T h e Journal o f the Am erican D en ta l Association
CLEFT LIP AND CLEFT PALATE* By TRUMAN W . BROPHY, M.D., D.D.S., Sc.D., F.A.C.S., F.A.C.D., Chicago, Illinois
L E F T lip, like cleft palate, is nearly always due to failure o f union o f w ell developed parts. This fact is now generally admitted. It must be remembered that there is enough tissue, but on ly enough, in cleft lip to form a normal lip. T herefore, any sacrifice o f tissue, other than that needed to freshen the edges and bring the misplaced tissues into normal re lationship is to be condemned. A striking example o f unnecessary waste o f valuable tissue, resulting in short ening o f the lip from angle to angle, is seen in the Rose operation. T here are at least twelve forms o f cle ft lip, one o f which is occasionally seen in the lower lip. T he time to operate depends not so much on whether the cle ft o f the lip is complete or incomplete, single or double, as on whether it is simple, or complicated by a separation o f the bones o f the palate and alveolar ridge. I f without the above mentioned com plication, and having either a normal palate or a cleft illustrated by Forms 1 to 6 inclusive and Form 15 o f my classification, the cleft lip should be operated on preferably at the beginning o f the second month i f the physical con dition o f the patient w ill admit. W hile I fu lly realize that the younger the child, the less the shock, I believe
it is safer practice to wait until the normal functions o f all the organs o f the body have been w ell established. The deferring o f the operation be yond this in case the health o f the child is not satisfactory w ill do no harm. I f the case is complicated by separation o f the bones o f the palate and alveolar ridge, as shown by Forms 7 to 14 and also Form 16, the lip is not operated on until the bones have been put in proper contact, immobilized and firm ly united. The foundation which Nature provided fo r the lips is formed by the alveolar process, supported by the premaxillary and m axillary bones; hence, the impor tance o f bringing the misplaced bones into correct position, firm ly immobilizing them, obtaining union and thus estab lishing a foundation fo r the lip which w ill enable the surgeon to impart to it anatomic perfection. It is a rule that a reliable foundation is essential to all dependable superstructures. T he lip is no exception to this rule in cleft lip." Usually, in single cleft o f the lip, i f the alveolar process and hard palate are involved, there is a further complica tion, the nose being diverted from the median line; the deflected vomer at tached to only one o f the m axillary bones, and one nostril abnormally wide and flattened. This calls fo r skilful surgery in conjunction with the opera tion on the lip. CLEFT PALATE
♦Read before the Section on M axillofacial Surgery and Surgical Prosthesis at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 24, 1926.
A cle ft palate may be complete or incomplete, single or double, simple or complicated.
B rop h y— C left L ip and C left Palate
T here are sixteen form s o f cleft palate, according to my classification, six o f which may involve the muscles o f the soft palate and sometimes the palatal arch from the tip o f the uvula to the line o f union between the prem axillary bones and the hard palate; while ten form s are complicated by clefts and misplacements o f bones and muscles. No two are alike anatomi cally. Three o f the group o f the six form s o f clefts are limited to the velum. Here, as in the lip, the time and sequence o f operations depend on the conditions presented. I f the cle ft is o f the soft palate only, in varying degrees, the operation is deferred until from the eighteenth to twenty-second month, to permit the thickening and strengthening o f the tissues, the operation being performed just before speech is established. Should cle ft lip accompany this condition, the lip is closed first, at from 4 to 6 weeks i f the general condition warrants. I f the cle ft o f the palate involves the aveolar ridge, separating the maxillae from the premaxillae on either or both sides, to a slight degree or to the extent that the premaxillae protrude, a different problem confronts . us. Here, the first step always is to adjust the misplaced bones in correct position, immobilize them and await their union before operating on the lip. I f single, or bipartite, cleft occurs, the choice o f time fo r operation is from fo u r to six weeks a fte r birth. I f tripar tite cleft presents, it is important that the child be not less than 3 months old when the operation o f moving the pre maxillae back into position is made. A t this time, the bones are sufficiently
