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Sunday, 15 July 2012

LABIOPALATOCHIZIS AND REPAIRS




LABIOPALATOSCHISIS

Cleft lip (labioschizis) usually arise scbagai congenital defects. This disorder occurs due to disturbances in the process of unification of the upper lip in the early embryo.
 Mild cleft lip appears to be only a small gap above the upper lip and no pins. Severe cleft palate can occur on both sides of the upper lip and form a slit up the nostrils and palate (labiopalatoschizis).
This situation is clearly interfere with sucking and menolan and speech disturbances. also facilitate the occurrence of respiratory tract infections. Therefore, severe cleft lip umuk needed surgery to correct abnormalities.

In Indonesia, the number of people with this disorder tcrtinggi largest in East Nusa Tenggara is six to nine people per 1,000 population. This number is very high when compared to cases in which only international one to two persons per 1,000 population.



Cleft lip surgery should ideally be held on the 3-month-old child in which at least 5 kilograms of body weight and blood hemoglobin levels greater than 10 g%. Were for patients with cleft palate held at 1.5 to 2 year olds to get the maximum talk.
The high incidence and complications that occur when a late follow up cleft lip is a serious problem. Therefore, the Referat will discuss how to make the diagnosis early so that complications can be prevented.
Labiopalatoschisis is a congenital disorder that is often found in Indonesia. In general it can be said that the incidence occurred labio or palatoschisis is 1 in 1000 live births. Indonesia has not been obtained for the incidence rate. Labiopalatoschisis incidence in men is 2x more often than women, when the incident palatoschisis it more often in women.
Genesis labiopalatoschisis ranks ninth out of 10 of the most frequent congenital anomalies are deformities of the feet, hydrocele, hypospadias, mongolismus, cryptorchidism, congenital heart disease, polidaktili, hemangioma, labiopalatoschisis, hydrocephalus.




A cleft lip is a separation of the upper lip That can extend into the nose.

CLASSIFICATION

Cleft lip is an abnormal formation of the lips during the process of fetal growth, such as cleft palate of the mouth. Cleft lip abnormality rate varies, from mild to severe rnulai (gap could reach the nose).
Several types of cleft lip is known is:

Incomplete unilateral
If the cleft gap occurs only at one side of the lip and not extending to the nose.

Complete unilateral
If the cleft gap occurs only at one side to the lip and nose mcmanjang.

Bilateral Complete
If cracks occur on both sides of the cleft lip and extending to the nose.



Cleft palate
This gap appears due to the closure of the palate are not perfect. This process occurs when the fetus is still in the mother's womb and be born until the moment, this raises the mouth slit open space tract to nasal respiration, even reaching the esophagus.

Cleft lip and cleft palate
Cleft lip and cleft palate may occur together or separately. The seriousness of this vulnerability affects the process of feeding the patient.




Illustrations and legends for "cleft lip and sky"
A. labiognathopalatoschizis unilateral
B. labiognathopalatoschizis bilateral
D. appear in the sky from the A
E. appear in the sky of the B
Compare with normal anatomy of C and F. All that is not normal anatomy should be corrected. Schizisla tan on bilateral, often sticking to the front of the premaxilla is growing, as was the "brake" by m. orbicularis did not connect.

Classification labio or palatoschisis useful to write down the diagnosis as well as describing the anatomical events contained in each case:
A. Fogh Anderson classification
- Group I: labioschisis (unilateral and bilateral 0, mild (incomplete) to severe (complete) the extent to incisive foramen.
- Group II: labio or palatoschisis (unilateral or bilateral)
- Group III: Palatoschisis hardware and software, behind the incisive foramen
- Group IV: Gaps in the face (facial cleft).

2. There is also a classification according to anatomic



- Pre-alveolar cleft (labioschisis)
Unilateral (right or left)
Bilateral
notching of the alveolus
- Post-alveolar cleft
Partial (soft palate only)
Complete (both)
Submucous cleft
- Alveolar or complete cleft (lip, palate and alveolus)
unilateral
bilateral



Examples of Unilateral and Bilateral Cleft Lip




Normal roof of mouth One-sided Two-sided cleft lip cleft lip
 Examples of cleft palate





Cleft of the back of soft palate Complete cleft of the soft palate Cleft of soft and hard palates Complete cleft lip and palate of



PATOFISIOLIGI

To understand the labio or palatoschisis, we must know the normal embryological development that occurs in the formation of the face, especially around the lips and palate.







