Congenital non-union of the palate: causes, symptoms, diagnosis, treatment

Non-healing of the palate is divided into through, blind and hidden, as well as one- and two-sided.

By cross-cutting are likely nonunion palate and the alveolar bone to the blind - nonunion palate, not combined with nonunion alveolar bone, which are classified into full (defect uvula, palate total) and incomplete or partial (defect within the soft palate).

Hidden nonunions are a defect in the fusion of the right and left half of the bone or muscle layers of the palate (with the integrity of the mucous membrane); they are also called submucosal nonsenses.

This classification is rather schematic and is not based on detailed analysis and consideration of topographic and anatomical features of numerous variants of palate defects. GI Semenchenko, VI Vakulenko, and GG Kryklyas (1967) proposed a more detailed classification, which provides for the division of non-injuries of the upper lip and face into median, lateral, oblique, transverse. Each of these groups is subdivided into subgroups, which, in total, exceed 30. This classification is convenient for coding in the statistical processing of material about birth defects in the maxillofacial region as a whole. As for the palate defects, they are divided into the following groups: isolated (not combined with non-affection of the lips), which, in turn, are divided into complete, incomplete, hidden and combined (combined with non-non-affectionate lips). All these defects are divided into pass-through (one- or two-sided) and blind (one- or two-sided).

Unfortunately, in this classification of palate defects only three circumstances are taken into account: the presence or absence of a combination of a palate defect with a lip defect; the extent of the defect in the anteroposterior direction; presence or absence of latent non-loss.

The above classifications do not meet, unfortunately, a number of very urgent and interesting surgeons' questions arising in the planning of the forthcoming operation or in the process of its implementation:

1. Is it possible to eliminate the defect of the alveolar process by cutting out (at the edges of the defect) two mucosal periosteal flaps on the pedicle and forming a duplicate of them?
2. Is it possible to eliminate a narrow gap between the edges of a gum defect by simply refreshing them only within the epithelium?
3. Are there conditions for the formation of flaps (capsized by the epithelial surface into the nasal cavity) in order to close the anterior part of the defect of the solid palate?
4. Is it possible to cut out the mucosal flaps to epithelize the upper surface of the hard palate in the place where the mucosal periosteal flaps were formed and shifted back?
5. What are the relationships between the edges of the solid palate defect and the opener and whether they allow the opener to use the opener's mucosa as an additional reserve of plastic material? Etc.

In this regard, we developed (Yu. I. Vernadsky, 1968) and use in the clinic a detailed anatomical and surgical classification of palate defects, which is described below in the section on the surgical treatment of palate defects. It is subject to the interests of precise planning and implementation of surgical intervention for each individual patient.

[1], [2], [3]

Symptoms of non-growth of the palate

Symptoms of non-growth of the palate vary significantly depending on whether the palate defect is isolated or combined with non-lipid incontinence.

The concomitant palate, general, systemic and local diseases are partially described above.

It should be noted that almost half of children and adolescents, even with isolated palate defects, had ECG violations in the form of sinus tachycardia, sinus arrhythmia, myocardial dystrophy, signs of blockage of the right foot of the atrioventricular bundle, extrasystole, etc. In addition, part patients on the background of ECG changes were found increased indices of rheumatropic and C-reactive protein, and on the part of the blood, erythropenia, hemoglobin, color reduction, leukopenia, eosinophilia or eosinopenia, lymphocytes ofiliya or lymphopenia, or monotsitofiliya monotsitopeniya.

The poor general status of "practically healthy" children directed by pediatricians to our clinic for uranophiloplasty was expressed in the form of positive reactions to C-reactive protein, hyper-a1, and a2-globulinemia against hypoalbuminemia, a "hyporeactive" type of fractional ESR curve, low indicators of monocyte shift and phagocytic number and index, which necessitated the postponement of the operation and additional medical measures.

Infringement of the immune system in children with congenital defects in the maxillofacial region is indicated by a decrease in the amount of cationic protein in peripheral blood leukocytes and smears-prints from the mucous membrane of the hard palate to 0.93 + 0.03 versus 1.57 + 0.05 in healthy children.

Almost every congenital defect of the palate is characterized by topographic and anatomical disorders of its osseous base and soft tissues of the oral part of the pharynx, the septum of the nose, and sometimes the entire upper jaw, upper lip and nose. The severity of these anatomical disorders depends on the degree of antero-posterior extent, the depth and width of the non-affection.

The most pronounced changes are observed in patients with bilateral non-affection of the upper lip, alveolar process and palate. Functional disorders and cosmetic deficiencies in such patients are due to the severity of anatomical disorders. So, with an isolated non-affection of only a soft palate, the child is in no way different from his peers. Only later (at school age) can be found some underdevelopment of the upper jaw and the westernization of the upper lip. However, even if there is only a latent (submucous) non-infirmity of the soft palate, the child usually speaks inaudible, nasal.

With an obvious non-disruption of the soft palate, the nasal is even more pronounced. This is explained by the shortening and functional inferiority of the soft palate as a valve that disconnects (in the production of appropriate sounds) the nasal part of the pharynx and the oral part or the oral cavity, as well as by hearing loss and gross dental-jaw deformities.

According to our clinic, all children with palate defects require logopaedic care, either because of pronounced inattention of speech with a nasal tinge, or about a distinct, but nasal speech.

Nutrition of children in such cases is usually broken slightly, as many of them, using the language as an "obturator," adapt to their defect and are able to suck the mother's breast.

In the presence of nonunion of hard and soft palate, the newborn also does not externally differ from normally developed children. However, in the first hours of its existence, severe functional disorders manifest themselves: the child can not suck the breast, as a rule, but the air jet entering the nasal cavity immediately falls into the mouth cavity. These violations are caused by the inability to create a vacuum in the child's mouth.

If non-palpitation of the palate is combined with one- or two-sided incision of the gum and lip, the described signs are even more pronounced. In addition, when the lips are not attached to all of this, the child's sharp disfigurement joins.

In a teleradiography survey of children with isolated palate incisions and combined with one- or two-sided incisions of the gums and lips, general changes in the bones of the face were revealed in the form of a retinoclination of the jaws, displacement of the maxilla posteriorly combined with a decrease in the length of the maxilla in the sagittal direction, underdevelopment of the anterior section of the upper jaw .

Compensatory enlargement of the alveolar process of the lower jaw in the incisors does not always restore the articular curve in the anterior part.

