A study of the congenital cleft palate deformity

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ProQuest Number: 10101456

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VmifeMKMW**b 6*19061 n# 0#7*X****!MbMdLtmm of deft BtlUUtJPralft lour., 44*122, 1828* *TCifear&#, op*cit*

It

and local© to his list#**’ Manley, C&rmody, Talbot md Bland listed malnutrition as a major factor, bat Carmody added fatal position, Talbot added hypophyseal derangement and Bland added impairment of the 4v S-'' S trophic nerve supply to the growing list of causes* * * * Mete* belie disturbances, position In utero and hypophyseal disturbances seemed sound to Brown in 1300 as associated or primary factors in

0

deft palate*

In 1811, Jacobson proposed the Waraekros hypothesis 7 of fmpernuaeraiy callages preventing union in the deft area, but 3

Peter thought it more likely that these were associated abnormalities. Quoting other investigators, Peter noted that Haymana and Hang thought the deft was due to faulty germ material) Pronhoefer, Winkd and Braudt attributed the deft to amnlotie lesions) Feldman believed it to be a combination of both* Ihlfdd thought it possible that increased intracranial pressure was the cause* Beneeke attributed the deft to lack of room in utero resulting in the tongue being pressed between the palatal plates, preventing union* Schorr thought It likely that an inherent embryonic defect was the cause and pointed to the frequency of associated congenital deformities* Peter placed more emphasis on •UeCte'ernciS0m’'in the amnion and failure of retraction of the tongue*9 feiyaat, WiliiST fwfilfll6£yt

tefiSS) Qffim

"Cermody, T*E«, op.cit, ^albei, Eugene, pn»eit* gasaa, is«jBiAi»... vBrown, •V.I., Qqti cMi»., /Jacobson, *#!*, '‘The surgical treatment of cleft palate1*, The Dental 011557, 1811* *5*fcor, Karl, MU-jstS*

IS

Blade# WPOU m article lft IBIA to rafale mm of the hypothecs# advanced ft# etielogie factor?i In oleffc palate* He pointed out that research did net substantiate the p&wmm of toxins or alcohol ss £L*of deft palate offspringe oecwed m frequently

« cause of elefte,

la. sell nourished ft# la undernourished p*wr#at#f dogs oho wera fed honefct&Xdiag diet still gave hirth to deft point# pap# besides* tho jaalm&rltioB theory did not explain cleft U p * Ho also ipseationed tho foot that tho embryonic ham$ m suggested hy Breplgr§ could cense the deft* m l pointed out that overgrowth of tho tongue docs not explain lip elefte#* Voodoo suggested another possible factor la *pathelogie affectations of the fooftle generative organ#* la

Hood

ravioeed the various opinions on etiology, hut edvaaeed no persons! 8

opinion*

C&earvia agdft advanced geop^phlool distribution as o cause

«fter a siu# of B w d ecmeerlptft** Cardwell listed the possible Oftueoa of deft palate hot selected heredity and naXnutritien as tho a

nest probable o a r

federepieX r**Xt#hod the poeeJM* ooatrihutory

eauaoo la. 19S7*^ Borrenee la hi# M n m n t e l survey of the literature listed all the possible e a a n f and added #^>erfeeuadtetIon# eternal ntdth of the ethnold end frontal region# of the skull, widening of the base of the anterior fe#s& of the skull, adenoid®, tongue tussore, epithelial dental Xenia*, sbmmsl fetal growth* syphilis, great age

#®owd# Hent^Jf&aafr

Etiology end treatment of eonge®its! cleft palate*, Pawn* £0140,, m $ *

^ h m d a * A#, “The troataeat of cleft pel&te*, 2h,ftl,J5ftatiCl.A.ga,giaa„, 2|c«rdmllf $mm op«elt« ®Fedemp^hit M&ttlwwr,

14

41H s n w m la pertee* ehildrsn «t tit® begtnriag t e at the t e «3f t e

family* teoerin© M a t t e l © © * , ©teg®® in a<© la t e

ateotie fluid* tetekia breeding t e ©eeeoue deficimiigr to those alrte^ proposed.** Bbmms, la m oteuar© report citribufced the

qmgmitffil defoxa&lgr to lew blood pressure*^ Wylghi t e d ho b e U e t e the deft resulted she© tho noth w ©©rrieo the wy *A lw so ihtoKisl position la ate©# freerae brought m tho © r t e M bo&es pressing tho t e a lato tec child*© ehte would prevent mion of tho palatal jmeeeeee*^ FltsM31thoa sdded attempted abortion t e tho aoaopaaeol state of the aether to the H o t of poe^lhl© cause#**