The development of face
At week 4, wherein the length of the embryo 3.5 mm, 5 pieces of primordia formed around the primitive mouth or stomadeum. At the end of the 8th week advance has been fully formed.
Prosessus five formed on the face are:
a) Prosessus frontalis, which grows from the head down. This is an upper limit Prosessus stomadeum. In further developments in week 5 and 6 are formed on prosessus two hoof-shaped nasal placoda stomadeum unrepresentative. The second is called prosessus plakoda nasomedialis and lateral which will then form part of the nose, upper lip, gums and the anterior palate, next to the front of incisive foramen.
b) A pair of prosessus maxillary, which is the superolateral border stomadeum.
c) A pair of mandibular prosessus, which is the lower limit stomadeum. Both fuse was underlined at week 4 and subsequently developed into the lower cheek, lower lip, mandible, gums and teeth.
Upper lip development of the theory are as follows:
Fusion theory prosessus: Prosessus evolve towards the front and the maxillary midline, below and close to prosessus nasolateralis prosessus nasomedialis growing faster down. Prosessus nasomedialis left and right to meet in the midline. At the meeting, highlighting that resemble fingers will fuse each layer epitelnya which will then be broken so that the mesoderm layer below it will fuse to form a normal upper lip. This fusion will occur at the end of the week beginning 6 to 7 weeks. Based on this classical theory, Arey (1947) put forward a hypothesis that the occurrence of cleft palate due to failure of fusion between the maxillary prosessus prosessus nasomedialis further described schematically by Patten:
a. First place each approach prosessus
b. After the meeting prosessus regression of epithelial lining
c. Mesoderm meet each other and hold fusion.
The theory of the labio or palatoschisis is as follows:
a. Labioschisis: Abnormal development of prosessus nasomedialis and maxillary
b. Palatoschisis: The failure of fusion between two prosessus palatine.
Etiology
 Until now labio or palatoschisis etiology is not known with certainty. Suspected that genetic factors (hereditary) and environmental factors (exogenous) play a role in the occurrence of defects ini.Umumnya there are several factors (multifactorial) are responsible for the labio or hereditary factors palatoschisis which is the most important factors:
Those factors are:
A. Genetic factors: labio or palatoschisis can be derived by heredity. Presumably these factors are heredity and non sex linked recessive. But sometimes seen also to be dominant because of its genetic basis is not only a single gene, but is polygenic.
The fact that can be seen diklinik are:
a. Events accompanied palatoschisis labioschisis more common in families who have members with this disorder.
b. In a normal family who have a disabled child, it is likely to occur in children palatoschisis labio or next is up to 15%.
c. If one parent has a disability is the possibility of blameless children increased.
2. Environmental factors:
a. Drugs: the man is clearly on aminopterin and thalidomide
b. Maternal age: the higher the age of pregnant women are at greater risk for children with disabilities melairkan.
c. Diabetes mellitus: a mother with diabetes three times more likely to give birth to children with labio or palatoschisis.
d. Other factors: rubella infection, radiation / radiation, vitamin deficiency, vitamin A overdose, and trauma.
3. Hormonal factors
Sex hormones
Testosterone, progesterone and diethylstilbestrol through the "barrier" placenta thereby affecting the "eminence" (bulge) genital embryo in early life are genetically female embryos and embryos that otherwise result in the feminization of genetic males - males.
Thyroid hormone
In the animal experiments, when performed before pregnancy thyroidectomi then there anomaly in the offspring.
Steroids
When a pregnant experimental animals injected with high doses of cortisone, it will provide offspring with a cleft of sky.
Adrenal hormones
Women who undergo surgery adrenalectomi, offspring often have abnormalities in the central nervous system.

EFFECT OF FUNCTIONS
The provision of nutrition problems
 Problems that occurred immediately after birth is a matter of feeding / nutrition. A cleft lip is more difficult to make a baby sucking mother putingsusu. Celga hidungah on the palate may also cause the milk you drink is inhaled into the nasal cavity. But on some form of nipple or with the use of artificial nipples, babies with cleft remains apat obtain adequate nutrition until surgery is performed. Sealin that, in some cases the baby may also use so-called artificial palate obturator to help meraka denagan eat normally.

