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Cleft Palate

Functions of the Palate

  • Hard palate
    • Supports the maxilla
    • Growth center of the maxilla
  • Soft palate (velum)
    • Mediates speech production by changing the configuration of the velopharynx

Embryology

  • Failure of fusion of the frontonasal and maxillary processes → between premaxilla and lateral maxilla
  • Lateral palatal shelves fuse later while rotating from vertical to horizontal and anterior to posterior

Bronchial Arch Derivation of Palatal Muscles

  • First Branchial Arch
    • Tensor veli pallatini
      • Innervated by CN V
  • Fourth Branchial Arch
    • Levatori palantini muscle
    • Other pharyngeal muscles
      • Innervated by CN X via the pharyngeal plexus

Anatomy

Normal Anatomy

  • Divided into primary and secondary palates at the incisive foramen
  • Primary palate (premaxilla)
    • Structures anterior to the incisive foramina
  • Secondary palate
    • Hard + soft palate posterior to the incisive foramina
    • Hard palate
      • Structural support and growth center for the maxilla
    • Soft palate (aka the velum)
      • Provides velopharyngeal competence
      • 5 Muscles
        • Levator veli palatini
          • Origin: Posteromedial aspect of the junction cartilaginous and bony segments of Eustacian tube
          • Insertion: Bilateral levators insert into one another at the palatal midline
          • Innervation: CN X (Vagus n.)
          • Function: Form a sling that suspends the soft palate from the cranial base
            • Contraction pulls the velum laterally, cranially, and posteriorly
            • Provides the velar component of velopharyngeal closure
        • Palatopharygeus
          • Origin: Two heads split from either side of the levator veli palatini muscle
            • Inferior head from oral surface
            • Superior head from nasal surface
          • Insertion: Runs inferiorly to ___
          • Innervation:
          • Function:
            • Forms the posterior tonsillar pillar
        • Palatoglossus
          • Origin: Dorsolateral transverse fibers of the tongue
          • Insertion: Fans out onto soft palate
          • Innervation:
          • Function:
            • Most superficial muscle of the soft palate
            • Forms the anterior tonsillar pillar
        • Tensor veli palatini
          • Origin: Greater wing of sphenoid bone + superolateral aspect of eustacian tube
          • Insertion: Hooks around hamuus to insert on fibrous tensor aponeurosis
          • Innervation
          • Function:
        • Muscularis uvulae
          • Origin: Tensor aponeurosis
          • Insertion: Base of the uvula
          • Innervation:
          • Function:

Classification of Cleft Palates

Veau Classification 

  • Defined in 1931 
  • Four types:
    1. Veau Class I = Isolated soft palate cleft 
    2. Veau Class II = Isolated hard and soft palate 
    3. Veau Class III = Unilateral cleft lip and palate 
    4. Veau Class IV = Bilateral cleft lip and palate
Veau Classification

Treatment

Goals of Hard Palate Repair 

  • Watertight barrier between oral and nasal cavities 
    • Prevent regurgitation 

Goals of Soft Palate Repair 

  • Restore levator sling + lengthen soft palate 
    • Restore velopharyngeal competence 
      • Required for normal speech 
    • Restore normal eustachian tube function 
      • Improve drainage 
      • Improve hearing 
      • Decrease risk of otitis media