ossified to retain their form . About two months a fter the bones have become firm ly united in their normal position and a perfect foundation has been built upon which to construct a normal lip and nose, the lip operation is performed. T he pressure o f the tongue in em b ry o , and later, no doubt, displaces upward the horizontal plates o f the m axillary and palate bones which often stand at an angle o f 70 degrees. This displacement renders the approximation o f the distal parts o f the cleft impracti cable. The surgeon should lower these malposed bones to a more nearly normal position. This is done by adjusting sil ver wires through the bones, above the alveolar processes, and the germs o f the teeth, always keeping above the horizontal plates o f the m axillary and palate bones and that portion o f the vomer that is bent in such a way as to become a part o f the hard palate but below the floor o f the orbit. This adjustment o f wires and lead plates, when correctly employed, lowers the malposed horizontal plates o f the bones and approximates the anterior one third or one-haif o f the bony cle ft and without disturbing any teeth, so that when erupted they w ill average w ell in regularity. I never have made the state ment that I always approximate the bones in the posterior part o f the cleft. Operation should be performed before ossification is fa r advanced, but I have moved the bones together in patients 4 years o f age. Besides the important step o f ■ securing union o f one third or one h a lf o f the separated bones o f the pal ate, including the management o f the premaxillae, and the lowering o f the
The Journal of the Am erican D ental Association
horizontal plates o f the bones that form the hard palate, we have a further step to consider, and that is the control o f the tuberosities in their relation to the so ft palate. T o place the tuberosi ties in normal position is also to place the muscles in normal position. W ithout a proper conception and execution o f these three fundamental steps in palatal surgery, there is small hope o f securing satisfactory form or function. Closing the lip first, depending on the traction o f the orbicularis oris muscle to approximate the bones, or passing a suture through the anterior part o f the separated maxillae and thus bringing them together, cannot secure immobility and union o f the separated bones. T he closing o f the lip and the result ant traction o f the orbicularis oris mus cle w i l l gradually move the anterior part o f the cle ft bones into contact, but the bones w ill hot, as a rule,, be normally approximated and united. Moreover, there cannot be union o f the bones with the mucoperiosteum intervening. They only meet and remain malposed, leaving the patient deformed throughout life. T he premaxillae should alw ays b e p r e
s e r v e d an d u tiliz ed to establish and m aintain th e n o rm a l d en ta l a rch , facial contour and the fu ll complement o f teeth. They should never be excised, fo r an irreparable deform ity is the un failing result. W h en the anterior part o f the cleft, which is nearly always wider at birth than the posterior, is brought together by the lip traction plan or by the single suture, the surgeon fails to give thought to lowering the highly elevated hori zontal plates o f the m axillary and palate bones, nor does he give consideration
to the consequent separation o f the bones posteriorly. Every surgeon experienced in this work should realize that, often times, these bones become widely separated posteriorly, owing to the moving together o f the anterior part o f the cleft. These bones cannot occupy a normal position unless measures are employed to overcome their eleva tion and separation. W ith muscular force applied anteriorly and with no re straining force posteriorly, the maxillae act as levers, the m alar processes becom ing the fulcrum s; and as the anterior ends o f the maxillae are drawn together, the posterior ends, with the aid o f the upward pressure o f the mandible, move apart. Unless steps are taken in early infancy to prevent the tuberosities from spreading (which is accomplished by the use o f wires not only anteriorly but also posteriorly), the bones w ill separate widely and the palate w ill be shortened to such an extent that perfect speech w ill seldom be secured. W hen united, the soft palate w ill be tense, too short to reach the postpharyngeal w all and w ith out flexibility or resilience. U tilizing a portion o f each palatopharyngeal muscle w ill lengthen the palate in such cases. I f lateral incisions are made in an attempt to relieve tension, a mass o f cicatricial tissue w ill result, making the soft palate thick, inflexible and inca pable o f perform ing its normal func tion. It must be remembered that lateral incisions oftentimes divide the fibers o f the tensor palati muscle, which has a tw ofold function: to make tension on the palate and to dilate the pharyngeal orifice o f the eustachian tube; which
B rop h y— C left L ip and C left Palate
may result in defective hearing, owing to the destruction o f the continuity o f the muscle and failure to dilate the tube. W hen the posterior wire is introduced in operating on the soft palate, it should be passed as nearly as possible through the center o f the tensor palati muscle as it swings around the hamular process, thus suspending the contraction o f the muscle until the palate unites. The horizontal plates o f the palate bones are elevated and the tuberosities are widely separated; consequently, the soft palate is also widely separated and may be, to some extent, atrophied fo r want o f use; but the width o f the ab normal c le ft is not due so much to atrophy as to the malposition o f the parts. SUM M ARY