 Social problems
 For some parents that there are problems in the receiving state that their child is different. Many parents feel unwarranted guilt, the worry that their children will be treated differently because of physical or difficulty berbicarannya.

Hearing Problems
Many children with clefts are more exposed to otitis media because of tubal fluid mendrainase eustachia can not be optimal from the middle ear to the kerongkonan. Fluid accumulation, increased pressure in the ears, and infection can occur so that the baby can be affected by fever and earache. If not handled immediately, the development of talking can also occur and hearing loss may persist. For the children with cleft myringotomy tubes inserted at the first reconstruction surgery.

Problems in Speaking
 Children with a cleft lip is usually normal or near normal sounding speech. While some children with a cleft paltum require a longer time than normal children to learn to speak. Usually they have kesulituan in pronouncing consonant sounds. However after the cleft is repaired, most kids can catch up and eventually be able to speak normally, although sometimes requiring speech therapy and additional surgery.

7.5 Problem Teeth
 In addition dentalis cavity larger than normal, it can also happen to lose, adding, malformation or misplaced teeth.

INFANT CARE WITH LABIOPALATOSCHISIS
Babies with labioschisis having trouble breastfeeding. This situation can be helped by using an artificial nipple. If there palatoschisis babies need to be given a drink by using a dot. Feeding is recommended in an upright position 15 º and the dot size is rather large.
First aid
- Information is clear - he explained to the parents about the cause, the impact, prevention, and business improvements that can be done.
- Note: The cause is difficult to determine, largely hereditary factor is not clear.
- Last theory: due to the disruption of mesoderm formation in place, which occurred at 10 weeks of pregnancy, when the second child was most likely due to this increased incidence of 5% or 15% if one parent juaga cleft.
- Prompts to save for repeated surgery.
Diagnosis
Labiopalatoskisis diagnosis comes from:

A. Anamnesis
o congenital defects / congenital form of cleft lip and or palate
o Can be accompanied by other congenital abnormalities.
o The difficulty nursing / feeding
o If you drink / eat out of the nose
o Talk nasal

2. Physical examination
o There is a gap in the lip and or palate or alveolar gnatum
o The gap can be complete or incomplete
o The gap can be unilateral or bilateral
o Searchable other congenital abnormalities
o Asymmetry of the nostril or nostril
o For the first operation (labioplasti) in infants have weight 5kg

THERAPY OR ACTION
Surgery to improve the shape of the lips quickly performed in cases of any age, but the babies are all done at an early age, usually around the age of 3 months with respect to "Formula Ten". Formula or the Rule of Ten Ten is:
A. Weight at least 10 pounds (4.5 kg)
2. Age at least 10 weeks
3. Hb> 10 g%
4. The number of leukocytes <10.000/mm3
Operation aimed to labioplasti anatomic shape and appearance of the lips are close to normal function. To achieve this goal need to be considered a benchmark that is
A. Improve the nostrils (ala nasi) in order to shape and located symmetrically.
2. Gives a good basic shape nose.
3. Improve the shape and position of Columella
4. Improve the form and function of the upper lip
5. Vermillon form.
Besides the general goal of surgery is to achieve
A. A normal appearance
2. Sucking and eating without any nasal regurgitation.
3. Good dentition
4. Perbicaraan normal
5. Normal hearing.

TECHNICAL OPERATIONS
Various closure techniques have been developed labio or palatoschisis in the last few decades of this. Most plastic surgeons choose Millard technique or modification.
Several surgical techniques are used for the unilateral labio or palatoschisis are:
A. Millard operation.
2. Onizuka operations (modifications of Millard)
3. Operation Le Mesurier
4. Operation Mirauld Brown
5. Operation Tennison-Randall







