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The problem of management of the premaxilla and prolabium in cleft palate patients
THE PROBLEM OF MANAGEMENT OF THE PREMAXILLA AND PROLABIUM IN CLEFT PALATE PATIENTS HERBERT A.
ECKER, M.D., D.D.S.
\I’illiamsport, Penn.g:hania
T
HE premaxilla and prolabium arise from the frontal-nasal process and join with the uniting .maxillary processes to form the upper jaw and lip about the seventh week of fetal life. Failure of union, complete or partial, results in varying degrees of cleft lip and palate. A bilateraI cleft lip and palate presents a special problem. Those of us interested in cleft palate rehabilitation are trying to learn what is best for the patient. There are many opinions regarding the handling of a bilateral cleft lip and palate, but there are two main differences. Before we can discuss these differences we should understand some facts related to this problem. (I) The premaxilla contains the deciduous and permanent first incisor teeth. Occasionally it will contain a second incisor tooth. The missing tooth or teeth must be replaced by a denture. Many times the erupted teeth are malposed and are replaced at the same time. (2) The prolabium per se does not contain muscle because embryologically the cleft exists before muscle formation starts. Muscular movement of the prolabium is accomplished by its union with the lateral borders of the lip. (3) The seventh nerve has no way of reaching the prolabium except through this union. The sensory nerve supply and vascular elements come from the nasal palatine route and are the sole support of the segment until union is established. Under normal conditions the upper lip is formed and the premaxilla loses its identity between the maxillary bones. The counteracting pressure of the lip and the tongue mold the alveolar bone growth of this new structure. In the unoperated cleft the labial forces are lacking and the premaxilla protrudes, while the buccal forces constrict the lateral segments and result in a bilateral cross bite. Surgical intervention as far as alveolar molding is concerned gives us a varying result dependent upon the position, elasticity and muscular power of the united lip. The main May,
1953
633
differences in lip surgery are in the use of the prolabium and its inferior vermilion and mucosa. Preservation of this structure results in a more equal labial-lingual molding balance and destruction of it increases the labial forces and results in lingual version of the upper anterior teeth. Another main difference is in the treatment given the protruded, twisted and elevated premaxilla. It has been resected, retroposed and molded backward forceably and gently. Resection is in disfavor except in late unoperated cases. Retroposing is accepted as long as the segment is not tilted backward and the cuts do not transect the nasopalatine vessels and nerves. This is done by making an oblique cut or excising a block or wedge of septum at least I “4 cm. posterior to the premaxilla. It is generaIIy agreed in rehabilitation groups that retroposing should be used only in extreme cases in which it is impossible otherwise to close the lip. Lip closure is most universally used to guide the positioning of the premaxilla. I agree that there is a temptation to use a heavy thumb in some cases. Even in these cases the desired result will be obtained if a two-stage closure is used. A secondary lip repair is always necessary, so a pulled lip scar is not an issue. There are three criteria to meet in COIIsidering Iip surgery. We strive for: (I) a mimimal lip scar, (2) mimimal associated nasal deformity and (3) a lip that is equal and full. A minimum scar can be obtained by making accurate incisions, carefully suturing the opposing segments and instituting meticulous postoperative suture line care. The latter is, I believe, the most important part of cleft lip surgery. The success or failure is in the hands of the nurse caring for the patient. The associated nasaI deformity is our most difficult problem. It stigmatizes a cleft patient as surely as does his defective speech. All we can accomplish in initia1 surgery is to equalize the tloor of each nostril and position each ala
634
Ecker-PremaxiIIa
and