The majority of patients have a direct bite or reverse incisor overlap up to a sharp shift of the chin forward in the type of prognosis due to an increase in the body of the lower jaw, between the permanent teeth of which diastemes and trembles are visible.

Due to the lag in the development of the upper jaw with non-growth of the palate, the alveolar process and the lip, flattening of the middle third of the face, upper lip, and cheek budding is often observed.

The most pronounced deformations of the skeleton occur with bilateral non-growth of the palate, combined with non-growth of the alveolar process and lip, namely: an increase in the length of the body of the maxilla as compared to the length of the mandible body by mixing the premaxillary forward; an increase and a sharp forward forward of the forward nasal awn: the deflection of the teeth forward on the intermaxillary bone; displacement of the base of the septum of the nose anteriorly; displacement of the inferior-lateral sections of the pear-shaped aperture posterior to the anterior nose awn: pronounced narrowing of the upper jaw.

From the first days of life, a child with a palate defect develops catarrhal changes in the nose, nose of the pharynx and underlying airways, which is associated with ingestion of food particles and respiratory failure. Sometimes develop clearly pronounced pharyngitis, eustachiitis, bronchitis or bronchopneumonia.

In connection with the violation of nutrition and respiration, the emergence of chronic inflammatory processes in the newborn gradually develops general dystrophy, and then - rickets, dyspepsia, diathesis.

Mortality of children with congenital defects of the palate and face reaches 20-30%, often they die shortly after birth.

The degree of involvement of the nasal mucosa in these children increases significantly with age. Observations showed that all children aged 1 to 3 years had acute and chronic catarrhal rhinitis, and by the age of 6, 15% of children already developed chronic hypertrophic rhinitis.

Since 3 years in children with congenital non-infirmity of the palate and lips, it is possible to identify gross changes in the upper respiratory tract as a deformation of the nose, quite often - curvature of the septum of the nose, chronic hypertrophic rhinitis, leading to a sharp hypertrophy of the inferior nasal conchaes and covering their mucosa. These changes in almost half of the patients are the cause of obstructed nasal breathing and do not decrease even after plaque plasty. According to reports, hypertrophy of nasal concha begins at the age of 4-5 years and reaches a significant degree by the age of 6.

Congenital disorders of the act of chewing, swallowing, salivation lead to a sharp increase in the seeding from the oral cavity, nose and throat of pathogenic staphylococcus and enterococci, and also to the appearance of unusual for these areas microbial species: Escherichia, Protein bacteria, Pseudomonas aeruginosa, etc. Obviously, this can be done to explain the fact that patients with non-infirmity of the palate often become inflamed palatines and nasopharyngeal tonsils increase, pharyngitis occur, ventilation and patency of eustachian tubes are disrupted, the middle ear inflames, decreases x as a result of eustachiitis and otitis.

Pneumatization of the temporal bones in patients with non-palate incisions is usually disturbed on both sides.

Severe disorders are noted not only in the upper respiratory tract, but also in the entire respiratory system; as a result, the vital capacity of the lungs and the pressure of the exhaled air jet are reduced, which is especially pronounced in case of through non-gaps.

Insufficiency of the function of the respiratory system causes the mimicry to malfunction during the conversation, the appearance of habitual disfiguring grimaces. Children with speech impairment arrive late in school and often do not finish it, as a result of which they are not intellectually developed.

Violations of the functions of chewing, swallowing, breathing and speech adversely affect the overall physical development (lag in growth and body weight compared with peers) and the condition (low hemoglobin, dyspepsia, etc.).

Treatment of palate neoads

Treatment of non-palate clefts should begin immediately after the birth of the child. It consists, first of all, in creating favorable conditions for feeding the baby and breathing, that is, it is necessary to exclude the ingestion of food from the mouth into the nose, and the breath, inhaled through the nose, immediately (without a preliminary heating in the nose) into the mouth. This is done with the help of the previously mentioned preformed palatine plate or obturator, which helps to separate the oral cavity and the nasal cavity and nose of the pharynx. The obturator should be floating; Apply it preferably after cheiloplasty in a maternity hospital. The base part of the obturator is made of rigid plastic, and the rest is made of elastic plastic, which makes it possible to correct the obturator, if necessary, using styacryl or other fast-hardening plastic. One of the indicators of the beneficial effect of the obturator is the fact that at the age of 1 to 2 years the weight of children using obturators exceeds sometimes the average weight of healthy children of the same age.

In cases of significant difficulties or complete failure of natural feeding in newborns, the obturator should be manufactured in the first hours of their life in a maternity hospital. If the defect of the palate is combined with nonadhesion of the lips and the child is cheloplasty, the following terms for manufacturing the obturator are recommended:

1. In bilateral non-alveolar process and palate, if cheiloplasty is performed in the first two days, the floating obturator is made on the 3rd-4th day after removal of the joints on the lip.
2. If the early cheiloplasty is performed in a child with unilateral non - affection of the alveolar process and palate, the oturation is postponed to 3-4 months, since before this age the bottom of the lower nasal passage is poorly expressed, which is the fixing point for the floating obturator with "through" non-growth of the palate.

In bilateral incisions, palate in young children, the fixing point is not the bottom of the nasal passage, but the entire defect of the palate in its anterior part, having a V-shape and facing the vertex to the posterior. In addition, the distal part of the obturator is fixed by uncombined halves of the soft palate, which adjoin its lateral surfaces and prevent it from sinking downward. To some extent, the adhesiveness factor also provides fixation of the obturator.

1. If the child with non-mutilation of the lip, alveolar process and palate produced cheiloplasty at the age of 6-8 months, the obturator is manufactured two weeks later, when the edges of the uncontracted alveolar process converge.
2. If, for one reason or another, cheiloplasty is not performed in the first day, the obturator is made in the first days of the child's life.

In the first day after manufacturing, the obturator should be used, stitching it with a thick silk thread; on the second day the thread can be left only for the night, and on the third - to extract completely. In children older than 3 years, you can recommend the use of an obturator without a thread.

According to AV Kritsky (1970), compensatory functional activity of the pharyngeal muscles can be used to fix the obturator. To this end , the author has designed a functional pharyngeal obturator, using which the nasal part of the pharynx in the process of speech and swallowing is closed by obtaining an exact and intimate contact between the walls of the pharynx and the fixed obturating part. The pharyngeal part of the obturator is made by the functional impression, obtained with the help of a special thermoplastic mass.

Terms of surgical treatment of palate neoads

The question of the term of the operation is decided by the authors in different ways. Previously, most domestic and foreign surgeons believed that the operation in case of non-growth of the palate should be performed during the formation of speech (in 2-4 years). However, operations at an early age were conducted, as a rule, under anesthesia and were often accompanied by high mortality, and therefore the operation was postponed for many years, sometimes not at all.