?h* acebteefil

theory © t e a to &r*e persisted la t e it&ysiure* Albert

in 1935

considered pwmmm la ate© & aojop factor.®* Frew reiterated t e &mm philosophy la 1938* Xa M o «speri«&ee* t e ©loft® ©eciorsd la offspring* of poor teher* t e do mu&uoHy fcetwy eorfc during the early stages of prsgntey* H# felt the tenges hold the wma&Xk&vw p i U t e sport till t e tin* ues p te for mica* t e tongue feeing forced i$>$fird by beswy lifting* ete.®

Btm&t cited Fitten 1 deflMtey ©0 414 ^linger several

years Inter* la 1044.^* ® OlStield* la l i d mentioned itenMrition ead •tentio fltsdd changes, Ghosts a d m o o d poor development of blood vessele

m a possible ©an** (1944) * t e $teits pointed out thct lesion occur* right «t*ths tia* of aeliteritXon induced by lypejrc&esls grarld&rua* bat *^W^ S S S S i7* SSp 5& S** OQ^eit* *mraii©r, Oscar* *Tfes pteiepoaiag cause© of deft palate t e her© lip** fawByflth lateaatftSaatol,,, ffnftflBra* 1914* p*4to« ®%igfet* ^itead in Bro»»M G.F*I***The surgical technique for the oper­ ate* of deft pels*#** 53*684* 10X1. t a t M U f a a * X.&. F d a t e ^ X t e g i l a t M d S * 737* 19S1. ^avls, Albert* Duns* ^bfeeri* ^i Efanry, Oral .tm tm tr ... St*I-o«lsil049, C.V.Soeby Company, p. 287.

20

Figure X* Edentulous upper Jeu m d ©tunroandiag awsculatur©. Bracing fron April© a Saisar*

* Figure I# X, ©rbleul^rle &rie at* ©1th I1 of it© sup­ erior labial insertion; depressor septi m.(2)j S, spheno­ palatine artaiyj 4, palatine artery and nervej 5, levator snguli oris &»f 8, tmceinelor a,; pf palatine aponeurosis; 10, tendon of tensor pslati m* IX, basular process©} X£, ptery^aandibulur ligament; IS, superior constrictor ®*f X4, p^topbaxyngcus m«| IS, palatoglossus »«) 16, levator pslati a.) 17, rlsorlue m*$ 18, facial artery m d vein; 18, buccal pftdf 20, parotid glaadj 21, m&meter m*j 22, tendon of tempered!© a*i £4, internal pterygoid au; 26, pharynx*

a

Figure 8* Frontal section Just anterior to junction of herd end soft palate, pfcowing relatione of oral and part-oral etrueturaa*

Figure 4* Drawing of Figure 8*

22

mmftmm of the lateral waXX of the ph&%gm$ and the anterior fibers probably Insert Into the posterior border of the thyroid eerfcllage* the peXcto gloaana anad© arises from the s&dlin© in the anterior part of the soft palate In e)jjTniliiMW[>ri>i-i-Tar"iit1T

S#®.*, gflaafM&itd elaft llpf

atsd

Lt^as *^glailM0* has * FObisrer* .i treatment of deft pdate1*, jfosita..jfent*XcuE*» estg, 1940* ^Oldfidd, 8*€*, flftgfl&fcs %«*per, John, "The recpoaslblliV of the surgeon in treating palatal and related defedg"fin*tortSgth..^.#xa.ln 58*687, 1946. %fadd«n, CUP.P.,"Harelip and deft palate*,jpgtegyougnal* ISilSS, 1049. ^ 5 r , %adcn, gftajflh

la

of the factional problems

indicated that the palatine aponeur­

osis «hi«h is attached to the posterior uaa&I spine normally, is

X drawn forward in clefts, mskiag Telophai^tigeai closure more difficult* Webster, in M i moist 03GC«XXeni and complete review of the literature, repeats tMi obaerv&tioa# Xu deft palsies, the movements of all Z

wmclm m m to bo modified to sob* degree*

Slaughter and Bredis

ssphasissd the growth prebles in deft pda to individuals and attri­ bute growth arrest* to early traumatic surgery* *]2vide»oo is available to abov that congenitally defoxnod part#* tmlefts permanently damaged, «KW «* W U M i W5tMI.S The author in eorasetittng cm the considerable arnomt of material cm morphology and growth and ddrdopmeoit* feels that the evidence twald see® to support the contention that there Is bo real deficiency of palatal tissues at birth to Boot cases, but that this tissue Is i&ispX&ced by the ineliaatiaa of the palatal plates* 1b normal smbzyonie deve&opseiit of the palate, the inclination of the developing secondary a*