symmetricaIIy. A Z-pIastic to Iengthen the coIumeIIa as advocated by Straith can be done a few years Iater on the more severeIy affected side. A tota rhinopIasty usuaIIy is required before the stigma is compIeteIy erased. A fuI1 and equa1 Iip can be accompIished only by preserving the inferior mucosa and vermiIion of the proIabium. It makes IittIe difference whether you approximate the segments by simply paring the opposing surfaces or use compIicated geometric designs. The growth of the proIabium must not be restricted by suturing the IateraI borders under it as you wouId in a biIatera1 BIair-MirauIt or Le Messurier procedure. Tennison’s stenci1 method is satisfactory in cases in which there is a Iarge proIabium. Surgeons such as Davis, Vaughn, ShuItz, May and Curtis have Iong advocated the preservation of the proIabium with its inferior vermilion and mucosa. This smaI1 tab of tissue, if unrestricted, wiI1 grow in Iength and assume its proper position between the IateraI segments of the Iip. Its growth, however, is dependent upon the Iack of interference with its blood supply in the preservation of the premaxiIIa and the use of non-traumatic procedures to retropose the premaxiIIa. This is a key point in the reevaIuation of our past cases in which we compare the preservation with the destruction and the end resuIts. AImost a11 primary Iip repairs done in infancy require a secondary repair. It is impossibIe to anticipate the extent of growth that wiI1 resuIt in any segment of the repaired Iip. This secondary repair can be done in three to four years, or it might even be deferred unti1 the patient wil1 cooperate with your efforts to minimize the Iip scar. By striving for a fuI1 Iip we avoid the constricted upper lip that so frequentIy requires an Abbe procedure. By not restricting the downward growth of the proIabium we avoid the “bunched” tissue that we see beneath the coIumeIIa. Some argue that this bunched-up tissue can be used to good advantage in the V-Y construction of a coIumeIIa which is most aIways necessary. A V-Y construction done in a case in which the proIabium has been aIIowed to grow reduces the over-al1 Iip deformity by narrowing each nostri1 floor and positioning each aIa, in addition to reducing the fuIIness of the Iateral portions of the lip. The secondary Iip repair can then be done a year or two Iater to accom-
ProIabium
in CIeft
PaIate
pIish the desired resuIt. UsuaIIy a11 that is required, ‘then, is the excision of a diamondshaped piece of tissue at the vermiIion border to eIiminate the notch and narrow the sutureline. An Abbe procedure can aIways be performed if necessary or the Iips can be equaIized, if not accompIished by orthodontia and prosthesis, by excising a portion of the lower lip. I wiI1 Ieave the discussion of tota palate surgery to others and confine my remarks to the premaxiIIa. The cIosure of the hard paIate whether done by mucoperiostea1 ffaps, bone flaps or by Vomer turnovers usuaIIy Ieaves the premaxilla unattached or floating. Proper Iip surgery wiI1 position it without too much posterior dispIacement. Our best resuIts are obtained if smaI1 flaps simiIar to Vomer flaps are used whenever the segments are cIbse enough to be swung across. It is nice to have the premaxiIIa stabiIized but it is not necessary. As I stated before, a prosthesis is aIways needed because teeth are missing and wiI1 have to be repiaced. Most prosthodontists prefer to ignore the teeth present rather than incIude them in the positioning of the anteriors. Some cover them with thimbIe crowns but most often they are removed and even the IabiaI plate of the premaxiIIa is resected to aIIow the positioning of the teeth without undue prominence. Many times a skin graft can be used to extend the IabiaI SUICUSwhich wiI1, in addition to aIIowing a Iabial ffange on the denture, free an attached and restricted Iip. Orthodontia can be heIpfu1 in rotating maIposed teeth in the premaxiIIa or positioning it for surgery. Operation performed this Iate wiI1 not stabilize the segment as union wiI1 be that of mucoperiosteum onIy; however, it wiI1 improve oraI-nasal hygiene if food is prevented from going to the nasa1 cavity. CIosure of subIabia1 perforations and the later extension of the SUICUS with a skin graft will aIso be heIpfu1. SUMMARY
Lip surgery shouId meet three criteria, that of minima1 scar, minima1 nasa1 deformity and fuIIness to the Iip. This can be accompIished by preserving the inferior vermiIion and mucosa of the proIabium. A V-Y coIumeIIa construction can be performed, foIIowed by a secondary .repair of the Iip and rhinopIastic procedures. The premaxiIIa can be stabilized American
Journal of Surgery
Ecker-Premaxilla
and
when the Vomer turnovers are done at approximately one and a half to two years of age or they can be ignored and partially resected in adulthood. A skin graft ridge extension is useful in freeing an attached lip and aHowing the seating of a denture with a labia1 fIange.