In the postwar years, in connection with the improvement of surgical techniques and methods of anesthesia, the lethality sharply decreased. But along with this, with every year there are more and more reports that operations at an early age entail the development of persistent anatomical deformations. The majority of foreign authors consider the optimal age for the operation to be 4-6 years.

According to available data, the deformation of the upper jaw after the early treatment of the through incisions is not so much associated with uranoplasty, but is the result of incorrect hey-loplasty.

Modern surgeons also disagree on the timing of operations on the palate. Thus, A. A. Limberg (1951) believes that with nonunion of soft and partial nonunions of the solid palate, the operation is permissible at the age of 5-6 years, and with the through operations - at 9-10 years.

Experimental data found that delays the development of the facial part of the skull, not only interference on the hard palate, but also a prolonged tamponade of the okolobloccal space.

Studying the long-term results of uranoplasty, MM Vankevich came to the conclusion that the degree of deformation is usually proportional to the amount of non-occurrence. However, as MD Dubov rightly points out (1960), the magnitude of non-occurrence is not only a quantitative concept. After all, the form of non-affection is determined not only by its length, but also by the degree of development of the palatine plates, the vomer and the muscles of the soft palate. The process of formation of the alveolar process and solid palate precedes the formation of the soft palate and ends about 2-4 weeks earlier. Thus, according to MD Dubov, the emergence of through -sections is obviously connected with an earlier and more intense (than with non-penetrant) exposure to harmful events on the developing fetus. Consequently, the degree of disruption of bone growth in the upper jaw is also different.

AN Gubskaya (1975), based on numerous clinical and anatomical studies, recommends the elimination of an isolated non-infrequence of the palate in 4-5 years, and combined with non-incision of the alveolar process and lips - at an older age. The author rightly emphasizes that it is necessary to distinguish between congenital (primary) and acquired (secondary) preoperative deformations of the maxillofacial region. If the primary - the result of a violation of the development of the fetus, the secondary - a consequence of the function of the muscles of the tongue and facial muscles, which, with their reduction, can distort the uncombed edges of the defect of the jaw and lip. The postoperative deformations of the jaw associated with this are associated with the use of early cheiloplasty by an irrational technique that leaves rough scars on the lip.

GI Semenchenko and co-authors (1968-1995) also consider the optimal age for the operation to be 4-5 years, and with good physical development and the absence of dento-maxillary deformations, even 3-3.5 years. E.N. Samar (1971) admits the possibility of eliminating the non-infirmity of the soft palate in 1-2.5 years, and of all other types of non-affliction - in the period from 2.5 to 4 years; However, he, like other authors, rightly considers the early operations to be permissible only under condition of the possibility of complex dispensary observation, prevention and treatment of possible postoperative deformations.

In connection with the accumulation of a huge actual clinical and experimental material and the introduction into practice of comprehensive dispensary treatment of patients with lip and palate defects, reports on the possibility of comparatively early surgeries (Kh. A. Badalyan, 1984, etc.) are increasingly appearing to prevent the development of secondary deformations of the whole facial skeleton (under the influence of the muscles of the tongue) and deterioration of the general condition of the child, in order to speed up the social rehabilitation of the child,

The age of the child is not the only criterion for determining indications for an operation. It is also necessary to take into account the degree of his physical and mental (mental) development, the severity of the transferred diseases, the nature and extent of the defect. Much mean and social conditions, the relationship between parents after the birth of a child with a defect, the availability of an opportunity to provide the child with orthopedic help (make a floating obturator) and conduct a full course of speech therapy.

Proceeding from the literature and long-term personal experience, in determining the duration of the operation for palate clefts, we consider it necessary to adhere to the following tactics: in isolated non- soft palate incisions, the operation is possible at the age of 1-2 years, but after the operation the child must necessarily undergo a course in speech therapy and be under the supervision of an orthodontist. When the first signs of developing deformation appear, the orthodontist is obliged to conduct appropriate preventive measures.

In the presence of nonunion of the entire hard and soft palate, the operation should be performed at the age of 2-3 years, then performing logopedic training under the supervision of an orthopedist-dentist. Monitoring the dynamics of the development of the palate and making adjustments to the obturator, worn in the intervals between speech therapy lessons.

With defects in the entire palate, alveolar process and lip, it is best to postpone the operation to 7-8 years.

However, whatever the defect, the child must be provided with an obturator as early as possible; Periodically it needs to be changed in connection with the growth of the jaw and the eruption of the teeth.

It is advisable to start the course of speech therapy from the early childhood, long before the operation. The term of the beginning of this training is determined by the degree of mental development of the child, which in many respects depends on parents, educators, family members: they should encourage the sick child to word formation, cause, strengthen possible and affordable sound combinations, teach him onomatopoeia, show and find a toy, or subject, accustom to the designation of the actions of objects, that is, to teach understanding of speech. If from the first days of life the child talks to him little, the development of the function of speech is delayed.

Preparation of the patient for surgery

Preparation of the patient for the operation should begin in advance and include sanation of the oral cavity, the nasal part of the pharynx, restorative treatment, including helminthology.

It is necessary to carefully examine all the organs and systems of the patient in order to determine whether there are any contraindications to the operation; To study a smear from a pharynx and a nose on diphtheria sticks and a hemolytic streptococcus; determine the sensitivity of the microflora of throat to antibiotics.

The complex laboratory and biochemical study of blood counts (leukocytes, agranulo- and granulocytes) and lipid peroxidation before surgery for a palate defect allows to determine the risk of postoperative complications, and thus the need for an individual antioxidant correction of the patient's immune status. For the integrated modulation of the immunological status of patients with congenital non-infirmities of the palate, pre-operative premedication with phenazepam in a therapeutic dosage is recommended.

If an operation is planned with the intersection of the neurovascular bundles of the palate by Yu.I. Vernadsky, it is necessary to prepare, fit and test (within 3-4 days) a training palatal plate and eliminate the deficiencies revealed in it, "to conduct a course of preoperative speech therapy, which should start from the second day after the child's admission to the clinic and conduct along with all other preoperative measures (this makes it possible to greatly facilitate the work of the speech therapist in the postoperative period).

If possible, this training in the clinic before the operation should be a continuation of the training, long begun at home or in kindergarten.

