Congenital palate adhesions: causes, symptoms, diagnosis, treatment

Non-union of the palate is divided into through, non-through and hidden, as well as unilateral and bilateral.

Through-and-through defects include non-unions of the entire palate and alveolar process, while non-through defects include non-unions of the palate that are not combined with non-union of the alveolar process, which are subdivided into complete (defect of the uvula, the entire hard palate) and incomplete or partial (defect within the soft palate).

Hidden nonunions are a defect in the fusion of the right and left halves of the bony or muscular layers of the palate (with the integrity of the mucous membrane); they are also called submucous nonunions.

This classification is rather schematic and is not based on a detailed analysis and consideration of the topographic and anatomical features of numerous variants of palate defects. G. I. Semenchenko, V. I. Vakulenko and G. G. Kryklyas (1967) proposed a more detailed classification, which provides for the division of clefts of the upper lip and face into median, lateral, oblique and transverse. Each of these groups is divided into subgroups, of which there are over 30 in total. This classification is convenient for encoding during statistical processing of material on congenital defects of the maxillofacial region as a whole. As for defects of the palate, they are divided into the following groups: isolated (not combined with cleft lip), which, in turn, are divided into complete, incomplete, hidden and combined (combined with cleft lip). All these defects are divided into through (one- or two-sided) and non-through (one- or two-sided).

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

The classifications provided do not, unfortunately, answer a number of very relevant and interesting questions for surgeons that arise when planning an upcoming operation or during its implementation:

1. Is it possible to eliminate the defect of the alveolar process by cutting out (at the edges of the defect) two mucoperiosteal flaps on a pedicle and forming a duplicate from them?
2. Is it possible to eliminate the narrow gap between the edges of the gum defect by simply refreshing them only within the epithelium?
3. Are there conditions for the formation of flaps (inverted by the epithelial surface into the nasal cavity) in order to close the anterior portion of the defect of the hard palate?
4. Is it possible to cut out flaps from the mucous membrane for epithelialization of the upper surface of the hard palate at the site where the mucoperiosteal flaps were formed and moved back?
5. What is the relationship between the edges of the hard palate defect and the vomer, and does it allow the mucous membrane of the vomer to be used as an additional reserve of plastic material? Etc., etc.

In this regard, we have 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 surgical treatment of palate defects. It is subordinated to the interests of precise planning and implementation of surgical intervention in each individual patient.

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Symptoms of Cleft Palate

Symptoms of cleft palate vary considerably depending on whether the defect of the palate is isolated or combined with cleft lip.

General, systemic and local diseases associated with non-unions of the palate are partially described above.

It should be noted that almost half of children and adolescents, even with isolated defects of the palate, had ECG abnormalities in the form of sinus tachycardia, sinus arrhythmia, myocardial dystrophy, signs of right bundle branch block, extrasystole, etc. In addition, some patients had elevated rheumatic tests and C-reactive protein levels against the background of ECG changes, and blood showed erythropenia, hemoglobinopenia, decreased color index, leukopenia, eosinophilia or eosinopenia, lymphocytophilia or lymphocytopenia, monocytophilia or monocytopenia.

The poor general status of “practically healthy” children referred by pediatricians to our clinic for uranostaphyloplasty was expressed in the form of positive reactions to C-reactive protein, hyper-a1, and a2-globulinemia against the background of hypoalbuminemia, “hyporeactive” type of fractional ESR curve, low values of monocyte shift and phagocytic number and index, E, which necessitated the need to postpone the operation and carry out additional therapeutic measures.

A decrease in the amount of cationic protein in peripheral blood leukocytes and smears from the mucous membrane of the hard palate to 0.93+0.03 versus 1.57+0.05 in healthy children indicates a disruption of the immune system of children with congenital defects of the maxillofacial region.

Almost every congenital defect of the palate is characterized by topographic and anatomical abnormalities of its bone base and soft tissues of the oral part of the pharynx, nasal septum, and sometimes the entire upper jaw, upper lip and nose. The severity of these anatomical abnormalities depends on the degree of the anterior-posterior extension, depth and width of the nonunion.

The most pronounced changes are observed in patients with bilateral non-union of the upper lip, alveolar process and palate. Functional disorders and cosmetic defects in such patients are due to the severity of anatomical disorders. Thus, with isolated non-union of only the soft palate, the child is outwardly no different from his peers. Only later (at school age) can some underdevelopment of the upper jaw and retraction of the upper lip be detected. However, even with only hidden (submucous) non-union of the soft palate, the child usually speaks slurredly and has a nasal voice.