Prolabium
RI AIH, V. P. and IVY, R. H. Essentials of Oral Surgery. St. Louis, 1944. C. V. Mosby Co. Bwwu, G. V. I. The Surgery of Oral Diseases and Malformations, Their Diagnosis and Treatment. Philadelphia, 1938. Lea 8; Febiger. D,wls, A. D. Unoperated bilatera1 complete cleft lips and palate in the adult. Plasl. I’d Reconstruct. Surg., 7: 482, 1951. DAVIS. W. B. Harelio and cleft DaIate. Ann. Surr.. 8;: 536, 1928; 881 140, 1929. kethods preferred in cleft-lip and cleft-palate repair. J. Internat. Coil. Surgeons, 3: i 16, 1940. Dc xx, F. S. Management of cleft palate cases involving the hard palate. Plast. r? Reconsfrucf. Surg., 0: 108, 1052.
I1 4ks1w, C. S. Personal communication.
:va.v,
1953
PaIate
635
W. C. and LIERLE, D. XI. Repair of bilateral cleft lip. Plast. e-9 Reconstruct. Surg., 4: 489, 1949, HYSLOP, V. B. and WYNN, S. K. Bone flap technique in cleft palate surgery. Pk. Ed Reconstruct. Surg., HUFFMAN,
9: 97, 1952. IVY.
IVY,
KEFEKENCES
in Cleft
R. H. and CURTIS. L. ExDeriences with newer procedures in cleft palate surgery. Ann. Surg., 100: 502, 1934. R. t I. Experiences in cleft palate surgery. Ann.
sur<., ,12: 775. 1940. KAZANJIAN. V. f-l. Abbe ooerations
in treating ., sccondary harelip deformities and defects of the upper lip resulting from cancer. Plasf. C’* Keconsfrucf. Surg., 2: 307, 1947. MAP, 14. Cleft lip repair after Ashauscn. I’hsf. (‘* Reronsfrucf. Surg., 2: 139, 1947. peregrinations. I’ksf. P hi I LLARD, D. R. Plastic Reconsfrucf. Surg., 5: 26, 1950 SF~~LTZ, L. W. Bilateral cIeft lips. Ph. t’- Rec.onsfruc.f. Surg., 3: 338, 1946. STRAITH, C. L. Elongation of the nasal c~~lumcll:~. Plasf. t’* Reconsfrucf. Surg., I : 79, 1940. TENYISON, C. 11;. The repair of the unilateral cleft lip by the stencil method. /‘last. (+* f
ECKER, M.D., D.D.S.
\I’illiamsport, Penn.g:hania
T
HE premaxilla and prolabium arise from the frontal-nasal process and join with the uniting .maxillary processes to form the upper jaw and lip about the seventh week of fetal life. Failure of union, complete or partial, results in varying degrees of cleft lip and palate. A bilateraI cleft lip and palate presents a special problem. Those of us interested in cleft palate rehabilitation are trying to learn what is best for the patient. There are many opinions regarding the handling of a bilateral cleft lip and palate, but there are two main differences. Before we can discuss these differences we should understand some facts related to this problem. (I) The premaxilla contains the deciduous and permanent first incisor teeth. Occasionally it will contain a second incisor tooth. The missing tooth or teeth must be replaced by a denture. Many times the erupted teeth are malposed and are replaced at the same time. (2) The prolabium per se does not contain muscle because embryologically the cleft exists before muscle formation starts. Muscular movement of the prolabium is accomplished by its union with the lateral borders of the lip. (3) The seventh nerve has no way of reaching the prolabium except through this union. The sensory nerve supply and vascular elements come from the nasal palatine route and are the sole support of the segment until union is established. Under normal conditions the upper lip is formed and the premaxilla loses its identity between the maxillary bones. The counteracting pressure of the lip and the tongue mold the alveolar bone growth of this new structure. In the unoperated cleft the labial forces are lacking and the premaxilla protrudes, while the buccal forces constrict the lateral segments and result in a bilateral cross bite. Surgical intervention as far as alveolar molding is concerned gives us a varying result dependent upon the position, elasticity and muscular power of the united lip. The main May,
1953
633