 LABIOPALATOSCHISIS

Cleft lip (labioschizis) usually arise scbagai congenital defects. This disorder occurs due to disturbances in the process of unification of the upper lip in the early embryo.
 Mild cleft lip appears to be only a small gap above the upper lip and no pins. Severe cleft palate can occur on both sides of the upper lip and form a slit up the nostrils and palate (labiopalatoschizis).
This situation is clearly interfere with sucking and menolan and speech disturbances. also facilitate the occurrence of respiratory tract infections. Therefore, severe cleft lip umuk needed surgery to correct abnormalities.
In Indonesia, the number of people with this disorder tcrtinggi largest in East Nusa Tenggara is six to nine people per 1,000 population. This number is very high when compared to cases in which only international one to two persons per 1,000 population.
Cleft lip surgery should ideally be held on the 3-month-old child in which at least 5 kilograms of body weight and blood hemoglobin levels greater than 10 g%. Were for patients with cleft palate held at 1.5 to 2 year olds to get the maximum talk.
The high incidence and complications that occur when a late follow up cleft lip is a serious problem. Therefore, the Referat will discuss how to make the diagnosis early so that complications can be prevented.
Labiopalatoschisis is a congenital disorder that is often found in Indonesia. In general it can be said that the incidence occurred labio or palatoschisis is 1 in 1000 live births. Indonesia has not been obtained for the incidence rate. Labiopalatoschisis incidence in men is 2x more often than women, when the incident palatoschisis it more often in women.
Genesis labiopalatoschisis ranks ninth out of 10 of the most frequent congenital anomalies are deformities of the feet, hydrocele, hypospadias, mongolismus, cryptorchidism, congenital heart disease, polidaktili, hemangioma, labiopalatoschisis, hydrocephalus.


A cleft lip is a separation of the upper lip That can extend into the nose.

CLASSIFICATION

Cleft lip is an abnormal formation of the lips during the process of fetal growth, such as cleft palate of the mouth. Cleft lip abnormality rate varies, from mild to severe rnulai (gap could reach the nose).
Several types of cleft lip is known is:

Incomplete unilateral
If the cleft gap occurs only at one side of the lip and not extending to the nose.

Complete unilateral
If the cleft gap occurs only at one side to the lip and nose mcmanjang.

Bilateral Complete
If cracks occur on both sides of the cleft lip and extending to the nose.



Cleft palate
This gap appears due to the closure of the palate are not perfect. This process occurs when the fetus is still in the mother's womb and be born until the moment, this raises the mouth slit open space tract to nasal respiration, even reaching the esophagus.

Cleft lip and cleft palate
Cleft lip and cleft palate may occur together or separately. The seriousness of this vulnerability affects the process of feeding the patient.




Illustrations and legends for "cleft lip and sky"
A. labiognathopalatoschizis unilateral
B. labiognathopalatoschizis bilateral
D. appear in the sky from the A
E. appear in the sky of the B
Compare with normal anatomy of C and F. All that is not normal anatomy should be corrected. Schizisla tan on bilateral, often sticking to the front of the premaxilla is growing, as was the "brake" by m. orbicularis did not connect.

Classification labio or palatoschisis useful to write down the diagnosis as well as describing the anatomical events contained in each case:
A. Fogh Anderson classification
- Group I: labioschisis (unilateral and bilateral 0, mild (incomplete) to severe (complete) the extent to incisive foramen.
- Group II: labio or palatoschisis (unilateral or bilateral)
- Group III: Palatoschisis hardware and software, behind the incisive foramen
- Group IV: Gaps in the face (facial cleft).

2. There is also a classification according to anatomic
- Pre-alveolar cleft (labioschisis)
Unilateral (right or left)
Bilateral
notching of the alveolus
- Post-alveolar cleft
Partial (soft palate only)
Complete (both)
Submucous cleft
- Alveolar or complete cleft (lip, palate and alveolus)
unilateral
bilateral



Examples of Unilateral and Bilateral Cleft Lip




Normal roof of mouth One-sided Two-sided cleft lip cleft lip
 Examples of cleft palate





Cleft of the back of soft palate Complete cleft of the soft palate Cleft of soft and hard palates Complete cleft lip and palate of



PATOFISIOLIGI

To understand the labio or palatoschisis, we must know the normal embryological development that occurs in the formation of the face, especially around the lips and palate.