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

According to our clinic, all children with defects of the palate require speech therapy either for severely slurred speech with a nasal tone, or for clear but nasal speech.

In such cases, children's nutrition is usually only slightly impaired, since many of them, using the tongue as an "obturator", adapt to their defect and are able to suckle their mother's breast.

In the presence of non-fusion of the hard and soft palate, the newborn is also outwardly no different from normally developed children. However, in the first hours of its existence, severe functional disorders appear: the child, as a rule, cannot suckle, and the air stream entering the nasal cavity immediately seems to fall into the oral cavity. These disorders are due to the impossibility of creating a vacuum in the child's oral cavity.

If the non-union of the palate is combined with one- or two-sided non-union of the gum and lip, the described signs are even more pronounced. In addition, with non-union of the lip, all this is accompanied by a sharp disfigurement of the child.

During teleradiographic examination of children with isolated non-unions of the palate and combined with uni- or bilateral non-unions of the gums and lips, general changes in the facial bones were found in the form of retroclination of the jaws, posterior displacement of the upper jaw in combination with a decrease in the length of the upper jaw in the sagittal direction, and underdevelopment of the anterior part of the upper jaw.

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

Most patients have a direct bite or reverse incisor overlap, up to a sharp forward displacement of the chin, like progenia, due to an increase in the body of the lower jaw, between the permanent teeth of which diastemas and tremas are visible.

Due to the delay in the development of the upper jaw with non-fusion of the palate, alveolar process and lip, flattening of the middle third of the face, upper lip, and sunken cheeks are often observed.

The most pronounced skeletal deformations occur with bilateral non-unions of the palate, combined with non-unions of the alveolar process and lip, namely: an increase in the length of the body of the upper jaw compared to the length of the body of the lower jaw due to the forward displacement of the premaxillary bone; an increase and sharp forward protrusion of the anterior nasal spine: forward deviation of the teeth on the premaxillary bone; anterior displacement of the base of the nasal septum; posterior displacement of the lower-lateral sections of the piriform aperture in relation to the anterior nasal spine: a clearly expressed narrowing of the upper jaw.

From the first days of life, a child with a defective palate develops catarrhal changes in the nose, nasal part of the pharynx and lower respiratory tract, which is associated with the entry of food particles into them and respiratory failure. Sometimes, clearly expressed pharyngitis, eustachitis, bronchitis or bronchopneumonia develop.

Due to the disruption of nutrition and breathing, the occurrence of chronic inflammatory processes in the newborn, general dystrophy gradually develops, and then rickets, dyspepsia, and diathesis.

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

The degree of damage to the nasal mucosa in such children increases significantly with age. Observations have shown that all children aged one to three years have acute and chronic catarrhal rhinitis, and by the age of six, 15% of children already develop chronic hypertrophic rhinitis.

Starting from the age of 3, children with congenital non-fusion of the palate and lip can show gross changes in the upper respiratory tract in the form of nasal deformation, quite often - curvature of the nasal septum, chronic hypertrophic rhinitis, leading to a sharp hypertrophy of the inferior nasal turbinates and the mucous membrane covering them. These changes in almost half of patients are the cause of difficult nasal breathing and do not decrease even after plastic surgery of the palate. According to available data, hypertrophy of the nasal turbinates begins at the age of 4-5 years and reaches a significant degree by the age of 6 years.

Congenital disorders of chewing, swallowing, and salivation lead to a sharp increase in the excretion of pathogenic staphylococci and enterococci from the oral cavity, nose, and pharynx, as well as to the appearance of microbial species unusual for these areas: Escherichia coli, Proteus bacteria, Pseudomonas aeruginosa, etc. Obviously, this can explain the fact that patients with non-union of the palate often have inflammation of the palatine tonsils and enlargement of the nasopharyngeal tonsils, pharyngitis, impaired ventilation and patency of the Eustachian tubes, inflammation of the middle ear, and decreased hearing as a result of Eustachitis and otitis.

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

Severe disturbances are observed 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 stream decrease, which is especially pronounced in through non-unions.