differences in lip surgery are in the use of the prolabium and its inferior vermilion and mucosa. Preservation of this structure results in a more equal labial-lingual molding balance and destruction of it increases the labial forces and results in lingual version of the upper anterior teeth. Another main difference is in the treatment given the protruded, twisted and elevated premaxilla. It has been resected, retroposed and molded backward forceably and gently. Resection is in disfavor except in late unoperated cases. Retroposing is accepted as long as the segment is not tilted backward and the cuts do not transect the nasopalatine vessels and nerves. This is done by making an oblique cut or excising a block or wedge of septum at least I “4 cm. posterior to the premaxilla. It is generaIIy agreed in rehabilitation groups that retroposing should be used only in extreme cases in which it is impossible otherwise to close the lip. Lip closure is most universally used to guide the positioning of the premaxilla. I agree that there is a temptation to use a heavy thumb in some cases. Even in these cases the desired result will be obtained if a two-stage closure is used. A secondary lip repair is always necessary, so a pulled lip scar is not an issue. There are three criteria to meet in COIIsidering Iip surgery. We strive for: (I) a mimimal lip scar, (2) mimimal associated nasal deformity and (3) a lip that is equal and full. A minimum scar can be obtained by making accurate incisions, carefully suturing the opposing segments and instituting meticulous postoperative suture line care. The latter is, I believe, the most important part of cleft lip surgery. The success or failure is in the hands of the nurse caring for the patient. The associated nasaI deformity is our most difficult problem. It stigmatizes a cleft patient as surely as does his defective speech. All we can accomplish in initia1 surgery is to equalize the tloor of each nostril and position each ala
634
Ecker-PremaxiIIa
and
symmetricaIIy. A Z-pIastic to Iengthen the coIumeIIa as advocated by Straith can be done a few years Iater on the more severeIy affected side. A tota rhinopIasty usuaIIy is required before the stigma is compIeteIy erased. A fuI1 and equa1 Iip can be accompIished only by preserving the inferior mucosa and vermiIion of the proIabium. It makes IittIe difference whether you approximate the segments by simply paring the opposing surfaces or use compIicated geometric designs. The growth of the proIabium must not be restricted by suturing the IateraI borders under it as you wouId in a biIatera1 BIair-MirauIt or Le Messurier procedure. Tennison’s stenci1 method is satisfactory in cases in which there is a Iarge proIabium. Surgeons such as Davis, Vaughn, ShuItz, May and Curtis have Iong advocated the preservation of the proIabium with its inferior vermilion and mucosa. This smaI1 tab of tissue, if unrestricted, wiI1 grow in Iength and assume its proper position between the IateraI segments of the Iip. Its growth, however, is dependent upon the Iack of interference with its blood supply in the preservation of the premaxiIIa and the use of non-traumatic procedures to retropose the premaxiIIa. This is a key point in the reevaIuation of our past cases in which we compare the preservation with the destruction and the end resuIts. AImost a11 primary Iip repairs done in infancy require a secondary repair. It is impossibIe to anticipate the extent of growth that wiI1 resuIt in any segment of the repaired Iip. This secondary repair can be done in three to four years, or it might even be deferred unti1 the patient wil1 cooperate with your efforts to minimize the Iip scar. By striving for a fuI1 Iip we avoid the constricted upper lip that so frequentIy requires an Abbe procedure. By not restricting the downward growth of the proIabium we avoid the “bunched” tissue that we see beneath the coIumeIIa. Some argue that this bunched-up tissue can be used to good advantage in the V-Y construction of a coIumeIIa which is most aIways necessary. A V-Y construction done in a case in which the proIabium has been aIIowed to grow reduces the over-al1 Iip deformity by narrowing each nostri1 floor and positioning each aIa, in addition to reducing the fuIIness of the Iateral portions of the lip. The secondary Iip repair can then be done a year or two Iater to accom-
ProIabium
in CIeft
PaIate
