also brings bony changes, most frequently in the form of hypertrophied hamulus due to abnormal pull of muscles. Another important variation in cleft palate is in the attachment of vomer to maxilla. In cases of incomplete cleft of secondary palate and in bilateral cleft, the vomer lies in the midline and is not attached to maxilla on either side. In unilateral complete cleft involving the primary and secondary palates, the vomer has a near right-angled deviation and articulates with the maxilla on the noncleft side.

An understanding of the anatomy of cleft palate is crucial to understand the surgical techniques and the management strategies in these patients.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Boo-Chai K. An ancient Chinese text on a cleft lip. Plast Reconstr Surg 1966;38:89-91.  Back to cited text no. 1
    
2.
Barsky AJ. Pierre Franco, father of cleft lip surgery: His life and times. Br J Plast Surg 1964;17:335-50.  Back to cited text no. 2
    
3.
Fauchard P.The Dental Surgeon or Treatise on the teeth Mariette, Paris1728;2:285.  Back to cited text no. 3
    
4.
Robert MJ. Treaty of the main objects of medicine, with a summary of most of the theses defended in the schools of Paris, from 1752 to 1764. Lacombe, Paris 1766;1:8.  Back to cited text no. 4
    
5.
May H. The classic reprint. The palate suture. A newly discovered method to correct congenital speech defects. Dr. Carl Ferdinand von Graefe, Berlin. Plast Reconstr Surg 1971;47:488-92.  Back to cited text no. 5
    
6.
Roux PJ: Memoir on staphyloraphy, or suture of the soft palate. Arch Sci Med 1925;7:516-38.  Back to cited text no. 6
    
7.
Dorrance GM. The Operative Story of Cleft Palate. Vol. 3. Philadelphia: Saunders; 1933.  Back to cited text no. 7
    
8.
Alcock T. Case of congenital division of the palate in which union of the divided parts was effected. Trans Assoc Apothec Surg Apothec Engl Wales 1823;1:377.  Back to cited text no. 8
    
9.
Mayo H. Case of congenital fissure of the soft palate. Lond Med Phys J 1827;2:119-22.  Back to cited text no. 9
    
10.
Goldwyn RM. Johann Friedrich Dieffenbach (1794-1847). Plast Reconstr Surg 1968;42:19-28.  Back to cited text no. 10
    
11.
Goldwyn RM. Bernhard Von Langenbeck. His life and legacy. Plast Reconstr Surg 1969;44:248-54.  Back to cited text no. 11
    
12.
Perko M. The history of treatment of cleft lip and palate. Prog Pediatr Surg. 1986;20:238-51.  Back to cited text no. 12
    
13.
Fergusson W. Observations on cleft palate and on staphylorraphy. Med Times 1844-45;2:256.  Back to cited text no. 13
    
14.
Hoffman WY, Mount DL. Cleft palate repair. In: Mathes SJ, editor. Plastic Surgery. 2nd ed., Vol. 4. Philadelphia: Saunders Elsevier; 2006. p. 249-69.  Back to cited text no. 14
    
15.
Agrawal K. Cleft palate repair and variations. Indian J Plast Surg 2009;42 Suppl: S102-9.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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