Insufficiency of the respiratory system function causes a disturbance of facial expressions during conversation, the appearance of habitual disfiguring grimaces. Children with speech disorders enter school late and often do not finish it, as a result of which they are not sufficiently intellectually developed.

Disorders of chewing, swallowing, breathing and speech functions have a detrimental effect on overall physical development (retardation in height and body weight compared to peers) and condition (low hemoglobin levels, dyspepsia, etc.).

Treatment of cleft palate

Treatment of non-unions of the palate should begin immediately after the birth of the child. It consists primarily of creating favorable conditions for feeding the child and his breathing, i.e. it is necessary to exclude the entry of food from the mouth into the nose, and the air inhaled through the nose immediately (without preliminary "warming" in the nose) into the mouth. This is carried out with the help of the above-mentioned preformed palatal plate or obturator, which helps to separate the oral cavity and nasal cavity and the nasal part of the pharynx. The obturator should be floating; it is desirable to use it after cheiloplasty in a maternity hospital. The base part of the obturator is made of rigid plastic, and the rest is made of elastic, which makes it possible to correct the obturator, if necessary, using styracryl or other quick-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 who used obturators sometimes exceeds the average weight of healthy children of the same age.

In cases of significant difficulties or complete impossibility of breastfeeding in newborns, the obturator should be made in the first hours of their life in a maternity hospital. If the palate defect is combined with non-fusion of the lip and the child has undergone cheiloplasty, the following terms for making the obturator are recommended:

1. In case of bilateral non-fusion of the alveolar process and palate, if cheiloplasty is performed in the first two days, the floating obturator is made on the 3rd-4th day after the removal of the sutures on the lip.
2. If early cheiloplasty is performed on a child with unilateral non-fusion of the alveolar process and palate, obturation is postponed until 3-4 months, since before this age the bottom of the inferior nasal passage, which is the fixing point for the floating obturator in case of “through” non-fusion of the palate, is poorly defined.

In bilateral non-unions of the 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 section, which has a V-shape and faces backward with its apex. In addition, the distal part of the obturator is fixed by the non-union halves of the soft palate, which are adjacent to its lateral surfaces and prevent downward movement. To a certain extent, the adhesive factor also ensures fixation of the obturator.

1. If a child with non-fusion of the lip, alveolar process and palate undergoes cheiloplasty at the age of 6-8 months, the obturator is made two weeks later, when the edges of the non-fused alveolar process come together.
2. If for one reason or another cheiloplasty is not performed within the first 24 hours, the obturator is made within the first few days of the child’s life.

During the first day after production, the obturator should be used by stitching it with a thick silk thread; on the second day, the thread can be left only overnight, and on the third day, it can be removed completely. For children over 3 years old, it is recommended to use the obturator without a thread.

According to A. V. Kritsky (1970), the compensatory functional activity of the pharyngeal muscles can be used to fix the obturator. For this purpose, the author designed a functional pharyngeal obturator, when using which the nasal part of the pharynx is closed during speech and swallowing due to obtaining precise and tight contact between the walls of the pharynx and the fixed obturating part. The author makes the pharyngeal part of the obturator using a functional impression obtained using a special thermoplastic mass.

Timing of surgical treatment of non-unions of the palate

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

In the post-war years, due to the improvement of surgical techniques and methods of anesthesia, the mortality rate has sharply decreased. But along with this, every year there are more and more reports that operations at an early age entail the development of persistent anatomical deformations. Most foreign authors consider the optimal period for surgery to be 4-6 years.

According to available data, the deformation of the upper jaw after early treatment of through-and-through non-unions is not so much associated with uranoplasty, but is the result of incorrect cheiloplasty.

Modern surgeons also differ in their views on the timing of operations on the palate. Thus, A. A. Limberg (1951) believes that in case of non-unions of the soft palate and partial non-unions of the hard palate, surgery is permissible at the age of 5-6 years, and in case of through-and-through ones - at 9-10 years.

Experimental data have shown that not only intervention on the hard palate, but also prolonged tamponade of the peripharyngeal space delays the development of the facial part of the skull.