psX&tsl plates is changed 9© by differential growth* (figures 6, 7 end $)* is the plates suing f*©» the vertical plane, superiorly into the horiecmtel plane as the tongue withdrawn, the

mmX septisi pro-

liferfetee dasBMsd to join the plates && they become united* It seems possible that a derangement of tbs coupler differential growth ^CK “-(

process©* night conceivable prevent the nasal sspim,right and loft tmnn' rrXffeiiiice, of the Ideff«alMtftb~vcni S^aganbeok type# served the por^oee^ Simiittimeout oXoetore of the herd and eeft palate 5 ime heat* Boedaorth ebaearmed you kangent^ofe operate end described hie tmiaaiqs* in X88B* Sejfrlgcrebioa imoetfceelft wee oeed* First he freshened the edges of the figure* He than divided the levator paXetl and i^r^gopalatineoft w-cl m

et the posterior border ©f

the laerd palate, lateral to the pterygoid itf&i&tw* irdcimg ©are not to eeetleR the posterior peXetl&e ***©«&t« Be then made one or in© i&etsiott® on either aide of the roof of the mouth* moor the eXmeelsr border, ritfr the ©aaneating nmeooe membrane feeing left int&ot# Incisions were made from behind* formsrd to avoid blood end to leave a aleor field for eattlag* the pevioetea* m e thee eep~ orated from the eepetier maxilla* m & after the flape mere eeaplefcely loosened, the freeh^ed edge$ m«re approximated mith ©ilk ligature#* tt&eoa and ®ueaard employed the mom Xangenbeofc operation and ©ubmitted AJnT1_i F o r ^ 0im* filliaa* *0m here lip Ih^JIriU# ft88*, X88«* Sg|a3L,.%«5tg»

m&

split .palate** teit^.Jfeur*. ,

efanwiel©, Th Of W

a

5««|B# X B 5 M 0 * Bsjftiaod-Les® < oporeticn for aloft pol«i#», «n*ofcM» «o *.h« 1880, i M # * M i m , 1880* dMft* ttel iloearo of tho soft palato mad by euecooeiYo eaoteri*#iiPP*420w21«

—Show s th e en d of th e first s tag e in a ‘'p u sh -b a c k o p e ra tio n ” perform ed for a cleft velum . T h e raised p a la ta l m ueo p e rio ste u m is held in position w ith silk su tu res.

Figure X9*

Show s th e second s tag e of th e “ pu sh -b a ck o p e ra tio n .” T h e p a la ta l m u co periosteiyn h a s been co m pletely freed from th e u nderlying b one an d th e nasal m ucosa d iv id ed from it’s connection w ith th e posterior b o rd e r of th e h ard p ala te .

figure £0*

62

back to allow collateral circulation to take over through the palatal aponeurosis* three months later, the smcoperloateum was again elevated, the bamular processes divided by* meatus of a chisel on each side above Its attachment to the pterygoid plate, and the cleft edge® freshened and sutured together In the midiin©*

1236,

J.B. Brown published his results using the *jpus*Wback" operation, which In soae eases, were dramatic*^ Colville adopted the Derranoe procedure of fracturing the haimiXar processes and also divided the posterior palataine vessels to let the palate drop upward and backward

to meet Passavsmt's ridge*

2

In 19h2, Baxter further revised

the Dorranea pushback tsohnlJie to correct shortening of the velum from previous surgery* He used the Brown method of splitting the muoo-pesioateal flap horlaontally, leaving the nasal passages sep-

arated from the oral cavity* He agreed with Veau that the superior raw surface of the flap resulted In contractures and made an inlay skin graft (from a hairless part of the body) i& protect the nasal 3# k surface* Kemper also recommended the "llned-flap ouch-back" 5, 6, 7 after the modification of Venn and Aahausen. 1fl'"lin%rSSn#' ''*}*¥*," wKiSngation of the partially cleft palate", Burg* (frnea* & flbst*, 63*768, 1236* '^Colvlll©, H.C., "Cleft palate", Proc*Austr#B 19U2* r-UlH^iT and1Cardoso, hary, "A method of minimising contracture following cleft palate operation", Jour«Plaatic & 3eoon« Burg*, 2*21u, 19H7* SKemper, John, "Cleft palate", Jour.Bral Burg*, 2*227, 19Uu °Axhausen» Oeorg, *Tecbnik und Sri^hls^re' Her Oaumenplastik, Ijeip2ig*1936, Thlerae* ’-----------^ --------- ----'Kemper, John, ".The responsibility of the surgeon In treating palatal and relatiSw defects”, Anoer*Jour*Orth# & Oral Surg*, 32* 667, m r . -----------------------