The development of face
At week 4, wherein the length of the embryo 3.5 mm, 5 pieces of primordia formed around the primitive mouth or stomadeum. At the end of the 8th week advance has been fully formed.
Prosessus five formed on the face are:
a) Prosessus frontalis, which grows from the head down. This is an upper limit Prosessus stomadeum. In further developments in week 5 and 6 are formed on prosessus two hoof-shaped nasal placoda stomadeum unrepresentative. The second is called prosessus plakoda nasomedialis and lateral which will then form part of the nose, upper lip, gums and the anterior palate, next to the front of incisive foramen.
b) A pair of prosessus maxillary, which is the superolateral border stomadeum.
c) A pair of mandibular prosessus, which is the lower limit stomadeum. Both fuse was underlined at week 4 and subsequently developed into the lower cheek, lower lip, mandible, gums and teeth.
Upper lip development of the theory are as follows:
Fusion theory prosessus: Prosessus evolve towards the front and the maxillary midline, below and close to prosessus nasolateralis prosessus nasomedialis growing faster down. Prosessus nasomedialis left and right to meet in the midline. At the meeting, highlighting that resemble fingers will fuse each layer epitelnya which will then be broken so that the mesoderm layer below it will fuse to form a normal upper lip. This fusion will occur at the end of the week beginning 6 to 7 weeks. Based on this classical theory, Arey (1947) put forward a hypothesis that the occurrence of cleft palate due to failure of fusion between the maxillary prosessus prosessus nasomedialis further described schematically by Patten:
a. First place each approach prosessus
b. After the meeting prosessus regression of epithelial lining
c. Mesoderm meet each other and hold fusion.
The theory of the labio or palatoschisis is as follows:
a. Labioschisis: Abnormal development of prosessus nasomedialis and maxillary
b. Palatoschisis: The failure of fusion between two prosessus palatine.
Etiology
 Until now labio or palatoschisis etiology is not known with certainty. Suspected that genetic factors (hereditary) and environmental factors (exogenous) play a role in the occurrence of defects ini.Umumnya there are several factors (multifactorial) are responsible for the labio or hereditary factors palatoschisis which is the most important factors:
Those factors are:
A. Genetic factors: labio or palatoschisis can be derived by heredity. Presumably these factors are heredity and non sex linked recessive. But sometimes seen also to be dominant because of its genetic basis is not only a single gene, but is polygenic.
The fact that can be seen diklinik are:
a. Events accompanied palatoschisis labioschisis more common in families who have members with this disorder.
b. In a normal family who have a disabled child, it is likely to occur in children palatoschisis labio or next is up to 15%.
c. If one parent has a disability is the possibility of blameless children increased.
2. Environmental factors:
a. Drugs: the man is clearly on aminopterin and thalidomide
b. Maternal age: the higher the age of pregnant women are at greater risk for children with disabilities melairkan.
c. Diabetes mellitus: a mother with diabetes three times more likely to give birth to children with labio or palatoschisis.
d. Other factors: rubella infection, radiation / radiation, vitamin deficiency, vitamin A overdose, and trauma.
3. Hormonal factors
Sex hormones
Testosterone, progesterone and diethylstilbestrol through the "barrier" placenta thereby affecting the "eminence" (bulge) genital embryo in early life are genetically female embryos and embryos that otherwise result in the feminization of genetic males - males.
Thyroid hormone
In the animal experiments, when performed before pregnancy thyroidectomi then there anomaly in the offspring.
Steroids
When a pregnant experimental animals injected with high doses of cortisone, it will provide offspring with a cleft of sky.
Adrenal hormones
Women who undergo surgery adrenalectomi, offspring often have abnormalities in the central nervous system.

EFFECT OF FUNCTIONS
The provision of nutrition problems
 Problems that occurred immediately after birth is a matter of feeding / nutrition. A cleft lip is more difficult to make a baby sucking mother putingsusu. Celga hidungah on the palate may also cause the milk you drink is inhaled into the nasal cavity. But on some form of nipple or with the use of artificial nipples, babies with cleft remains apat obtain adequate nutrition until surgery is performed. Sealin that, in some cases the baby may also use so-called artificial palate obturator to help meraka denagan eat normally.

 Social problems
 For some parents that there are problems in the receiving state that their child is different. Many parents feel unwarranted guilt, the worry that their children will be treated differently because of physical or difficulty berbicarannya.