Methods of surgical treatment of palate neoads

Proceeding from the simplest (non-detailed) classification of palate defects, MD Dubov (1960) recommends two variants of the operation;

1. radical uranoplasty according to A. A. Limberg (with through defects);
2. the same operation, but supplemented with a patch for MD Dubov (with imperfect defects). Operation (uranostafiloplastika) includes the creation of anatomical integrity of the hard and soft palate, as well as the restoration of its functional activity. The name of the operation comes from the Greek words "uranos" - the palate and "staphyle" - "the tongue of the soft palate."

The method of radical Uraostafiloplasty according to A. A. Limberg

The operation of this technique involves the following steps (Figure 139):

1. Refreshing the edges of the defect by excising the strips of the mucosa and cutting the periosteum.
2. Formation of mucus-periosteal flaps on the hard palate along the Langenbeck II. P. Lvov.
3. Excretion of vascular-neural bundles from large palatine orifices (according to PP Lvov or AA Limberg).
4. Lateral incisions along the wing-jaw folds of the mucous membrane to the lingual surface of the alveolar process in the last large molar tooth of the lower jaw (according to Halle-Ernst) and mesopharyngeal constriction.
5. Interlaminar osteotomy (according to A. A. Limberg).
6. Freshening the edges of a defect in the soft palate region by stratification or excision of the mucosal band.
7. Sewing the halves of the soft palate with a three-row suture (mucous membrane from the side of the nose, muscles of the soft palate, mucous membrane from the oral cavity).
8. Stitching of the flaps within the solid palate with a double-suture.
9. Tamponade of okolothill niches and covering the entire palate with an iodine-shaped tampon.
10. Imposition of a protective palatine plate and attachment to the head bandage.

To facilitate the removal of the neurovascular bundles (according to LL Lvov) and interlaminar osteotomy (according to A. A. Limberg), it is recommended to use two instruments: bone forceps and nippers for radical uranoplasty.

ES Tikhonov (1983) proposed for this purpose a special bit, the use of which excludes the possibility of traumatizing the vascular-neural bundle, which is derived from the large palatine foramen.

The described technique of the operation, best realized by the most modern tools, can be called radical only purely conditional, since it does not always provide a radical (one-stage) elimination of non-occurrence. Firstly, if the entire palate and the alveolar process are not divided, this technique involves closing the defect in its anterior section only during the second stage of the operation. In this connection, MD Dubov, VI Zausaev, BD Kabakov, and other authors, supplementing the "radical" operation of AA Limberg, proposed special techniques for the elimination of the defect in the anterior section, thereby achieving a single-stage operation.

Secondly, with medium and very large dimensions of the defect in the middle and posterior regions of the palate, the vascular-neural bundles deduced (according to PP Lvov or AA Limberg) from the apertures do not allow the palatal creases to be brought together without tension. This often determines the observed divergence of the joints at the boundary of the hard and soft palate. The suggestion of some authors to stretch the vascular-neural bundles from the bone orifice was also of little effect.

To reduce the fettering effect of deduced vascular-neural bundles on mucosal periosteal flaps, it is sometimes recommended to resect not only the edge of the large palatine foramen but also the posterior wall of the wing-palatine canal. However, such gross and traumatic destruction of the skeletal base of the hard palate usually does not justify itself, so they should be avoided.

Thirdly, even with a single-stage elimination of the entire palate defect in the postoperative period, the length of the soft palate is almost constantly reduced, which leads to its inferiority as a valve, and hence to inferiority of speech.

The main causes of postoperative shortening of the restored (according to AA Limberg) soft palate and the associated decrease in the functional result of the operation are:

1. return of the medial lamina of the pterygoid appendage (during operation) to its former position, as confirmed by experimental studies;
2. scarring of the surface of the soft palate facing the nasal part of the pharynx;
3. the formation of coarse cicatricial cords in the peripheral niches, which is largely promoted by tamponade with their iodine-shaped gauze, as well as the inevitable stratification of the end of the medial pterygoid with which it attaches to the pterygoid process.

After all, during splitting of the plates, the wing of the prominent process automatically splits and the place of attachment to it with the dnaimnaya muscle.

Fourthly, the operation on AA Limberg often leaves behind a rough and powerful scars on the mucous membrane of the soft palate facing the nasal part of the pharynx, as well as the peripheral niches, which sometimes leads to the formation of a lower jaw contracture and requires one more stage of surgical intervention (for example, plasty of the mucous membrane with counter triangular flaps).

Uranistaphyloplasty can be considered radical only when it is produced in one stage and necessarily gives persistent anatomical and functional results (i.e., normalization of speech, eating and breathing). Any repeated operation on the palate testifies to its negligence or, as a rule, about unsuccessful primary intervention. It should not be known to leave defects in the anterior part of the hard palate, hoping to close them in the second operation, as this is always difficult to do because of cicatricial changes in the tissues. You can not also condemn the patient to lifelong using obturating prostheses. It is unreasonable to apply Filatov's stem in preschool age with primary plasticity of the palate.

Methods of radical (one-stage) uranostafiloplasty according to Yu. I. Vernadsky

The key to the effectiveness of uranostaphyloplasty in anatomical and functional terms is compliance with the following requirements: individualization of surgical intervention; use of the entire resource of plastic material; full and unhindered rapprochement of the non-infected halves of the soft palate and its displacement back to the posterior pharyngeal wall. Therefore, when carrying out uranostaphyloplasty, it is necessary to take into account all the anatomical and surgical features of the palate defect in each particular patient.

The features of each variant of the operation are described below. Let us list those general manipulations that are mandatory for all variants of the operation.

1. Intentional intersection of the vascular-neural bundles emanating from large and small palatine orifices, if they need to be removed from the bone ring - a large palatine foramen. Necessity in this arises in practically all children after 10-12 years, adolescents and adult patients who were not operated in a timely manner (at 1-8 years) for one reason or another. They always have a more or less pronounced underdevelopment of the palate in which the mucus-periosteal rags of the hard palate or half of the soft palate of the whip-ri and, to varying degrees, posteriorly, to extend the soft palate or narrow the pharynx, or to lift the arch of the soft palate. The possibility of deliberate crossing of these neurovascular bundles is justified by the presence of vascular anastomoses between the branches of the ascending and descending palatine arteries.
2. Simultaneous elimination of the entire defect even with a "through" palate defect; the anterior part of the defect of the solid palate is closed due to two so-called "anterior-palatine" flaps inclined to the nose, or one flap according to the methods of MD Dubov, VI Zausaev, or BD Kabakov.
3. Formation of duplicate mucosa at the border of the soft and hard palate and in the distal part of the defect of the solid palate due to one or two flaps of the mucosa of the bottom of the nasal cavity. Due to the presence of these flaps, which we call "posterior-palatine", it is possible to prevent rough scarring of the nasal surface of the mucosally-periosteal flaps and soft palate, displaced back and sewn together.
4. Completion of interlaminar osteotomy according to A. A. Limberg (if it is made) by insertion of a wedge (from spongy allo- or xenochondrality) between split wings of the pterygoid process, which gives them a stable position and stimulates the formation between them of bone regenerate, strengthening plate in the diluted position. In addition, this prevents the inner plate from returning to its original position and thereby nullifying the surgeon's narrowing of the throat and lengthening of the soft palate.