Studying the long-term results of uranoplasty, M. M. Vankevich came to the conclusion that the degree of deformation is usually proportional to the magnitude of non-union. However, as M. D. Dubov (1960) rightly points out, the magnitude of non-union is not only a quantitative concept. After all, the form of non-union is determined not only by its length, but also by the degree of development of the palatine plates, vomer and muscles of the soft palate. The process of formation of the alveolar process and hard palate precedes the formation of the soft palate and ends approximately 2-4 weeks earlier. Thus, according to M. D. Dubov, the occurrence of through non-unions is obviously associated with an earlier and more intense (than in the case of non-through) effect of harmful factors on the developing fetus. Consequently, the degree of disturbance of the growth of the upper jaw bone also varies.

A. N. Gubskaya (1975), based on numerous clinical and anatomical studies, recommends eliminating isolated non-union of the palate at 4-5 years of age, and combined with non-union of the alveolar process and lip - at an older age. At the same time, 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 ones are the result of impaired fetal development, then the secondary ones are a consequence of the function of the muscles of the tongue and facial muscles, which, when contracted, are capable of distorting the non-unified edges of the defect of the jaw and lip. The accompanying postoperative deformations of the jaw are associated with the use of early cheiloplasty using an irrational technique, leaving coarse scars on the lip.

G. I. Semenchenko and co-authors (1968-1995) also consider the age of 4-5 years to be the most optimal for performing the operation, and with good physical development and the absence of dental and jaw deformities even 3-3.5 years. E. N. Samar (1971) allows for the possibility of eliminating non-union of the soft palate at 1-2.5 years, and all other types of non-union - in the period from 2.5 to 4 years; however, he, like other authors, rightly considers early operations acceptable only under the condition of the possibility of comprehensive dispensary observation, prevention and treatment of possible postoperative deformities.

In connection with the accumulation of a huge amount of factual clinical and experimental material and the introduction into practice of complex dispensary treatment of patients with defects of the lip and palate, there are increasingly more reports about the possibility of comparatively early operations (Kh. A. Badalyan, 1984, etc.) in order to prevent the development of secondary deformations of the entire facial skeleton (under the influence of the muscles of the tongue) and deterioration of the general condition of the child, to accelerate the social rehabilitation of the child, etc.

The child's age is not the only criterion for determining the indications for surgery. It is also necessary to take into account the degree of his physical and mental (intellectual) development, the severity of past illnesses, the nature and size of the defect. Social and living conditions, the relationship between the parents after the birth of a child with a defect, the availability of orthopedic care for the child before surgery (making a floating obturator) and conducting a full course of speech therapy training are also important.

Based on literature data and many years of personal experience, when determining the timing of surgery for non-unions of the palate, we believe it is necessary to adhere to the following tactics: in case of isolated non-unions of the soft palate, surgery is possible at the age of 1-2 years, but after the surgery, the child must undergo a course of speech therapy training and be under the supervision of an orthodontist. When the first signs of developing deformation appear, the orthodontist is obliged to carry out appropriate preventive measures.

In the presence of non-fusion of the entire hard and soft palate, the operation should be performed at the age of 2-3 years, followed by speech therapy training under the supervision of an orthopedic dentist, who monitors the dynamics of the development of the palate and makes adjustments to the obturator, which is put on during breaks between speech therapy lessons.

In case of defects of the entire palate, alveolar process and lip, it is better to postpone the operation until 7-8 years.

However, whatever the defect, the child should be provided with an obturator as early as possible; it should be changed periodically due to jaw growth and teething.

It is advisable to start a course of speech therapy training from early childhood, long before the operation. The start date of this training is determined by the degree of mental development of the child, which largely depends on parents, educators, family members: they should encourage the sick child to word formation, evoke, strengthen possible and accessible sound combinations, teach him onomatopoeia, show and find a toy, any object, accustom to designating the actions of objects, i.e. teach understanding of speech. If from the first days of the child's life they talk to him little, then the development of the speech function is delayed.

Preparing the patient for surgery

Preparation of the patient for surgery should begin in advance and include sanitation of the oral cavity, nasal part of the pharynx, general strengthening treatment, including helminthological treatment.

It is necessary to carefully examine all the patient's organs and systems to determine whether there are any contraindications to surgery; examine a smear from the throat and nose for diphtheria bacilli and hemolytic streptococcus; determine the sensitivity of the throat microflora to antibiotics.

A comprehensive laboratory and biochemical study of blood parameters (leukocytes, agranulo- and granulocytes) and lipid peroxidation before surgery for a palate defect allows determining the degree of risk of postoperative complications, and thereby the need for individual antioxidant correction of the patient's immune status. For integral modulation of the immunological status of patients with congenital nonunions of the palate, preoperative premedication with phenazepam in a therapeutic dosage is recommended.