In conclusion, I wish to emphasize these points. 1. Union o f the separated bones o f the palate and alveolar processes, with special attention to preservation and cor rect posing o f the premaxillae, to be ob tained before closure o f accompanying cleft lip. 2. Bringing the malposed palatal plates o f the m axillary bones downward by always passing the wire sutures above the alveolar processes instead o f through them, thus bringing into proximity the edges o f the cleft fo r one-third or oneh a lf its length. 3. Prevention o f spreading o f the tuberosities by controlling them at the time o f the anterior closure, thus laying a reliable foundation fo r constructing a normal soft palate by avoiding the cause o f tension and shortness when united, .and providing instead fo r length
and flexibility, which is essential to cor rect speech. P R E O P E R A T IV E
P O S T O P E R A T IV E
TREATM EN T
Not the least important step in the correction o f lip and palate defects is the preparation o f the patient and the a fter care. W hen the patient, i f a child under 10 years, enters the hospital, the first step should be a careful general exami nation, preferably by a pediatrician, to determine the physical condition, diet requirements, etc. T o counteract the acidosis, which is increased by fasting before operation and by the anesthetic, a 3 per cent sodium bicarbonate solution should be given in all feedings fo r at least three days preceding operation. Acidosis should be suspected in all cases, and the soda treatment liberally employed. Radiographing the chest is a part o f the routine, to discover any enlargement o f the thymus gland, a condition which would contraindicate administration o f an anesthetic. I f found, a roentgenray treatment is promptly given, one treatment usually being sufficient to reduce the gland to norm al; after which, within three to six weeks, the operation may be safely undertaken. I f exposure to a contagious disease is sus pected, cultures should be taken from the nose and throat prior to operation. I would counsel all surgeons against allowing parents or friends to urge haste in operation. T hey do not realize the importance o f the certainty o f a good condition, and allow the pressure o f business or fam ily cares to weigh too heavily. Plenty o f time should be in sisted on fo r preparation.
T h e Journal o f the American D ental Association
T here should be no feeding fo r four hours previous to operation, and sodium bicarbonate should be administered to within two hours. B efore the child leaves the operating table and while he is still under the anesthetic, 6 per cent glucose, from 100 to 15 0 c.c., should be given by hypodermoclysis. T w o hours after opera tion, glucose and sodium bicarbonate, in the above mentioned solutions should be given frequently by mouth. The first feeding is eight hours a fter oper ation, usually a small amount, but su f ficient. A fte r the lip and soft palate operations, quiet is imperative, and in addition to the foregoing treatment, it w ill probably be necessary to give paregoric (camphorated tincture o f opium, U. S. P .). I f we can keep the child on glucose fo r tw enty-four hours or forty-eight hours a fter the soft palate operation, it is advantageous to do so. T he use o f the actinic ray has been found o f great value, both to sterilize the field o f operation and to promote healing afterw ard. D ISCU SSIO N O F T H E
LOGAN, M OOREHEAD AND BRO PH Y:
George A. Dorrance, Philadelf/iia, P a.: It is unfortunate that so many papers are w rit ten on the technic rather than on the speech results obtained in cleft palate surgery. I hope shortly to be able to give you the final results in as many as 500 cases in which operation has been perform ed by a great many different surgeons. I am positive that many men are optimistic about the speaking ability in these postoperative cases. There is little that is new in these papers. D r. Brophy holds to his idea that the younger the child is when operated on, the less shock experi enced fro m the operation. T h at may be true with his cases, but I find that the older the child is when operated on, the less the shock
experienced. T he adhesive plaster and bow that D r. Logan uses in cleft lip is one o f the most serviceable appliances that we have in this work. A s regards the action o f different muscles, there is only one muscle that pulls the palate upward, the levator palati. Now, w hy does not this muscle close off the palate a fte r the operation? First and forem ost, it is. the tensor palati muscle, and it acts as a guy rope, preventing the levator palati from acting. In cleft palate cases, it is always short. In the surgery o f any other part o f the body, tendon lengthening would be done, but that is impossible here. The tensor palati muscle goes upward and then inward to form the two sides o f a righ t angle triangle. In m y cleft palate w ork today, I break off the hamular process, thereby allow ing the tensor palati muscle to become an accessory elevator. In this way, not only does it assist the levator palati, but also any guy rope tension that might have existed disappears. I think this is more often done than the surgeon realizes. A fte r a careful anatomic study o f this region o f the body, both on the normal child and on one cadaver having a cleft palate, I am sure that to obtain a satisfactory result, it is neces sary to divide, or better change, this tensor into a levator palati. Another point Dr. Brophy insists on is that, i f you wish to lengthen the soft palate so that