Anatomic Characteristics of the Cleft
The ultimate goal in treating cleft patients is to perform reconstructive surgery that creates a normal appearance and restores function. The following will describe the normal anatomy of the lip, nose and palate, including the medical terms used to identify specific structures. This is done witht he hope that the explanations and figures will facilitate your understanding of the terms used by members of the multidisciplinary team in the assessment and treatment of your child. This terminology may also be helpful in reviewing textbooks and other literature about the causes and treatment of cleft deformities.
The Upper Lip.
The lower margin of the upper lip is called the vermilion and is characterized by its rosy color. The line or ridge between the skin of the upper lip and the vermilion is called the vermilion border. The term Cupid’s bow is used to describe the concave or dipped portion of the vermillion border in the center of the upper lip. Above the center of the upper lip is a dimple called the philtral dimple, and the raised ridges on either side of thsi dimple are the philtral columns or lines. The portion of the upper lip between the two philtral colums is know as the philtrum. In unilateral clefts, the philtrum remains attached to the larger portion of the lip. In bilateral clefts, the philtrum is isolated from the lateral lip segments. In this case, it is called the prolabium. When the doctor talks about the length of the lip, he means the length of skin from the base of the nose to the lower margin of the vermilion.
Normal Anatomy of the Upper Lip
The upper lip is composed of orbicularis oris muscle covered by skin on the outside and mucous membrane on the inside. many other muscles are attached to the obicularis oris muscle, and together they work to create the movements and power required for speaking, eating and forming facial expressions. The orbicularis oris muscle constitutes the major bulk of the upper and lower lips.
The Nose.
The nose can be thought of as a tent of skin supported in the center by a post of cartilage called the nasal septum which separates the nose into the right and left chambers. The nasal septum also separates the two large sinuses underlying the cheek bones which are called the maxillary sinuses.
The shelves on the lateral walls of the nasal cavities are called turbinates. A deviated septum may cause the tubinates to become abnormally enlarged, and, in order to improve breathing, the lower or inferior turbinates may need to be partially removed. The nostirls include the external ports or openings, as well as the skin and cartilage surrounding them. In unilateral and bilateral celfts, the nostrils are deformed. The tip of the nasal septum ends below the nasal tip. Both nostrils and the nasal tip are supported by the lower lateral cartilages which define the size and shape of the nostrils. The columella is the skin bridging the nasal tip and upper lip.
View Inside the Nose.
The Palate.
The palate is the roof of the mouth. It consists of two portions: the hard (bony) palate and the soft, muscular palate. The palate separates the nasal cavity from the oral cavity.
Normal Palate: Profile View.
The hard palate is composite of several bony structures. Three primary sets of bones comprise the hard or bony palate. From front to back they are the premaxillary bones, the maxillary bones and the palatine bones. They meet in the center of the palate at the midline maxillary suture. The arch of the hard palate is called the palatal arch.
The hard palate constitutes the anterior portion of the entire palate and lies directly behind a horseshoe-shaped bony arch which supports the teeth. This arch is called the alveolus. The teeth protrude from a ridge known as the alveolar ridge. The hard palate is immobile and is surrounded by the alveolar ridge. The flesh that covers the hard palate is called mucoperiosteum. It is used in cleft palate repair to close the hard palate defect.
Normal Palate: Frontal View
The soft palate lies behind the hard palate. It ends with a little flap that hangs down from the soft palate called the uvula. The soft palate is composed of several muscles and fibrous tissue (all of which is attached to the posterior edge of the bony palate). The soft palate is mobile and plays a decisive role in speech production. This primary function of the soft palate is dependent on the levator (veli palatini) muscle. Reconstruction of this muscle is an important part of cleft palate surgery.
Behind the palate lies the pharynx or throat. The pharynx begins behind the nose and extends down to the voice box or larynx. The upper part of the pharynx is described as the nasopharynx, and the lower part behind the mouth is called the oropharynx.
Normal Throat.
The soft palate performs many functions. One of its roles is to close off the back of the nose during swallowing. This keeps food and fluids from being forced through the nose when a person eats and drinks. The soft palate also plays a major role in speech. Since it acts like a veil over the pharynx, it is sometimes called the velopharynx. When the soft palate does not close completely or properly while making certain sounds, the patient is said to have verlopharyngeal insufficiency or velopharyngeal incompetence. This functional impairment in cleft patients is marked with a nasal quality of speech called hypernasality.
Nasal air “escapes” during speech because the soft tissue fails to close the gap between the soft palate and the pharyngeal wall.
Figure. To eliminate the problem of air escape, a flap from the pharyngeal wall is stitched to the soft palate. Small spaces are left on each side of the flap for normal breathing through the nose.
Other terms used to describe the deformity are:
Anterior: Toward the front of the body or in front of
Posterior: Toward the back of the body or behind
Lateral: To the side of the body or away from the middle of the body
Medial: Toward the middle of the body
Superior: Toward the top
Inferior: Toward the bottom
Unilateral: One-sided
Bilateral: Both sides