Some authors instead of coldness apply (for the same purpose) an autograft from the posterior regions of the solid palate edge, obtained by resection of the bone in the region of the edge of the large palatine hole, thus increasing the traumatism and duration of the operation.

5. Implementation of mesopharynoconstriction without vertical incisions of Ernst. The approach to the peripheral space is "hidden" - through two horizontal sections of the mucous membrane (one behind the uppermost, the other - behind the bottommost tooth).

If the patient has sharply expanded the oral part of the pharynx or if a considerable movement is required inside the underdeveloped halves of the unintegrated soft palate, a horizontal incision behind the uppermost tooth is continued on the upper transitional fold and a triangular flap is cut out here according to VI Titarev; the incision behind the extreme lower tooth is continued on the lower transitional fold and a triangular flap is cut out by GP Mikhailik-Bernadskaya. Between these incisions, the mucosa is stripped off and a bridge-like flap is formed from it, using a T-shaped curved scalpel blade for this purpose. Raising the bridge flap of the mucous membrane, pushing it down a little, exfoliate the surrounding tissues with Cooper scissors or a special rasporotor and fill the peripheral niches with cathegut bunches (processed by boiling) or thin strips of the canned shell of the testis of the bull. After this, lay the flap back and suture the wound along the line of the two specified horizontal incisions.

Due to the formation of the two triangular flaps moving inward (along with the corresponding displaced half of the soft palate), unimpeded approach and stitching of the underdeveloped halves of the soft palate (without tension in the seams) is to a large extent ensured.

6. Tamponade of the okolothillous wound niches with catgut and dull suturing of the wound in the retro-molar areas relieve the patients of painful bandages, the threat of iodoform intoxication and allergic reactions to it, prevents the formation of scarring on the mucosa and the development of contracture of the mandible. In addition, the data of clinical and experimental morphological studies conducted by our staffs allow us to conclude that the tamponade of the interplastic gaps (formed as a result of the cleavage of the pterygoid process) and the peripheral niches are slowly dissolving material and their closure is "tightly" (as far as possible) isolated huge wound surfaces (located in close proximity to the base of the skull and deep layers of the neck) from continuous contact with the microflora of the mouth, food masses, saliva, with gauze (soaked to the same protoplasmic poison - iodoform), which can cause scarring in the rough sides of the pharynx and thus nullify the results achieved by the surgeon mezofaringokonstriktsii retrotransposition and the soft palate. Some authors use a brephoplast for tamponade of the hypoglossal niches.
7. Surgical treatment according to any of the following options, being one-stage, does not provide for any preliminary (preparatory) or additional (corrective), pre-planned interventions on the palate; the need for them after surgery arises either as a result of the inept actions of the surgeon or the divergence of the sutures because the surgeon did not take into account the "hidden" osmosomatic contraindications to the operation that are revealed only in -depth examination of the patient whom the district pediatrician or therapist found practically healthy and without all the doubts sent to such a difficult operation as uranostafiloplastika.
8. To prevent the development of a significant reaction of the tissues around the seam canal, all superficial seams on the mucosa in the area of the hard palate and in the retromolar regions are superimposed from a thin (0.15 mm) soft and most elastic plastic thread (polypropylene, silane, nylon), and in the soft palate - from a thin catgut.
9. With a significant increase (in comparison with the norm) of the transverse dimensions of the middle part of the pharynx and the width of the defect, an interlaminar osteotomy is performed, and one or two catgut skeletons or a squamous testicle of the bull testis are introduced into the hypoglossal niches.

If the overall condition of the child and the local conditions (the correct ratio of jaw fragments, a favorable index of non-affection) allow early uranophiloplasty, then in these cases it is desirable to conduct both cheloplasty, which halves the number of surgical interventions, and provides a pronounced economic effect, early medical and social rehabilitation the patient; Together with this, especially the vigilant care of the orthodontist and the timely correction of the relationship between the jaws are required.

In those cases when the child is operated on the palate defect at an older age, with a generally significant widening of the oral part of the pharynx, we must form a triangular flap of the mucous membrane along the cheek (near the extreme teeth of the upper arch of the vestibule of the mouth) according to VI Titarev and we move it to the wound in the area of the posterior-lateral part of the hard palate. In the lower arch of the mouth of the mouth behind the extreme lower tooth, we cut out the flap along GP Mikhailik-Bernadskaya and move it inside, covering the lower-inside part of the wound.

At the end of the operation, close the seam line with iodoform-gauze tampons (strips) or styrofoam only within the hard palate; the protective plate does not have a tail part, so that the seams on the soft palate remain bare and the possibility of irritation of the root of the tongue is eliminated by the plate.

In cases where the operation is performed in young children or if the protective palatine plate is not properly fixed, the mucosa-periosteal flaps are fixed to the solid palate with polymer adhesive KL-3. The advantages of this method are as follows:

1. the child avoids the unpleasant sensations associated with the removal of the impression from the upper jaw;
2. for 2-3 days the preoperative period is shortened at the expense of the time necessary for the production of the protective palatine plate and its wearing in the preoperative period with the aim of adapting to it;
3. there is no need to use iodoform tampons that sometimes cause an allergic reaction in children;
4. significantly care for the care of a postoperative wound;
5. formed (after retrotransposition of the palate) wound in the anterior region, healing by secondary tension under the polymer film, covered with a delicate plastic scar tissue; this prevents the development of gross scars deforming the upper jaw;
6. saves the time of the doctor and dental technician, as well as the necessary materials for the production of a protective palatine plate.