If an operation with transection of the vascular-nerve bundles of the palate according to Yu. I. Vernadsky is planned, it is necessary to make, fit and test (within 3-4 days) a protective-training palatal plate and eliminate the shortcomings identified in it, conduct a course of preoperative speech therapy training, which should begin on the second day after the child is admitted to the clinic and be carried out along with all other preoperative measures (this makes it possible to significantly facilitate the work of the speech therapist in the postoperative period).

If possible, this pre-operative training in the clinic should be a continuation of the training that began long ago at home or in kindergarten.

Methods of surgical treatment of non-union of the palate

Based on the simplest (non-detailed) classification of palate defects, M.D. Dubov (1960) recommends two surgical options;

1. radical uranoplasty according to A. A. Limberg (for through-and-through defects);
2. the same operation, but supplemented by a flap according to M.D. Dubov (for non-through defects). The operation (uranostaphyloplasty) 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" - palate and "staphyle" - "soft palate tongue".

Radical uraiostaphyloplasty method according to A. A. Limberg

The operation using this technique includes the following stages (Fig. 139):

1. Refreshing the edges of the defect by excising a strip of mucous membrane and dissecting the periosteum.
2. Formation of mucoperiosteal flaps on the hard palate according to Langenbeck-II. P. Lvov.
3. Removal of vascular-nerve bundles from the large palatine openings (according to P.P. Lvov or A.A. Limberg).
4. Lateral incisions along the pterygomaxillary folds of the mucous membrane to the lingual surface of the alveolar process at the last large molar of the lower jaw (according to Halle-Ernst) and mesopharyngoconstriction.
5. Interlaminar osteotomy (according to A. A. Limberg).
6. Refreshing the edges of a defect in the soft palate by separating them or excising a strip of mucous membrane.
7. Suturing the halves of the soft palate with a three-row suture (the mucous membrane from the nasal side, the muscles of the soft palate, the mucous membrane from the oral cavity side).
8. Suturing of flaps within the hard palate with a double-row suture.
9. Tamponade of the parapharyngeal niches and covering the entire palate with an iodoform tampon.
10. Applying a protective palatal plate and attaching it to the headband.

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

E. S. Tikhonov (1983) proposed a special chisel for this purpose, the use of which eliminates the possibility of injury to the vascular-nerve bundle brought out of the large palatine foramen.

The described method of operation, even when performed with the most modern instruments, can be called radical only conditionally, since it does not always provide a radical (one-stage) elimination of non-union. Firstly, in case of non-union of the entire palate and alveolar process, this method provides for the closure of the defect in its anterior section only during the second stage of the operation. In this regard, M. D. Dubov, V. I. Zausaev, B. D. Kabakov and other authors, supplementing the "radical" operation of A. A. Limberg, proposed special techniques for eliminating the defect in the anterior section, thereby achieving a one-stage operation.

Secondly, in the case of medium and very large defects in the middle and posterior parts of the palate, the vascular-nerve bundles removed (according to P. P. Lvov or A. A. Limberg) from the openings do not allow the palatal flaps to be brought together without tension. This is the reason for the frequently observed divergence of the sutures at the border of the hard and soft palate. The proposal of some authors to pull the vascular-nerve bundles out of the bone opening also turned out to be ineffective.

To reduce the restrictive effect of the removed vascular-nerve bundles on the mucoperiosteal flaps, it is sometimes recommended to resect not only the edge of the large palatine foramen, but also the posterior wall of the pterygopalatine canal. However, such rough and traumatic destruction of the bone base of the hard palate usually does not justify itself, so they should be avoided.

Thirdly, even if the entire defect of the palate is eliminated in one stage, a decrease in the length of the soft palate is almost always observed in the postoperative period, which leads to its inferiority as a valve, and hence to speech impairment.

The main reasons for postoperative shortening of the restored (according to A. A. Limberg) soft palate and the associated decrease in the functional result of the operation are:

1. return of the medial plate of the pterygoid process, which was separated (during surgery), to its original position, which has been 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 constrictions in the peripharyngeal niches, which is significantly facilitated by tamponade with iodoform gauze, as well as the inevitable delamination of the end of the medial pterygoid muscle by which it is attached to the pterygoid process.

