Cleft lip and cleft palate are the most common congenital anomalies of the head and neck occurring as 1 in 750 live births. In Orientals it is 1:500, in Caucasians it is 1:1000 and in black Americans it is 0.4:1000. The recent views suggest that clefts are due to multifactorial etiology involving many genes and environmental factors. The isolated cleft palate is more heterogeneous. Associated anomalies are seen in cases as Robin syndrome and Fallot's tetralogy. Drugs during pregnancy, consanguinity, and exposure to radiation are common environmental causes in the etiology (Decker and Du Plessis, 1980: His 1901: El-Rakhawy,1978: Stark and Kernahan 1959: Stark, 1954: Wyszynski et al 1997)

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Picture 1

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Picture 2: Example of bad surgery out-come

In Saudi Arabia and Malaysia: The Tabuk region lies in the North West of Saudi Arabia. It is a wide district with greatly increasing population. It was calculated that the incidence of cleft palate only 1:350 of live births. For cleft lip or palate, it is 1: 250.

Incidence in Malaysia was estimated as 1: 700

It was observed that the flow of complete type is more in Malaysia than in Saudi Arabia, while isolated lip or palate are more common in Saudi Arabia. (See table 1 and 2)

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Table 1: Nationality of patients

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Table 2: Associated family history and associated conditions

Patient was left for age of three months to close the lip. Some cases were seen after this age and I called them (Neglected cases). Palate was closed before two years in this group which included 8 cases using Veau Wardil technique, and 15 cases treated by modified Von-Langenpeck technique.

Lip was closed in the first week of life. Palate was closed between 7 and 10 months age. 25 cases were treated in this way using Modified Von Langenpeck technique.

Modification of Von Langenpeck technique: This was done by wide dissection of the mucous membrane of the lateral walls of the pharynx together with double opposing Z-plasties in the soft palate to elongate the palate and uvula (Furlow's technique).(Pavy, 1994: Lindsay 1975: Von Langenbeck,1861). Backward stitch of the mucosa was done to help to narrow the velo-pharyngeral orifice. In both techniques the other steps were greatly similar. Lateral gauze packs were placed and left in place for 3, to 5 days. (Demonstration 2, 3 and 4)

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Illustration 2:Von Langenpeck - Paevy

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Illustration 3: Furlow's modification

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Illustration 4: Veau Wardil Technique

Wide dissection of the mucosa over the lateral and posterior pharyngeal walls and packing it with gauze was done. Backwards stitching of mucosa by the side of the new uvula. Cress-cross stitches in the mucoperiosteal flaps helped to stabilize the suture line. Placed packs were kept enough period of time until a good healing occurred. Two Z plasties were made posteriorly to elongate the antero-posterior length of the soft palate and decrease the velo-pharyngeal orifice. Antibiotics were continued for 2 to 3 days. Post-operatively the patient was given oral fluids and liquid diet for one week.

The timing of surgery was reviewed by Jaques (1997) and Rosenstein (1999) who recommended combined integrated co-operation between the Plastic surgeon and the orthodontist from time of birth to adolescence, for better or full esthetic and functional use of all dentition. Posnick(1996), Fukoda et al (1998): Lukash et al (1998): Mishima et al (1998): Serevans et al (1998): Brauman et al (1999) and Millard (1999), all used pre-surgical casts or appliances to correct the alveolar arch deformities until the surgery for the lip was achieved. They had good results, but the cost of the appliance is too high.

Our observation in illustration 6, a patient 40 years old came with old burn and ectropion of lower lip showed forwards projection of lower teeth, made me think of early lip closure in complete cleft varieties.

In this study, the author used the lip as a natural appliance to correct the residual alveolar arch deformity, but it should be done as early as possible and it showed acceptable results. Paevy (1994), in France, started to close the lip in the first week of life. He used to operate more than 250 cases per year. He used also to close the palate as early as possible. Heidbuchel et al (1998) studied the effects of early treatment on maxillary arch development in bilateral cleft palate. A study on dental casts between 0 and 4 years of age, showed good results regarding dental and speech outcome.

Ysunza et al (1998), published a study included 41 patients whom were operated at the age of twelve (12) months, and 35 patients were operated at age of six (6) months. He discovered that the outcome of speech was significantly enhanced in the 6 months group, and no compensatory articulation disorders were seen. Both groups had the same degree of maxillary collapse which is less in early operated cases.

It was found in bilateral clefts, that delaying the palatal surgery after the 10th month of age is better for achieving enough growth of the palatal shelves, and fusion of the primary palate and the alveolar arch.

Complications in group (I) were mainly due to delay in lip closure. This delay gave a chance for more stability of palatal shelves, arches, and alveolar margins in the abnormal place, which makes it difficult later to be closed well.

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Case 9: 12 years old girl with neglected cleft palate after immediate closure

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Case 13: Another 8 years old neglected cleft palate after closure

Two techniques were used, Veau technique and Von Langenbeck technique.

Najmi (1999) used a full thickness skin graft, Malek as in Pavy (1994), Owman-Moll (1998) closed the palate in two stages. In our study we used Von Langenpeck with Fowler's Modification. We added the following points: wide dissection of lateralpharyngeal walls and keeping the packs for few days in lateral slits created after moving the flaps.

Hardens and Mazaheri (1972) studied the effects of cleft palate on the growth of alveolar margins. They showed also the effects of treatment.

Takahashi et al,(1997) started to do alveolar bone grafting for the residual alveolar nothes.

Vacher et al, (1997) studied the effect of treatment on the musculature of the soft palate and correlation to the outcome of treatment. In fact, this effect needs a more detailed study.

Williams et al (1998) studied the velo-pharyngeal function after palatal surgery.

In our study the speech therapist gave a very good comment about the speech out come in patients treated early by the new scheme.

In our study we tried to return the normal anatomy of the lip and palate as early as possible. We regain the normal anatomy by early closure of the lip. No complications were seen.

Dr.Ahmed Hussein A.E.R.Rahoma Associate Professor Cons. Plastic Surgeon Faculty of Medicine University Technology Mara Shah Alam Selangor Darul Ehsan, Malaysia Office: Level 11 Selayang Hospita Selayang,86100 Selangor Darul Ehsan Malaysia Tel: +60128904106 Home and fax: +60361374870 E mail ahmedhusseinr@yahoo.com, ahmedhussein@salam.uitm.edu.my