It is based on the following very significant criteria that the surgeon must take into account when planning and performing the operation in each specific case:

1. Is there a one- or two-sided non-affection of the alveolar process?
2. What is the distance between the edges of the defect in the gingiva (alveolar process) and the anterior third of the hard palate?
3. Is the right and left cracks symmetrical in the bilateral defect of the alveolar process?
4. What is the ratio of the edges of a solid palate defect to the opener?
5. Is it possible to cut out the flaps from the mucosa of the bottom of the nasal cavity?
6. What is the degree of underdevelopment of the soft palate and enlargement of the oral part of the pharynx (mesopharynx)?
7. How large is the anterior-posterior extent of the defect?
8. Is there a hidden non-dissolution of a hard, soft palate or palatine tongue?
9. What is the relationship between the hidden and the explicit parts of non-affinity?

In accordance with these criteria, we have divided all types of palate non-infestation into five main topographic-anatomical classes:

• I - unilateral clear incisions of the alveolar process, gum tissue and entire palate;
• II - two-sided, apparent non-alignment of the alveolar process and the entire palate;
• III - the apparent non-intersections of the entire soft palate, combined with the apparent or concealed non-division of all or part of the hard palate;
• IV - obvious or hidden nedrashcheniya only soft palate;
• V - all other nonunions, ie, the most rare (including hidden - submucosal), which are combined or not combined with non-affection of the lips, cheeks, forehead or chin.

The first four classes are divided into subclasses. Each subclass of non-affinity corresponds to a certain variant of the operation, which is distinguished by one or another feature.

The first four classes include the most common defects of the palate. The number of combined features in different departments of the defect is in fact much larger.

Let us characterize in detail the subclasses of the first four classes of defects and the features of operations, caused by the topographic-anatomical structure of each defect.

/ class. One-sided non-growth of the alveolar process, gum tissue, the entire hard and soft palate.

Subclass 1/1. In the anterior part, the edges of the defect are sufficiently far apart, which allows us to cut two mucosal periosteal flaps, called anterolateral flaps, within the gum and anterior third of the hard palate and tilt them 180 ° with the epithelial surface into the nasal cavity. The opener is not spliced with the edges of the defect throughout its entire length, which makes it possible to cut out two symmetrical, identical in length so-called tracheal flaps from the mucous membrane of the bottom of the nasal cavity and then sew them together. If a small width of the defect does not allow us to tip two of the anterior flaps in the nose, one flap should be cut using the method of VI Zausaev or BD Kabakov.

A new, so-called "method of gentle cheyloranastafiloplasty" is proposed for defects belonging to 1/1 subclass. Its main stages are: they cut out, cut off and overturn the main and additional mucosa-periosteal flaps, remove the vascular-neural bundles emanating from the large palatine orifices, remove the tendon m.tensor veli palatini from the gamulus, release the mobilized flap on the palate from the posterior edge of the hard palate and the inner surface of the medial plate of the pterygoid process of the base bone.

Flaps are separated from the nasal mucosa at the border of the hard and soft palate. The sections of the mucosa in the retromolar spaces extend beyond the alveolar process, dissect the submucosal layer in this area and expose the hook of the pterygoid process, from which the flap is separated in the layer of interfacial space, without changing the place of attachment of the pharyngeal muscle. Mobility of the flaps is provided by separating the tissues from the inner surface of the inner plate of the pterygoid appendage of the base bone to the lower pole, where the pharyngeal-palatine muscle is attached. Refreshes the edges of non-affection and layer-by-layer suturing with catgut and polyamide yarn, after which polymer glue КЛ-3 is applied to the sewn flaps and horizontal plates of the palatine bone. Wounds in the wing-maxillary spaces are sutured with catgut, taking into account the retrotransposition of the palate. The defect in the anterior part of the palate is closed with the help of either interlocking 180 ° flaps, or flaps MD Dubov, BD Kabakov, or a flap on the leg from the side of the mucosa of the upper lip.

Subclass 1/2 differs from the first in that the vomer is spliced along its entire length with one of the edges of the defect, which makes it possible to cut one long enough in the region of the bottom of the nasal cavity and a second very short posterior graft. On the vomer, you can carve a median flap and sew it to the said long posterior flap.

In carrying out uranostaphyloplasty in children with unilateral through incisions of the palate LV Kharkov noted that some elements of this operation need to be improved. First, in the process of uranostaphyloplasty (with defects of 1/2 subclass), two main mucosal-epiglottis flaps are cut out, which are always of different size and are found in different in size and shape jaw fragments: a small fragment is always underdeveloped, shorter in length, while the large fragment is "turned" in the opposite direction from non-growth and is significantly distal to the midline. Secondly, the basic palatine mucosal-periosteal flaps, displaced after retrotransposition and fixed to the bone, denude the lateral sections of the hard palate, in which the wound always heals by secondary tension.

Analysis of literature data and experimental, clinical studies conducted by LV Kharkov have shown that in cases of excretion of neurovascular bundles from large palatine orifices according to PP Lvov, scarring of the lateral sections on the palate is one of the main causes of deformation development in the postoperative period. Thirdly, the most frequent place of formation of postoperative palate defects is the border of the hard and soft palate, where the flaps experience the greatest tension, and, in addition, a place above the area of non-affection where there is no underlying tissue.

In connection with these circumstances, LV Kharkov (1986) developed the procedure of the operation, including the following stages: cutting out and cutting off the main palatine mucosal-periosteal flap only on a larger fragment of the palate, removing the neurovascular bundle from the wing-palatine canal and Cutting off the flap from the posterior edge of the hard palate, dulling it from the hook and freeing the medial surface of the inner plate of the pterygoid process of the base bone; refining the edges of non-affection, cutting off the mucosal periosteal flap from the bone edge on a small fragment not more than 0.5 cm wide, cutting out two triangles in the region of the hard and soft palate for Z-plasty, releasing the soft palate from the posterior edge of the hard palate on a small fragment the sides of the nasal mucosa, the elimination of the palate defect by layer-by-layer suturing with catgut and polyamide filament, cutting out and cutting off on the cheek a tongue-shaped flap on the foot with a base in the wing-jaw space e in a larger moiety, moving it to the palate and crosslinking at the distal side from the center and displaced posteriorly main palatal flap.

