Cleft lip and dentoalveolar cleft repair

A cleft lip is repaired in the same manner, whether incomplete or accompanied by a cleft of the alveolar process.

CL repair involves reconstructing the fissure in the incisive bone and lip to separate the oral and nasal cavities. It is done by reconstructing the floor of the nasal passage and oral cavity, followed by the cleft lip's closure. Malpositioned incisor teeth are extracted a few weeks before CL repair to allow flap design and oral closure.

A three-step approach is used to repair complete bilateral clefts of the primary palate.

• Repair of the floor of the nasal passage
• Repair of the cleft of the primary palate
• Repair of the cleft lip

The procedure may be complicated by the attachment of the philtrum to the incisive gingiva and a deficiency of lip tissue because of the cleft's extent.

Infraorbital nerve block, with the dog in dorsal recumbency, is recommended during a cleft repair.

A pedicle flap is created from the medial nasal wall, based at the margin of the cleft's medial side along the floor of the nares.

The mobilized flap is reflected laterally to the lateral lip mucosal side of the cleft.

The laterally rotated flap is sutured with 5-0 rapidly absorbable monofilament suture material in a simple-interrupted pattern to the incised recipient site in the labial mucosa.

Once the nasal floor is created, a transposition flap of the oral mucosa is moved over the repaired nasal floor.

With the dog in sternal or dorsal recumbency, an incision (1) is made from the medial side of the cleft lip, across the most ventral aspect of the philtrum ending at the level of the contralateral alar fold commissure. The incision is separated into two layers (a dermal and a labial mucosal layer, respectively) by blunt and sharp dissection.

A second incision (2) is made on the lateral side of the cleft in the hairy cutaneous lip, beginning halfway along the vertical course of the lateral cleft margin.

The first flap is created from the cleft's lateral side, elevated, and transposed to the first incision (1). The lip margins are sutured together to recreate the lip (2).

The mucosal surfaces are sutured in a simple interrupted pattern with 5-0 rapidly absorbable monofilament suture material with the knots placed on the mucosal surface. Suturing the dermal layer starts by placing the suture from the midpoint of the laterally created dermal flap to the dorsal aspect of the medial flap using 4-0 non-absorbable monofilament suture material. Additional sutures are placed to complete the dermal closure.

If there is tension on the suture line, dehiscence will likely occur.

If dehiscence occurs and the defect is clinically significant, the repair is delayed for 4-6 weeks to allow the tissues to heal.

Multimodal perioperative analgesia is provided by combining opioids and non-steroidal medications. Analgesia is provided for 5-7 days postoperatively.

A broad-spectrum antibiotic is continued for 10-14 days postoperatively depending on the nature, complexity, and duration of the surgical procedure and the presence of complicating factors (e.g., rhinitis).

Postoperative monitoring is required. Evaluate for oral swelling and impaired breathing. The patient is hospitalized overnight, and the surgical site is checked the next day. The surgical site is then evaluated weekly until healing is confirmed (6 weeks postoperatively). Skin sutures in cases of cleft lip repair should be removed 10-14 days postoperatively.

The most common complication is dehiscence. If it occurs and the resulting defect is of clinical significance, then repair is delayed for 4-6 weeks to allow the tissues to heal.

Although the placement of a feeding tube (e.g., esophagostomy or gastrostomy) could be considered, in most cases, oral intake of food can begin following complete recovery from anesthesia. A liquid or a soft blended diet is used for 2 weeks, followed by a slow conversion to a soft diet over the following 2 weeks. Chew toys must be avoided for 6 weeks.

The oral cavity should be carefully rinsed twice daily with an antiseptic oral rinse (e.g., chlorhexidine gluconate 0.12%).

Young dog with a bilateral cleft of the lip and dentoalveolar cleft.

Preoperative dental radiograph showing the occlusal view of the rostral maxillae.

Preoperative 3D CT image showing the exact size and shape of the defect.

Surgical planning and removal of the incisive bones.

Establishment of the nasal floor after removal of the incisive bone.

Complete repair of the oral site of the dentoalveolar cleft.

Repair of the cleft lip on the left side.

Complete repair of the bilateral cleft lip and dentoalveolar cleft.