it w ill close off, it is better to use the palati pharyngeus muscle. This action is to draw the palate outward and downward. Nature overcomes this by having the salpingopharyngeus and the levator o f the pharyngeus elevate the pharynx. W hen this occurs, the palati pharyngeus relaxes, and has no action. T herefore I do not see how anything can be gained by lengthening the palate by the use o f these muscles. Secondly, it does not make any difference how long the palate, the ques tion is whether the levator palati can draw the palate up and close off the nose from the pharynx' in conjunction with the superior constrictor muscle. W hen patients do not speak w ell a fte r an operation or norm ally have a short palate, I sometimes use the f o l low ing operation. I free the entire palate from its anterior attachment, dissect it back, separate the aponeurosis, divide the hamular process and a llo w the whole palate to fa ll
B rop h y— C left L ip and C left Palate
backwards fo r about three-quarters inch. Now, everything is relaxed, and we can easily sew the two sides o f the palate with out the least bit o f tension, which is essential in these cases. Now, in the anterior part o f the hard palate, there w ill remain an opening into the nose and mouth. This I close with an ord in ary denture. In selected cases, this operation has proved very satisfactory in my hands. A s fo r the time o f operation, the lip and alveolar m argin in every case should be operated on as soon as the child is in good condition. As to the time fo r the cleft palate cases— the closure o f the posterior part o f the
cleft palate, the experience o f the older sur geons confirms this statement. I f the child is operated.on when it is very young, one or more operations are required; whereas, at from 6 to 8 years o f age, one operation w ill suffice. I realize that the parents o f these children are very anxious fo r early operation, but i f they knew what I know, they would defer these operations until the child was 6 to 8 years old, when the tissues are much stronger and better to w ork on and the m or tality is less. No one mentioned the Lane operation. Anatom ically and physiologically, it is a ll wrong. I do not find many advo-
Fig. 1.— Doited line, incision fo r retrotransposition (L w o w -G a n ze r); broken line, incision fo r fissurorrhaphy (DiffenbachLangenbeck) ; starred line, incision fo r mesopharyngoconstriction (Ernst-H alle) ; x, hamulus pterygoideus infraction (B illro th ).
Fig. 2.— Retro transposition; fissurorrhaphy; mesopharyngoconstriction. Broken line, cel luloid plate.
hard palate— a ll say that this should be done before the child begins to speak. I disagree, fo r the fo llo w in g reasons. ( In the first place, there are two places where the cut off occurs, posterior to the eustachian tube and again in the anterior nares, and I wish to say that the anterior nares are o f great assistance in the results in cleft palate cases. I f they are s t i m u la t e in speech training, better results w ill be assi. "d. The m ortality in the cases that have been ; aired early, say, fro m 2 years, is fa ir ly li '. Considering the whole country, and all la ses o f surgeons, it is at least 5 per ceri' When the w ork is done at fro m 6 to 8 r s , the m ortality is not more than 1 p^r i . In the literature on
cates o f it except to close partial defects a fte r one o f the other operations. I would like to hear the general consensus o f opinion on this operation as it is still quoted in the textbooks. A . Limberg, Leningrad, Russia: The surgical treatment o f cleft palate must have fo r its chief aim not only its anatomic resto ration, but also the restoration o f its normal function. The operation must not involve either a maiming o f the m axillary bone or impediment to its grow th (m aldevelopm ent). W e use three typical operative methods fo r restoring the cleft palate to its norm al an atomic shape and function: (Figs. 1 and 2 ) . ( l ) fissurorrhaphy; ( 2 ) retrotransposition; (3) mesopharyngoconstriction. The first consists o f the w ell known relieving incisions o f Dieffenbach-Langenbeck, with exfoliation
The Journal o f the American D ental Association
o f the mucoperiosteal flaps. But we cannot lim it ourselves to this operation. It does not give the sought-for lengthening of. the palate, and we cannot be sure o f a prim ary union o f the n ew ly approximated edges. By con tinuing the incision fo rw a rd up to the median line and by exfoliating the whole fro n t flap up to the edge o f the hard palate from which it has to be separated (severed), without, however, in ju ring the palatine artery, we obtain a retrotransposition. It is to be noted that, a fte r this separation o f flaps,
H alle3 (B erlin ) the idea o f a new method o f operating, which can be designated as a mesopharyngoconstriction. An incision pene trating through the mucosa, beginning from the middle o f the last molar and going ver tically down to the lingual surface and aver age height o f the mandible, is made. The muscles o f the lateral w all o f the pharynx are then bluntly separated though the sfatiuni parafharyngeum (Corning, 1922, p. 125, Fig. 10 7 ) and pushed to the middle. By this operation, the joining o f the edges o f the cleft is made easier and the shape o f the
Fig. 4.— Occlusive celluloid plates.
