Uranoplasty for children: what is it, radical according to Limberg

Developmental defects can not only look unattractive, but also cause a lot of trouble in the development of a child in the future.

Modern medicine gives hope for getting rid of pathologies of the facial part of the skull.

Congenital WRGN

Congenital cleft palate (cleft palate) is a common type of pathology at birth. It is a violation of the integrity of the palatine space, the soft shell of the palate.

It is manifested by violations of the connecting part between the oral cavity and the nasal cavity. In half percent of cases, it is accompanied by damage to the upper lip, popularly called the "cleft lip".

Timely treatment with modern methods does not pose a danger to the life and health of the baby, it allows you to completely eliminate all associated defects.

Congenital cleft of the upper lip and palate (CRGN) refers to developmental defects that cause pathological changes in organs and systems:

1. Anomalies in the development of the general skeletal system.
2. Curvature of the maxillofacial skeleton (underdevelopment of the upper jaw - micrognathia), dentoalveolar arch.
3. A decrease in the number of embedded tooth buds or they may be absent altogether (anodontia).
4. Underdevelopment of the muscular system, primarily of the articulatory apparatus.
5. Pathology of the cardiovascular system.
6. Hearing dysfunctions.
7. Disorders of the vestibular apparatus, functions of the left hemisphere of the brain.
8. Damage to the peripheral, central parts of the nervous system.

Complete and incomplete clefts are distinguished.

Incomplete ones spread to the uvula, the soft part of the palate and affect the hard part. They are also called blind. Full or through clefts are those in which the crack passes through the hard palate and ends in a lip incompleteness.

How common is it?

Palatine clefts are the most common forms of pathological abnormalities of the maxillofacial apparatus. The disorder ranks second among all congenital anomalies and accounts for 30% of them.

The probability of having a child with a similar defect is 1 in 1000.

Boys are more susceptible to violation. Cleft is rarely a solitary disorder. The presence of accompanying pathologies may indicate the development of syndromes, of which more than 150 are known.

Expert video:

Reasons for the appearance

Scientists have identified 3 genes that trigger the development of a deviation.

However, such gene mutations are the cause of disorders in only 5% of cases.

The rest of the reasons leading to WRGN:

• the environment of the embryonic period, especially the early stages of pregnancy;
• transferred infections during this period of fetal formation;
• poisonous elements;
• taking medicines;
• lack of vitamins (especially folic acid);
• addictions;
• mature age of primiparous: in a woman after 35 or even 40 years, the risk of developmental abnormalities increases;
• genetic predisposition;
• defective cells at conception.

Treatment methods

Surgery is the only treatment option. There are no other treatment options for the disease.

The restoration of integrity is accompanied by the formation of the correct anatomical configuration of the jaw apparatus, the correct position of the palatine, pharyngeal muscles, and complete restoration of functionality.

Uranoplasty - an operation to reconstruct, correct a cleft and other defects of the palate and upper lip. The purpose of the operation is to restore the integrity of the palatine surface, narrowing of the pharynx by connecting previously formed flaps of nearby tissues.

The technique, stages and age of the surgical intervention are selected for each child individually, taking into account:

• the complexity of the pathology;
• condition of the facial apparatus;
• the level of development of tissues, bones;
• the presence of concomitant orthodontic deviations.

The preparatory stage is consulted by a supervising pediatrician, orthodontist, anesthesiologist, speech therapist.

Video from an expert on correction methods:

Suitable age for surgery

There is no consensus regarding the age limit for surgery. First of all, defects of the soft palate are eliminated. The process is called bicycle plastic. Surgery is usually performed between the ages of birth and 3 years.

Some surgeons consider the optimal age for such manipulation to be 10-14 months.

Earlier conduct is impossible due to the small size of the oral cavity, and also involves the refusal of breastfeeding after surgery. The child should be able to eat from a spoon. Carrying out subsequent manipulations is recommended no earlier than six months later.

Suturing of the cleft of the hard palate is carried out in 4-6 years. The opinion of most surgeons is unanimous: all manipulations should be carried out at preschool age. A sufficient time interval is required for complete regeneration, for the establishment of speech therapy functions.

When a cleft is combined with a cleft lip, it is corrected - cheiloplasty. In any case, the process of complete restoration of the plate is lengthy, must be clearly planned, ensured by the interaction of specialists.

Contraindications

The operation is preceded by a preparatory period of diagnosis.

Contraindications to surgery:

• intrauterine hypotrophy;
• hypoplasia;
• childbirth injuries;
• prematurity;
• asphyxia;
• anemia;
• from the respiratory system: pneumonia, aplasia of the lungs;
• congenital heart defects;
• spinal hernia;
• fistulas located in the digestive tract;
• other serious defects and developmental anomalies.