Hearing Problems
Many children with clefts are more exposed to otitis media because of tubal fluid mendrainase eustachia can not be optimal from the middle ear to the kerongkonan. Fluid accumulation, increased pressure in the ears, and infection can occur so that the baby can be affected by fever and earache. If not handled immediately, the development of talking can also occur and hearing loss may persist. For the children with cleft myringotomy tubes inserted at the first reconstruction surgery.

Problems in Speaking
 Children with a cleft lip is usually normal or near normal sounding speech. While some children with a cleft paltum require a longer time than normal children to learn to speak. Usually they have kesulituan in pronouncing consonant sounds. However after the cleft is repaired, most kids can catch up and eventually be able to speak normally, although sometimes requiring speech therapy and additional surgery.

7.5 Problem Teeth
 In addition dentalis cavity larger than normal, it can also happen to lose, adding, malformation or misplaced teeth.

INFANT CARE WITH LABIOPALATOSCHISIS
Babies with labioschisis having trouble breastfeeding. This situation can be helped by using an artificial nipple. If there palatoschisis babies need to be given a drink by using a dot. Feeding is recommended in an upright position 15 º and the dot size is rather large.
First aid
- Information is clear - he explained to the parents about the cause, the impact, prevention, and business improvements that can be done.
- Note: The cause is difficult to determine, largely hereditary factor is not clear.
- Last theory: due to the disruption of mesoderm formation in place, which occurred at 10 weeks of pregnancy, when the second child was most likely due to this increased incidence of 5% or 15% if one parent juaga cleft.
- Prompts to save for repeated surgery.
Diagnosis
Labiopalatoskisis diagnosis comes from:

A. Anamnesis
o congenital defects / congenital form of cleft lip and or palate
o Can be accompanied by other congenital abnormalities.
o The difficulty nursing / feeding
o If you drink / eat out of the nose
o Talk nasal

2. Physical examination
o There is a gap in the lip and or palate or alveolar gnatum
o The gap can be complete or incomplete
o The gap can be unilateral or bilateral
o Searchable other congenital abnormalities
o Asymmetry of the nostril or nostril
o For the first operation (labioplasti) in infants have weight 5kg

THERAPY OR ACTION
Surgery to improve the shape of the lips quickly performed in cases of any age, but the babies are all done at an early age, usually around the age of 3 months with respect to "Formula Ten". Formula or the Rule of Ten Ten is:
A. Weight at least 10 pounds (4.5 kg)
2. Age at least 10 weeks
3. Hb> 10 g%
4. The number of leukocytes <10.000/mm3
Operation aimed to labioplasti anatomic shape and appearance of the lips are close to normal function. To achieve this goal need to be considered a benchmark that is
A. Improve the nostrils (ala nasi) in order to shape and located symmetrically.
2. Gives a good basic shape nose.
3. Improve the shape and position of Columella
4. Improve the form and function of the upper lip
5. Vermillon form.
Besides the general goal of surgery is to achieve
A. A normal appearance
2. Sucking and eating without any nasal regurgitation.
3. Good dentition
4. Perbicaraan normal
5. Normal hearing.

TECHNICAL OPERATIONS
Various closure techniques have been developed labio or palatoschisis in the last few decades of this. Most plastic surgeons choose Millard technique or modification.
Several surgical techniques are used for the unilateral labio or palatoschisis are:
A. Millard operation.
2. Onizuka operations (modifications of Millard)
3. Operation Le Mesurier
4. Operation Mirauld Brown
5. Operation Tennison-Randall













OPERATION PLAN
Age Action Plan
0 months Born with a congenital defect, oversight by the pediatrician
3 months of operation I: - unilateral
- Bilateral
Terms of rule of ten: age> 10 weeks, weight> 10 pounds
(5 kg), Hb> 10mg/dL, leukocytes <10,000 / mm3.
Whenever possible rhinoplasty (extended operation)
 nostril retainer
During the 3-6 months
6 months of operation he: labioplasty bilateral / alternative to heavy
1 to 1.5 years of operation II: palatoplasty (pushback / VY)
One month after this surgery speech therapy program by a speech therapist
2 years If there is oro-nasal fistula surgery  III fistula closed
3-4 years of operation IV: when secondary repair labioplasty need to do first before kindergarten
4-year nursing program where the teeth / occlusion by drg.orthodonsi
8-10 years old V Operations: If there is still a gap the gums, bone graft done. Donor bone chips from the pelvic bone, the approach
14-16 years / adult Operations VI: when necessary
A. Secondary repair third labioplasty
2. Rhinoplasty  nostril retainer
3. Repushback palatoplasty