According to LV Kharkov's observations, the described technique has the following advantages:

1. due to the cutting and cutting off only one mucosal periosteal flap on the hard palate, the duration of the operation is halved and gross traumatization of the underdeveloped small fragment of the palate is excluded, which favorably affects its further development;
2. the maximum tension of the flaps on the boundary of the hard and soft palate is eliminated completely or leveled by dispersing the seam line with the help of two mutually displaced triangles, which allows to largely prevent the occurrence of postoperative or so-called "secondary" palate defects in this area;
3. the symmetry of the soft palate tissues along the length is achieved due to the release of the soft palate tissues on a small fragment from the posterior edge of the hard palate through an oblique incision at the border of the hard and soft palate;
4. favorable healing of wounds on the palate in the anterior and middle parts of the defect is facilitated by the fact that the seam line is located on the bone base, and not in the middle of the palate defect, that is, between the mouth and nose cavities;
5. due to the movement of the mucosal flap on the foot of the nape with the base in the wing-jaw space, where (according to thermovision) the area of the most intensive circulation is determined, the area of wound healing by secondary tension in the area of the base of the alveolar process significantly decreases, which excludes the formation of gross scars.

These factors contribute to the correct and early formation of the palate, acceleration of the normalization of the function of the hard and soft parts of the palate, prevention of postoperative maldevelopment of the upper jaw and, as a result, an incorrect ratio of the teeth of the upper and lower jaws.

Since 1983 LV Kharkov uses a new technique of uranostaphyloplasty with unilateral through incisions of the palate, belonging to 1/2 of the subclass. According to this technique, the defect of the solid palate is eliminated by the vomer stripe. The operation provides for sequential execution of the following steps:

1. cutting out and cutting off the muco-periosteal flap on the vomer with the base on a larger fragment; while the size of the flap should exceed the dimensions of the defect of the solid palate;
2. dissection of the mucous membrane to the bone on a small fragment parallel to the edge of the defect of the solid palate with a deviation from it by 3-4 mm; while a narrow strip is cut off downwards - it will cover the seam line from the side of the nasal cavity, and the soft tissues of the opposite side will be sewn with the vomer stripe;
3. stitching of the vomer flap with the raised edge of the soft tissues on the opposite side along the entire edge of the palate defect;
4. in the lower pole of the vomer unit, a "lining" flap is cut out and tilted to 180 °, which is sewn in the same plane with the vomer;
5. at the boundary of the hard and soft palate, two angular mucosal-periosteal flaps are cut and cut off, which release from the posterior edge of the hard palate, the hook and the medial surface of the inner plate of the pterygoid process of the base bone;
6. refresh the edges of non-growth in the soft palate and tongue;
7. layered overlap in the area of the tongue, soft palate, vomer and on the border of the soft and hard palate

Postoperative period

In the first 3-4 days after surgery, the patient is shown a strict bed rest.

Surgery for congenital non-affliction in the maxillofacial area causes significant disorders in the functions of the body in infants undergoing local anesthesia; they manifest themselves both during the operation and in the immediate postoperative period. In older children and adults, who have plastic palate produced under anesthesia, the greatest shifts are noted in the first day after the operation. In the postoperative period, their cardiovascular system has greater compensatory reserves than the respiratory system. If the hemodynamic changes associated with the operation are usually aligned no later than the third day after, the compensation of the shifts in the respiratory system is usually delayed up to two weeks. The study of the erythropoietic function in connection with the operation of blood loss has shown that the body of these patients copes with the loss of red blood cells at the same time as the body of healthy individuals. However, the restoration of iron stores in the body, especially infants with a violation of the correct process of feeding, is slowed down and requires special therapy. Therefore, the author believes that transfusion of blood with excess of the volume lost - for infants up to 5 ml per 1 kg of weight, and for older children and adults - up to 20-30% of the volume of blood loss - serves as an effective means of replenishing iron stores in the patient's body. Replenishment of blood loss and oxygen therapy in the postoperative period help the body of these patients to compensate for respiratory distress and help prevent acute postoperative respiratory failure.

Observations convince:

• reimbursement of operating and postoperative blood loss should be carried out not on the basis of the "volume per volume" principle, but before the normalization of central and peripheral hemodynamics;
• application of droperidol and xanthinol allows to exclude vomiting and hiccups, eliminate psychoemotional instability of patients and create good conditions in the wound for its favorable outcome;
• it is highly advisable to use parenteral nutrition in the early postoperative period after uranostaphyloplasty, including protein preparations in combination with a solution of glucose (which provides energy needs of the organism), as well as hormones, vitamins and insulin that regulate metabolism and increase digestibility of introduced protein hydrolysates. With this method of nutrition, rest is created for the operated palate, the pain factor associated with food intake is eliminated, the wound is not infected with food, it is possible to carry out adequate nutrition and thereby facilitate the fastest normalization of metabolic processes, the normal course of the postoperative period. If the protective palatine plate is not firmly fixed on the teeth, it should be relocated with a quick-hardening plastic. To fix the protective plate on the head cap, we resort only in exceptional cases (when the upper jaw has no teeth or very few).

After the operation, under endotracheal anesthesia or under local potentiated anesthesia, the patient may have vomiting, which should be warned by the one who cares for him.

If nasal breathing is difficult, an air duct or a rubber tube with a diameter of 5-6 mm is used (MD Dubov recommends that the end of the tube protruding from the mouth be split and diluted in the form of a slingshot).

Within a few hours and even the first day after the operation, mucus-bloody fluid can be released from the mouth and nose, which should be soaked with gauze balls.

In the evening on the day of the operation, if the patient wishes, you can give him a small amount of liquid food: kissel, liquid semolina, sweet tea with lemon, various fruit and vegetable juices (up to 0.5-1 cups).

In the first day after the operation, being in a hindered state under the influence of narcotic drugs, the patient, as a rule, is able to take liquid food; However, the next day, he usually refuses to drink and eat because of severe pain when swallowing (due to lasting for several days swelling of the pharynx, palate, throat). As shown by clinical studies, in connection with trauma, forced "defensive" starvation and lack of feeding from a spoon or through a drink in the organism of the operated child, the protein composition of the blood changes (decrease in the level of albumins and an increase in al- and a2-globulins), and nitrogen balance and water-electrolyte exchange. Therefore, during the first 3-4 days, the patient should be fed through a thin probe inserted into the stomach before or during surgery. Nutrient mixtures should be liquid, high-calorie and vitaminized (jelly, porridge, broth, juice, tea with lemon, raw eggs, etc.). A detailed description of diets for feeding through a probe is presented below.

If after the operation there was a profuse bleeding from under the plate, it must be removed, a bleeding vessel should be found, squeezed and bandaged. A tight tamponade under the protective plate is not recommended, since it can cause a circulatory disturbance in the formed palate. At the same time, 10 ml of 10% calcium chloride solution should be administered intravenously.