Most often, such deviations make it impossible to use anesthetics.

Uranoplasty methods, their advantages and disadvantages

There are two main approaches to eliminating WRGN:

1. One-stage early cleft repair is a radical method.
2. A two-stage sparing technique with step-by-step suturing of the soft and hard palate.

Radical plastics are technically difficult and traumatic. Recommended for children 3-6 years old. Getting rid of the defect at this age allows the child to adapt, guarantees complete healing, and reduces the risk of deformity due to tissue scarring.

Babies under 2 years old, as a rule, undergo only operations using a gentle technique, which allows the child to develop speech skills. Radical uranoplasty slows down the growth of the jaw.

According to Limberg

Radical intervention is mainly carried out according to the Limberg method by forming an integral surface due to the muco-periosteal tissues and tissues of the soft part:

1. Isolation of mucoperiosteal flaps. Symmetrical incisions are made along the alveolar ridge at a distance of 2-4 mm from the gum. Retransposition is in progress: the parts are connected with an angular cut.
2. Releasing the neurovascular bundles of the palatine foramen by means of resection. To lengthen the soft palate, the mucous epithelial layer of the nasal cavity is cut off and displaced from the edge of the hard palate.
3. Interlaminar osteotomy. A chisel is used to separate the hook of the pterygoid process with a small section of the plate and the muscles of the soft part. This allows you to maintain the integrity of the muscles, to carry out suturing within the soft palate.
4. Narrowing of the middle part of the pharynx - mesopharyngoconstriction. Manipulation involves the dissection of the mucous membrane on both sides of the pterygo-jaw folds: the muscle mass stratifies, moves to the middle.
5. Dissection of the previously refreshed edges of the existing cleft in all parts of the soft palate.

The soft palate will have 3 layers of sutures: nasal mucosa, muscles, oral mucosa of the soft palate. As a result, stapling (staphylorrhaphy) of the early exfoliated areas close to each other occurs on the solid.

The second stage of radical uranoplasty is possible. With a wide cleft in the anterior part, the palate is displaced to the pharynx using a skin flap on the leg. The skin is taken from the shoulder or femoral region, which is applied to the wound surface of the palatine flaps.

The methods and sizes of the skin for grafting are determined by the complexity, type of cleft.

The elements of uranoplasty according to Limberg are also used in a sparing technique, in operations for other pathologies in older children or in adults.

One-stage uranoplasty pursues the goal of completely eliminating the cleft in one operation. Supporters of this intervention believe that a one-time intervention causes less harm to the psychological state of the child, an accelerated period of rehabilitation.

Adherents of two-stage uranoplasty believe that sequential operations reduce the risk of malformations of the jaw.

Gradual uranoplasty has its negative sides:

1. Long-term existence of pathology.
2. The use of obturation preparations in case of a long break between stages.

Favorableness for the development of the upper jaw when using the two-stage technique should be considered critically: the study of this indicator included various groups of patients, the study did not randomized.

Modern studies of the radical and gentle method show that the development of the upper jaw does not directly depend on the chosen technique. The sparing technique gives worse speech performance in children than with the radical method.

According to Frolova

In 1972 g. professor L.E. Frolova proposed a new method of treating the cleft palate. The method involves a phased disposal of the disease, depending on the one-sided and bilateral RHGN.

Stages for unilateral pathology:

1. Up to a year, lip shape correction (cheiloplasty), soft palate surgery (cycloplasty) with narrowing of the pharyngeal ring are performed.
2. At 2-3 years old - intervention on a solid.

Sequence of actions in case of a two-way violation:

1. Up to one year old, unilateral cheiloplasty, cycloplasty.
2. After 2-3 months. manipulation on the other hand.
3. In 2-3 years, the elimination of defects in the hard palate.

Stages of uranoplasty on video:

Other options for uranostaphyloplasty

Numerous studies have allowed scientists to achieve the development of more advanced methods of surgical intervention for ERHN.

In 1968 g. NS. AND. Vernadsky proposed the intersection of the neurovascular bundles, regardless of their size, overturning the flap for stitching in anterior sections, the use of the bottom nasal membrane to overlap the border of the soft and hard palate, suturing periopharyngeal muscles.

More gentle and progressive proposals were developed by G. I., Vakulenko V. I., Davydov B. N., Kharkovym L. V. Group of scientists: E. V. Gotsko, I. M. Got, M. AND. Migovich proposed a technique for bridging the crevice in two layers by layer-by-layer suturing.

Postoperative period

The rehabilitation period is 3-4 weeks, carried out in a dispensary observation. Its duration is determined by the complexity of the pathology, the age of the patient.

A well-performed operation is not enough for complete recovery; it is necessary to carry out complex rehabilitation measures.