Palatoplasty surgery at an older age caused the speech center is familiar with the pronunciation - nasal pronunciation or wrong, and tebiasa by using the muscles of the soft palate is not true. Palatoplasty done the age range 18 months to 2.5 years, where children do not speak fully. In the flap technique was carried saaat mukoperiosteal palate and septum nasi. In the soft palate incomplete schizis try not extend to the front and rear with a V - Y plasty.
 Parents should train the child to talk properly (informal) if the pronunciation - there is still a nasal pronunciation maih means no leakage into the nasal sound, if you can not also do pharingoplasty before school (formal). In case this is done to narrow the flap retropharingeal oronasal relationship ( 6 years).



Before the school children, conducted with the aim panoramix photo:
 To view the maxillary bone defect  if necessary, bone graft from the iliac bone (bone spongiosa)

Before the school children, conducted with the aim panoramix photo:
 To view the maxillary bone defect  if necessary, bone graft from the iliac bone (bone spongiosa)
 When the permanent canine teeth are ready to grow visible than a third of the milk tooth root is resorbed think - about the age of 8.5 years.
Psychologists are required when there are complaints - complaints of personality growth.
Management completed when growth stops, no complaints or when no longer able to fix it so that there is hypoplastic maxilla (front to rear direction). If the complaint is to do surgery menojol Le Fort I osteotomy to advance the maxilla.

POST-SURGERY CARE
Postoperative care is very big role in giving the final appearance of the lips that have undergone reperasi. smooth scar tissue that would be obtained if, during the post-surgical treatment is well done. Treatment consists of:
- Installation of a second elbow splint on hand to prevent the baby's hand holding the lip
- Lips openly admitted starting the first postoperative day.
- Luka operation cleaned from the remnants of blood clot and debris with a solution of H2O2 per day.
- After cleaning, wound spiked with antibiotic ointment.
- Stitches removed on the fifth day until the seventh day.


Postoperative complications
Some of the complications which may include:
A. Airway obstruction
Closed due to blood clots or mucus. This can be overcome by suction.
2. Bleeding
3. Opening of the suture
Can be caused due to tension in the sutured tissue, may also be due to children crying, loud talk or eat solid food. Can be given sedatives to calm the child. Tissue tension can be reduced by cutting hamulus. The opening of the wound can be caused by systemic diseases or long-term use of corticosteroids.
4. Fistula
Fistulas can occur because of epithelial tissue that should be excised is still lagging behind. Fistula may close spontaneously, when it can not be oiled regularly with a solution of nitras Argenti as cauterization.
5. Talk is not perfect
Occurs when the palatoplasty performed after the child can speak or if operating results do not meet the anterior posterior distance sufficient to produce a normal voice.



REFERENCE


Brunicardi, F. Charles, et al. Schwartz’s PRINCIPLES OF SURGERY, 8TH EDITION. Mc Graw-Hill’s Companies. USA : 2005.
- De Jong, Wim. Samsuhidajat, R. Buku Ajar ILMU BEDAH, edisi revisi. EGC. Jakarta : 1997.
- Mansjoer. Arif, dkk. Kapita Selekta Kedokteran. Edisi Ketiga. Jilid 2. Media Aesculapius FKUI. Jakarta. 2000.
- Reksoprodjo, S. Kumpulan Kuliah Ilmu Bedah. Jakarta : Binarupa Aksara, 1995
- Sadler, T.W. Embriologi Kedokteran LANGMAN, edisi ke-7. Penerbit EGC. Jakarta : 2000.
- Soegondo. Diwyo, LABIOPALATOSCHIZIS / Sumbing Bibir Langitan
- www.plasticsurgery.org/public_education/procedures/
- www.bupa.co.id
- www.pedisurg.com

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