63

Beepite fflsaajws modifications of th« Lfingoribeck procedures for closure of the cleft palate by soft tissue* a number of s&sn are stlH aware of its limitations. Hansfield* in I9h6 advocated the use of nasal and vomer flaps to close the hard palate. This technique Is

not nest* Vort %ealeherg closed unilateral Hp-d«**-nalai© splits

In 1901 by this method*

^ogb-Andorson mentions its use in 1$>U2.^

Waldron states that he has used this technique for the past sixteen years

Merrifleld has made frequent us® of the vomer flap and feels

that It interferes less with growth than any other technique.** However* this mans only a partial closure* and full closure must be decided on later* cither by more surgery or a prosthesis. Butty m a M M

th* phiuyngul b luk operation In X91&J

This

Involves bringing flaps from the lateral and posterior walla of .the phasym to reduce the anterowposterlor pharyngeal space and make velcppharyngoBl vaivtng easier* Who

fsmmml

states of .stapiylorrs^by

wrsao^st&phyloxrapfiy

shows a tewed toward a ateiwtUB 4£spXsce&$ut of tissues* The more radical approach*® are finding fewer adherents* Advances in the field have been primarily in asepsis and testsmeat&tie***

»

. W O

m

*u y^*cit»T

^Personal coiapsinxcation to

the author* 19U9* ^Personal eoraaiunicatifm to the author* 19h9. ^Beatty* E*$** "Cleft palate"* Annals of QtaU* ifainoi** & Laryngol.*

64

Contrary b® the reporte of ssisy wibea?® lo the field* Brophy «&# met the first to e&voe&t* bony elomir© of ©plit p®late* In X8£6t Btoffoafeoob yecoa^e&ded XebereX iacteloae through the mucosa sad bee® %

e sow* from the jpeterlor I'.ordor of th» Js&rd palate to the I anterior t&mSj&m of the atoft, &g m sid in closure* Even earlier*

Bobovt bad efeatsa ©xlssmil fi^lieaeee that oouid bo used to comprees the c&effc pel&iee*

(Hgpre 0.)

- F ro m R o b e r t t o d e p i c t o n e o f t h e e a r l y i n s t r u m e n t s u s e d fo r c o m p r e s s io n f o r a c a s e a f flic te d w ith l i p - j a w - p a l a t e s p l i t .

Hgtaro Win In X8$6f do teoutiA ooTiteod the u&e &x m iatro-*oroX-JsCk^eerew typo Of ttotoX bnioo to force the msdllsxy halves th® %oqu«^a«thod of cauterizing the tmioa* He . .

*

He then

considered

Ililll tflin^.-

gffobart* M«| or^clt^,..^ %oati», de. wBe®~&©~lievr* m m eesrteaent dee o& dti pcXaie% Z*'2%L» 1836* 461oquei, £uXce,

m

fractwo o f little cm&wumco* in article appeared in the I*amtal, ni fla^.J»e|%Pf in X0&1* describing an operation by $r Boehring, a nephew of Bieff«ibaa|i* Hie operation m e done between the tenth end 1 twentieth year* *mhm the bene* ere relatively planti*"* By complete longitudinal incielona and with apeelal fereape, the

segments were

foreed together -and wired# the edges of the fleenre were then entered or cauterised. f M e type of operation wee criticised ty Jouxdaia, the a he later reeorted to oomprowUm In the closure of a hare-lip# JArngenbook reported the nee of the Bnehring tiehnique for bil&toral lipJ&w-pal&te olefte ae early ae 184$*

field (1861) separated the 4 ae*i&X«e from the malar heme* before pressing then into contact# ifandaftfeitpg recommended the eeoee fcrocedtare nod noted that Btjlliiien s had need graded compres^im to dloee a deft in 1444* in anonymous article appeared in the SltilfiSL&SflfiS & 1 X@df« advocating a horae-aho© leaped damp of the jae&Mierew type* pref®rrafcLy on the younger age A $ret$>* Hegler* reporting on am article appearing In the Australian wrote*11! on not aware that the subject of using preaanre In treating fissure of the palate has bean before suggested. 1 am ineilmed to thlcfe that it hae not* # * I we® first led to try it on the dead body of & child* which had died three wec&e after birth* * * Sy irxr^