September 2019 HSC Section 1 Congenital and Pediatric Problems

Gingivoperiosteoplasty and Alveolar Bone Grafting

Fig. 6. Z-palatoplasty: distinct nasal and oral layers.

Fig. 8. Z-palatoplasty: closed oral layer.

Von Langenbeck palatoplasty Von Langenbeck introduced the concept of lateral-releasing incisions to decrease tension. These incisions are made around the alveolar ridge and preserve anteriorly and posteriorly based flaps while sparing the gingiva laterally. The medial cleft edge incisions at the oral/nasal mucosa junction are carried posteriorly to the uvular apex. If neces- sary, vomer flaps may be designed and elevated to the skull base to compensate for short nasal flaps to ensure a tension-free closure. The hard palate flaps are elevated in a subperiosteal plane laterally to medially. As with previously described tech- niques, the greater palatine neurovascular bundles need to be identified and preserved. The subper- iosteal dissection is carried along the lateral nasal wall to the undersurface of the inferior turbinate bilaterally. Nasal submucosal dissection is com- pleted along the posterior edge of the hard palate, releasing the levator veli palatini from its insertion at the junction of the hard and soft palate. Closure is done with a 4–0 Vicryl starting with the nasal layer in a simple interrupted fashion, incorporating vomer flaps anteriorly. The apex

of the uvula is closed with a single horizontal mattress suture. Next, the intravelar veloplasty is completed. Interrupted or horizontal mattress su- tures are used to reorient the levator veli palatini along the posterior velum to create the levator sling. Oral closure is then done with simple interrupted sutures using a 4–0 Vicryl working posteriorly to anteriorly. Finally, the relaxing incisions are stabi- lized with interrupted sutures through the medial gingival edge and microfibrillar collagen hemo- static agent is placed in the open defects laterally. Oxford/three-flap technique The Oxford/three-flap technique is used in incom- plete clefts that extend into the hard palate, but do not penetrate the alveolar margin. The flaps are designed as described previously for a two- flap, except the incision is carried from the apex of the cleft to the lateral incisor on each side and then around the alveolar margin ( Fig. 9 ). Two flaps are raised in a similar way as the two-flap technique ( Fig. 10 ), but when the flaps are sewn together anteriorly, they are sewn to the remaining anterior mucosa, which is the third flap ( Figs. 11–13 ).

Fig. 7. Z-palatoplasty: closed nasal layer.

Fig. 9. Oxford/three-flap: starting to make the flaps.

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