By William E. Schultz, DVM For The Education Center
Originally published in Veterinary Practice News, January 2015 – Download as a PDF
Introduction
Dentoalveolar cleft and cleft lip are congenital palatal defects resulting from incomplete merging or fusion of the two palatine shelves that normally unite in the fetal formation of the face and jaws.[1,2] Cleft lip is defined as a fissure involving the upper lip, while the dentoalveolar cleft is a fissure involving the portion of the alveolar bone immediately around the teeth.[1] Incomplete palatal closure is attributed to hereditary, nutritional (folic acid deficiency), hormonal, mechanical or toxic causes.[2]
In some neonates, the degree of the cleft defect is so severe that they are unable to nurse and soon die. Many neonates with palatal defects develop rhinitis, various respiratory infections and middle ear disease.[1,2]
The main goal of the surgical repair of palatal defects is to separate the oral and nasal cavities by establishing the nasal floor. Once this is achieved, the cleft lip may be corrected.
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- Figure 1. Pre-operative view
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- Figure 2. Ventral pre-operative view
Patient
Clifford, a 6-week-old golden retriever, was admitted with a unilateral cleft lip and dentoalveolar cleft with premaxillary deformity. The cleft extended into the right nares with the nares open dorsally. Tooth 502 was missing, and the left rostral premaxilla and soft tissue were skewed cranially (Figures 1 and 2).
The owner brought the dog in with the complaint of nasal congestion after meal intake. We decided to not delay the surgery in order to avoid the potential development of a bacterial rhinitis (secondary to food passing into the nasal cavity through the defect).
Physical examination showed that Clifford had a sufficient amount of tissue to repair his defects. The availability of the CO2 laser allowed the surgery to be performed on such a young patient.
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- Figure 3. The osteotome was used to elevate the deformed premaxilla.
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- Figure 4. Laser resection of the gingiva allowed access to the premaxilla prior to trimming the margins.
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- Figure 5. Laser resection of the gingiva was made access to the caudal aspect of the premaxilla.
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- Figure 6. Excess bone was trimmed from the caudal aspect of the premaxilla to allow for normal placement of the incisors.
Surgical Equipment
- 4020 flexible fiber waveguide Aesculight CO2 laser with tipless adjustable spot size hand piece. (Hand piece is shown in Figures 4, 5, 6, 8 and 9.)
- Small osteotome (Figure 3).
- Stainless steel wire and 20-gauge needle.
Laser Settings
- Power: 6 W
- Laser mode: SuperPulse
- Spot size: 0.25 mm
Anesthesia
The patient’s pre-anesthetic physical exam and blood test results were normal. He was pre-anesthetized with atropine, acepromazine and torbutrol. General anesthesia was induced with propofol and maintained on sevoflurane. The endotracheal tube was wrapped in saline- soaked gauze to prevent inadvertent laser puncture.
Procedure
The premaxilla was elevated with an osteotome (Figure 3). Gingiva was incised to gain access to the bone (Figures 4 and 5). The caudal aspect of the elevated premaxilla was trimmed with the laser to allow the teeth to be parallel with the mandibular incisors (Figure 6).
The 4020 Aesculight laser model is capable of producing 100 watts of peak SuperPulse power. In combination with the elevated water content in the young growing bone, this allowed for accurate char-free ablation and cutting. After trimming was completed, the bone was wiped with saline-soaked gauze. Then the premaxilla and deciduous teeth were reattached with stainless wire using a 20-gauge needle as a manual drill (Figure 7).
The laser was then used to freshen the edges of the nares and the upper lip (Figures 8 and 9). The gingival mucosa was cut to allow the left upper lip to move to the right, thus filling in the defect. Closure was completed using 3-0 Monocryl sutures in an interrupted pattern.
Tension mattress sutures were placed in the region of the philtrum. The immediate post-op picture shows very good apposition of the lip and nares (Figure 10).
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- Figure 7. The bone was checked for placement of the stainless wire suture.
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- Figure 8. The dorsal aspect of the nares deformity was freshened.
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- Figure 9. The medial aspect of the deformity was freshened.
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- Figure 10. Immediately post-operative view
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- Figure 11. 3 weeks post-operative view
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- Figure 12. Clifford with his handler three weeks post-operative.
Post-Operative Care Instructions
The patient was released the afternoon of the procedure. The owner was instructed to give him liquid Metacam for three to four days post-operatively, only as needed, and a broad-spectrum antibiotic for 10 days. A blended diet was recommended for two weeks, followed by a gradual transition to soft food for about four weeks. Withholding chew toys and hard objects was advised for approximately six weeks.
Follow-Up Evaluation and Suture Removal
The three-week follow-up exam showed a normal bite and excellent healing with a good cosmetic outcome. The wire sutures were removed from the bone, and the Monocryl sutures also were removed. Clifford is a happy puppy and is eating and drinking normally. His owners plan to use him as a therapy dog with children suffering from similar maxillofacial birth defects.
Conclusion
The CO2 laser allowed for operating in a highly vascular area with virtually no bleeding. With the degree of cleft involving the premaxilla and the nares, the hemostasis provided by the laser enabled precise incisions and tissue removal that would have been very difficult with steel. CO2 laser surgery is performed in a non-contact mode, and the lack of tissue friction during resection resulted in less mechanical tissue trauma. Moreover, non-contact cutting combined with the laser’s bactericidal properties helped to reduce the risk of inflammation. The recovery was uneventful, and the owner was pleased with the outcome.
Dr. Will Schultz graduated from Michigan State University in 1973 and opened a companion animal practice in 1974. He has been a board member with the Synbiotics Reproductive Advisory Panel, the Society for Theriogenology and the Theriogenology Foundation. He has spoken at veterinary conferences and to associations and national specialties because of his special interest in canine reproduction. He has lectured and published articles on transcervical and surgical inseminations using fresh, chilled and frozen semen. Soft tissue and orthopedic surgery are his other areas of interest, with laser surgery being an important modality for over 20 years. Schultz currently uses a 40-watt flexible waveguide CO2 laser with constant wave and SuperPulse modes.
References
- Merretta SM. Cleft palate repair techniques. In: Verstraete FJM, Lommer MJ, eds. Oral and maxillofacial surgery in dogs and cats. Edinburgh: Saunders Elsevier, 2012:351-61.
- Hedlund CS, Fossum TW. Surgery of the digestive system. In: Fossum TW, ed. Small animal surgery, 3rd ed, St. Louis, MO: Elseveir/Mosby, 2007;272-6.
This Education Center article was underwritten by Aesculight of Bothell, Wash., the manufacturer of the only American-made CO2 laser.