pIish the desired resuIt. UsuaIIy a11 that is required, ‘then, is the excision of a diamondshaped piece of tissue at the vermiIion border to eIiminate the notch and narrow the sutureline. An Abbe procedure can aIways be performed if necessary or the Iips can be equaIized, if not accompIished by orthodontia and prosthesis, by excising a portion of the lower lip. I wiI1 Ieave the discussion of tota palate surgery to others and confine my remarks to the premaxiIIa. The cIosure of the hard paIate whether done by mucoperiostea1 ffaps, bone flaps or by Vomer turnovers usuaIIy Ieaves the premaxilla unattached or floating. Proper Iip surgery wiI1 position it without too much posterior dispIacement. Our best resuIts are obtained if smaI1 flaps simiIar to Vomer flaps are used whenever the segments are cIbse enough to be swung across. It is nice to have the premaxiIIa stabiIized but it is not necessary. As I stated before, a prosthesis is aIways needed because teeth are missing and wiI1 have to be repiaced. Most prosthodontists prefer to ignore the teeth present rather than incIude them in the positioning of the anteriors. Some cover them with thimbIe crowns but most often they are removed and even the IabiaI plate of the premaxiIIa is resected to aIIow the positioning of the teeth without undue prominence. Many times a skin graft can be used to extend the IabiaI SUICUSwhich wiI1, in addition to aIIowing a Iabial ffange on the denture, free an attached and restricted Iip. Orthodontia can be heIpfu1 in rotating maIposed teeth in the premaxiIIa or positioning it for surgery. Operation performed this Iate wiI1 not stabilize the segment as union wiI1 be that of mucoperiosteum onIy; however, it wiI1 improve oraI-nasal hygiene if food is prevented from going to the nasa1 cavity. CIosure of subIabia1 perforations and the later extension of the SUICUS with a skin graft will aIso be heIpfu1. SUMMARY
Lip surgery shouId meet three criteria, that of minima1 scar, minima1 nasa1 deformity and fuIIness to the Iip. This can be accompIished by preserving the inferior vermiIion and mucosa of the proIabium. A V-Y coIumeIIa construction can be performed, foIIowed by a secondary .repair of the Iip and rhinopIastic procedures. The premaxiIIa can be stabilized American
Journal of Surgery
Ecker-Premaxilla
and
when the Vomer turnovers are done at approximately one and a half to two years of age or they can be ignored and partially resected in adulthood. A skin graft ridge extension is useful in freeing an attached lip and aHowing the seating of a denture with a labia1 fIange.
Prolabium
RI AIH, V. P. and IVY, R. H. Essentials of Oral Surgery. St. Louis, 1944. C. V. Mosby Co. Bwwu, G. V. I. The Surgery of Oral Diseases and Malformations, Their Diagnosis and Treatment. Philadelphia, 1938. Lea 8; Febiger. D,wls, A. D. Unoperated bilatera1 complete cleft lips and palate in the adult. Plasl. I’d Reconstruct. Surg., 7: 482, 1951. DAVIS. W. B. Harelio and cleft DaIate. Ann. Surr.. 8;: 536, 1928; 881 140, 1929. kethods preferred in cleft-lip and cleft-palate repair. J. Internat. Coil. Surgeons, 3: i 16, 1940. Dc xx, F. S. Management of cleft palate cases involving the hard palate. Plast. r? Reconsfrucf. Surg., 0: 108, 1052.
I1 4ks1w, C. S. Personal communication.
:va.v,
1953
PaIate
635
W. C. and LIERLE, D. XI. Repair of bilateral cleft lip. Plast. e-9 Reconstruct. Surg., 4: 489, 1949, HYSLOP, V. B. and WYNN, S. K. Bone flap technique in cleft palate surgery. Pk. Ed Reconstruct. Surg., HUFFMAN,
9: 97, 1952. IVY.
IVY,
KEFEKENCES
in Cleft
R. H. and CURTIS. L. ExDeriences with newer procedures in cleft palate surgery. Ann. Surg., 100: 502, 1934. R. t I. Experiences in cleft palate surgery. Ann.
sur<., ,12: 775. 1940. KAZANJIAN. V. f-l. Abbe ooerations
in treating ., sccondary harelip deformities and defects of the upper lip resulting from cancer. Plasf. C’* Keconsfrucf. Surg., 2: 307, 1947. MAP, 14. Cleft lip repair after Ashauscn. I’hsf. (‘* Reronsfrucf. Surg., 2: 139, 1947. peregrinations. I’ksf. P hi I LLARD, D. R. Plastic Reconsfrucf. Surg., 5: 26, 1950 SF~~LTZ, L. W. Bilateral cIeft lips. Ph. t’- Rec.onsfruc.f. Surg., 3: 338, 1946. STRAITH, C. L. Elongation of the nasal c~~lumcll:~. Plasf. t’* Reconsfrucf. Surg., I : 79, 1940. TENYISON, C. 11;. The repair of the unilateral cleft lip by the stencil method. /‘last. (+* f