Important points of the rehabilitation period

Correct rehabilitation measures will help to restore the normal functions of the oral cavity most painlessly and quickly. When eliminating defects in the soft part, the plate is used according to indications; when correcting the hard part, plates are required.

Rehabilitation activities include:

1. Abstaining from talking for the first 10 days.
2. After each meal, a solution of potassium permanganate is used as an antiseptic.
3. After 7-9 days, a dressing is done, repeated every 2-3 days.
4. Tampons are gradually removed from the mouth.
5. After 14 days, a thermoplastic mass is applied to the plates in order to pressurize the tissues, smooth out scars. Gradually the thickness of the applied layer increases. The plate is completely removed one and a half months after the operation. When eating, speech therapy classes, while sleeping, it is allowed to take it off.
6. Correct nutrition involves the intake of grated high-calorie food in liquid form. In the early days, infusion therapy may be prescribed. The procedure avoids reflex vomiting and provides the patient with the necessary fluid and nutrients.
7. When switching to independent nutrition, an abundant alkaline drink is provided.
8. The first dressing is the beginning of speech therapy sessions. It is possible to detect dysfunction of the pharyngeal muscles in case of impaired articulation. Re-correction is required. The opharyngeal ring is assessed. If necessary, procedures are performed using an endoscope, X-ray.
9. To normalize breathing, as well as speech functions, breathing exercises are performed.
10. After 2 weeks, a special set of exercises is carried out, a finger massage.
11. Antibiotics are used to prevent the development of infectious diseases.
12. When pain occurs, various analgesics.

Possible complications

The most common complication of uranoplasty is the divergence of the edges of the transition region of the hard and soft parts. Necrosis of stitched flaps, short length, limited movement, large scars are the result of technical errors.

With a shortened soft palate with normal speech development, a second operation is not required. Small defects in the anterior part of the hard palate that do not interfere with normal speech and do not allow food to enter the nasal cavity do not require correction.

The presence of a through defect at the border of the soft and hard palate requires repeated manipulation.

Frequent complications, even with a successful operation, are:

• speech impairment due to hearing impairment, articulation, normal formation of sounds;
• breathing disorder;
• dental problems: deformed tooth structure, malocclusion, susceptibility to caries, incorrect number or position of teeth;
• susceptibility to various infections of ENT organs: frequent otitis media, sinusitis due to food entering the nasal sinuses, the development of colds due to impaired breathing;
• distortion of the functions of the upper pathways of the digestive system;
• external defects;
• psychological consequences: adaptation in society is somewhat difficult.

Evaluation of results

The results of the operation are evaluated by several specialists:

1. A systematic examination is carried out by a surgeon.
2. The result is necessarily assessed by an orthodontist, if necessary, additional treatment is carried out.
3. Consultation with an otolaryngologist to assess the functioning of ENT organs.
4. Classes with a speech therapist, carrying out various tests allows you to determine the correctness of breathing, speech, the development of the auditory and speech apparatus.
5. In some individual cases, an immunologist and a defectologist are consulted.
6. In the presence of external skin defects, they resort to aesthetic surgery.

First of all, examinations and classes with the child are carried out, if necessary, additional activities are carried out: analyzes, testing, procedures (ultrasound, X-ray, MRI).

Abnormal development of the jaw is not a sentence yet. Patient attitude to the long process of treatment and the rehabilitation period, the choice of competent specialists and clinics with modern tools and equipment will help to fully restore the functionality of the maxillofacial apparatus with minimal consequences.

Compliance with all the rules and recommendations will help a child with a congenital defect feel absolutely normal in relation to peers.

Answers to parents' questions

Parents of children with WRGN often have questions.

Let's consider the most common ones.

Does 2-stage surgery affect the growth of the upper jaw?

Studies give an unambiguous answer: the variability of the forms of uranoplasty does not directly affect the development of the jaw apparatus. The growth of the upper jaw depends on the skill of the surgeon, the patient's age and personal anatomical features of development (bone mineralization).

Does the development of the upper jaw depend on the age at which the operation is performed?

This dependence exists. It is not recommended to carry out the operation earlier than 3 years by a radical method and not earlier than 4-6 years to carry out the second stage to eliminate the cleft of the hard palate.

Do the timing and stages of the operation affect the development of the child's speech?

The statistics are as follows: 92-98% of patients with a radical form of intervention quickly and fully restore / acquire speech skills. The sparing method "inhibits" the development of the speech apparatus.

Will aesthetic defects remain on the face?

Supporters of the radical method are in favor of minimal defects in the skin. Earlier intervention helps to restore appearance. The individual ability to regenerate external tissues is the main factor in aesthetic defects. There are special means in the form of an ointment, cream for the speedy healing of the epithelial layer. The use of special laser therapy is possible. In any case, the defects, if they remain, are very minor.