very often the whole soft palate shifts from 1 to 2 cm. backward by simple muscular traction. In cases o f incomplete cleft, a v-shaped incision, proposed by Lwow1 in 1925, is very convenient. I f the cleft is more extensive, the Ganzer method is to be advised. The width, depth and height o f the cleft and mesopharynx are always measured in our cases. These measurements, when com pared w ith the normal, show us the unusual width o f the mesopharynx in most o f our patients. This circumstance gave Ernst2 and 1. L w ow : Seventeenth gress, Leningrad, 1925.
2. Ernst, F . : Plastic Operations on Hard Palate, Zentralhl. f. Chir., 5 2: 464 (Feb. 28) 1925. Arch, f. Idin. Chir., 138: 170, 1925.
palate is also improved. A ll these three operations can be done at one time. It is safer, however, to separate them. First, we can do the fissurorrhaphy and mesopharyngo constriction, and some months later, the retrotransposition, i f there is any need fo r it. A ll these new operative methods can be ac complished only with the aid o f an occlusive celluloid plate, which, a fter the operation, is fixed to the teeth. The operative field is protected by it from contamination and the palate flaps are immobilized. (Figs. 2 and 4 .) These methods usually make it pos sible fo r the lesion to close by prim ary in tention. In the rare cases in which we have 3. H a lle: Ztschr f. Hals-Nasen-Ohren-Heilkunde 1 2: 377, Part 2, 1925.
B rop h y— C left L ip and C left Palate
a partial separation o f the edges, I apply plate sutures with the fo llo w in g new method (F ig. 3 ) : A small celluloid plate (a ) with two long, strong silkworm ligatures (c ) is placed on the nasal surface o f the soft palate. The ligatures are then pulled through the w alls o f the side wounds, where they are passed through sm aller celluloid plates (b) and fixed by lead shots ( d) . The position o f the side plates, which alone cause pressure, being perpendicular to the direction o f the traction, makes cutting through o f the stitches impossible and permits a draw ing together o f the flaps. These plates have a great advan tage over the methods o f plate sutures described by B lair, Brown and Brophy. I never make use o f these methods because o f the in ju ry they may cause to the palatal flaps. The fo u r ends o f the silkworm ligatures are not cut off, but are le ft under the occlusive celluloid plate. In three or fo u r days, we can enforce the traction o f the ligatures by
adding a second lead shot ( e) between the first one and the celluloid plate. It is in dispensable to tie a silk ligature to the middle plate (F ig. 3/ ), so as to be able to draw it aw ay behind the velum when the treatment has come to an end. I have applied these methods in thirty-eight cases in patients from 2 } 4 to 27 years, and in a ll o f them, good results ensued. The approximated edges united by prim ary intention, and the shape o f the palate was quite satisfactory. In fo u r cases only, on the first dressing did we have a partial separation o f the edges. An imme diate appliance o f the plate sutures gave the best results, so that the anatomic and func tional restoration o f the palate was gained by first intention, as in the other cases. I am sorry that I cannot explain all the particulars o f these operations and the postoperative treatment because my time is limited. I have tried in these fe w words to give you an idea o f the different methods we use fo r the restoration o f the palatal cleft.