During the dressing, swabs are exchanged, richly soaked in blood. Taking them off, water the palate with a thin trickle of hydrogen peroxide solution; Foam, oxidizing flaps, washes away clots of blood and mucus. After the foam is removed with gauze balls, the palate is covered with fresh iodoform strips and the protective palatine plate is put on again.

Within 7-10 days after the operation, it is advisable to administer antibiotics intramuscularly, and 10 to 15 drops of their solution should be instilled into the nose.

At a high body temperature (39-40 ° C), antipyretic agents are prescribed.

Dressings are made every 2-3 days, alternating irrigation with 3% r-rum hydrogen peroxide and 1: 5000 r-rum potassium permanganate and removing from the palate plaque (slueshchivshiesya epithelial cells, food, exudate).

Patients of childhood complain of pain when swallowing in the first 1-2 days; in adults the pain is stronger and lasts longer. Therefore, if necessary, prescribe analgesics.

Sutures are removed on the 10-12th day after the operation. By this time, they partially cut through and disappear.

The closest anatomical outcomes of surgical treatment

The anatomical outcome of the operation on the palate is determined by the completeness of the preoperative preparation, the choice of the required surgical option, the surgical technique of the surgeon, postoperative treatment and care of the patient, and the behavior of the patient himself.

When evaluating the results of an operation, the authors usually do not take into account deliberately left defects in the anterior part of the palate. But even without taking them into account, the number of cases of divergence of sutures after surgery and the appearance of postoperative defects varies from 4 to 50%. According to available data, among the complications of primary uranoplasty, most often there is a rupture of the entire palatine tongue or its perforation, perforation of the roof of the palate, rejection of the pharyngeal flap,

In our opinion, first, in the number of unsuccessful operations, it is necessary to include all those cases in which there is a need to re-close the intentionally left defect in the front non-injury section. Secondly, we consider it absolutely unacceptable to evaluate the immediate anatomical outcome of an operation without taking into account the type (extent) of the cracks.

According to our clinic, favorable anatomical outcomes of operations by the method of J. I. Vernadsky were observed in 93-100% of cases, which is caused by the following factors: individualization of surgical intervention for each patient; quite sufficient retro-transposition and mesopharyngeal constriction, provided by the intersection of the vascular-neural bundles and a broad detachment of bridge-shaped retromolar flaps; one-step-by-step and radical operation on any of its main options; careful attitude to the main mucus-periosteal flaps, which are kept by silk "holders" and do not injure with tweezers. Avoiding the application of very frequent and tight stitches, as this can lead to tissue necrosis along the seam line, where the blood network is already insufficiently developed.

In the postoperative period, favorable factors are facilitated by such factors as correct position of the flaps, resting them with a well-fitted (before surgery) protective palatine plate. It should be evenly, not tight (loose) to lay on the operated palate iodoform-gauze tampons. In cases of a child's disease after surgery, any acute infectious disease (scarlet fever, measles, flu, sore throat) may result in complete divergence of the sutures. This complication indicates an inadequate preoperative examination of the child.

Remote anatomical results of operations

The study of distant anatomical results of operations in patients undergoing surgical treatment according to the methods of Yu.V. Vernadsky and LV Kharkov shows that due to the duplication of the mucous membrane in the posterior third of the hard palate and on its border with the soft palate, the tamponade of the okolo-phylum niches is biological (absorbable) material, the introduction of xenochondrality between the plates of the pterygoid processes, as well as suturing the okoloblocular wounds tightly and the absence of the traditional vertical dissection of the mucosa into the p (according to the method of Gantser) and other features of the applied techniques it is possible to achieve high functional capacity of the soft palate. This is due to the fact that the palate or not at all shortens in the healing process of the wound or is shortened slightly.

Experimental-morphological evidence suggests that the introduction of allo- or xenocity into the interplastic space gives a more stable result of interlaminar osteotomy than the insertion of iodine-shaped gauze between the plates. Gradually dissolving, the interpenated allo- or xenocity is replaced by the newly formed bone tissue, which firmly fixes the inwardly displaced plate in the position prescribed by it (in the operation). Filling oclohlotochnyh niches with a bioresorbable material (skeins catgut) provides less rough scarring of the wound than under the cover of iodoform tampons. This explains the more persistent anatomical result of the operation (long soft palate, narrowed to the norm of the pharynx), which, in turn, determines a higher functional outcome of the treatment, ie, the patient clearly pronounces all sounds. To a large extent, the formation of the palate (first along the stent, and then the plastic ledge, layered on the protective palatine plate) and logopedic training of the patient before and after surgical treatment also contribute to this.

Remote functional (speech) results of uranoplasty and uranostaphyloplasty

Unfortunately, there are no generally accepted criteria for assessing pronunciation after uranostafiloplasty. In order to objectify the evaluation of the functional effect of plaque plastics, the method of spectral analysis of speech is used.

The clarity of speech is determined not only by the anatomical effectiveness of the operation, but also by many other factors (the presence or absence of a rumor in the patient, tooth-jaw deformities or shortening of the tongue bridle, speech therapy training and exercise therapy, etc.); Therefore, it is possible to judge the effectiveness of the actual operations with respect to the quality of speech only when all other factors affecting the function of speech are compared.

According to the data of various authors, in most patients after uranostafiloplasty according to the methods of Yu. I. Vernadsky speech was significantly improved (on average, 70-80%). Only in a small group of patients, as a result of a significant initial shortening of the soft palate after surgery, the pronunciation improved slightly.

As the results of spirometry showed after 6 months of exercising exercise, most of the children operated on for the inconsistent palate incisions do not lose air through the nose when exhaled or significantly reduced, and there is no air leakage at all for the isolated soft palate defects.

To assess the functional state of the palate of the palate during surgery and to predict the outcome of surgical treatment, a method is used to account for the magnitude of the heat flux in the palate tissues. This method, unlike the conventional rheographic methods, is easy to implement, does not require significant time and expensive equipment, it is applicable at all stages of the operation and in the postoperative period, due to which it can be used in patients of different ages.

To increase the effectiveness of operations in the sense of speech restoration, it is necessary to eliminate the accompanying defects of the maxillofacial region-the shortening of the frenulum of the tongue, the absence of teeth, especially the anterior ones, cicatricial deformity and shortening of the lips, cicatricial synechiae in the nose,

To reduce the number of postoperative purulent-inflammatory complications, it is recommended to perform im-munocorrective therapy before the operation and prescribe antibiotics, sulfanilamide preparations, furazolidone after the operation. Normalization of the composition of the microflora of the mouth, throat and nasal part of the pharynx is also facilitated by immunization with staphylococcal anatoxin.