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

Fourthly, the operation according to A. A. Limberg often leaves behind coarse and powerful scars on the mucous membrane of the soft palate facing the nasal part of the pharynx, as well as the peripharyngeal niches, which sometimes leads to the formation of contracture of the lower jaw and requires another stage of surgical intervention (for example, plastic surgery of the mucous membrane with counter triangular flaps).

Uranostaphyloplasty can be considered radical only if it is performed in one stage and necessarily gives stable anatomical and functional results (i.e. normalization of speech, food intake and breathing). Any repeated operation on the palate indicates its non-radical nature or, as a rule, an unsuccessful primary intervention. Defects in the anterior part of the hard palate should not be deliberately left, hoping to close them during a repeated operation, since this is always difficult to do due to cicatricial changes in the tissues. It is also impossible to condemn the patient to lifelong use of obturating prostheses. The use of Filatov's stem in preschool age for primary plastic surgery of the palate is unjustified.

Methods of radical (one-stage) uranostaphyloplasty 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 the plastic material; complete and unimpeded convergence of the unfused halves of the soft palate and its displacement back to the back wall of the pharynx. Therefore, when performing uranostaphyloplasty, it is necessary to take into account all the anatomical and surgical features of the palate defect in each specific patient.

The specifics of each variant of the operation are described below. We will list the general manipulations that are mandatory for all variants of the operation.

1. Intentional transection of the vascular-nerve bundles emanating from the greater and lesser palatine foramina if they need to be taken out of the bony ring - the greater palatine foramen. The need for this arises in almost all children after 10-12 years, adolescents and adult patients who were not operated on 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 case it is necessary to significantly shift the mucoperiosteal flaps of the hard palate or halves of the soft palate inward and, to varying degrees, backward in order to lengthen the soft palate or narrow the pharynx, or raise the vault of the soft palate. The possibility of intentional transection of these vascular-nerve bundles is justified by the presence of vascular anastomoses between the branches of the ascending and descending palatine arteries.
2. One-stage elimination of the entire defect even with a “through” defect of the palate; the anterior section of the defect of the hard palate is closed by means of two so-called “anterior-palatine” flaps, turned into the nose, or by one flap according to the methods of M. D. Dubov, V. I. Zausaev or B. D. Kabakov.
3. Formation of a duplication of the mucous membrane at the border of the soft and hard palate and in the distal part of the defect of the hard palate due to one or two flaps of the mucous membrane of the bottom of the nasal cavity. Thanks to the presence of these flaps, which we call "posterior-palatine", it is possible to prevent rough scarring of the nasal surface of the mucoperiosteal flaps and the soft palate, displaced backwards and sutured together.
4. Completion of interlaminar osteotomy according to A. A. Limberg (if it is performed) by inserting a wedge (made of spongy allo- or xenocolloid bone) between the split plates of the pterygoid process, which gives them a stable position and stimulates the formation of bone regenerate between them, strengthening the plates in the spread position. In addition, this prevents the return of the inner plate to its original position and thereby reducing to zero the narrowing of the pharynx and lengthening of the soft palate achieved by the surgeon.

Some authors, instead of cold palate, use (for the same purpose) an autograft from the posterior parts of the edge of the hard palate, obtained by resecting the bone in the area of the edge of the large palatine foramen, which increases the trauma and duration of the operation.

5. Carrying out mesopharyngoconstriction without vertical Ernst incisions. The approach to the parapharyngeal space is carried out "hidden" - through two horizontal incisions of the mucous membrane (one behind the extreme upper, the other - behind the extreme lower tooth).

If the patient's oral part of the pharynx is sharply widened or if significant displacement of the underdeveloped halves of the unfused soft palate inward is required, the horizontal incision behind the extreme upper tooth is continued to the upper transitional fold and a triangular flap is cut out here according to V. I. Titarev; the incision behind the extreme lower tooth is continued to the lower transitional fold and a triangular flap is cut out according to G. P. Mikhailik-Bernadskaya. Between these incisions, the mucous membrane is separated and a bridge flap is formed from it, using a T-shaped curved scalpel blade for this. Having lifted the bridge flap of the mucous membrane, having pushed it down somewhat, the peripharyngeal tissues are stratified with Cooper scissors or a special raspatory and the peripharyngeal niches are filled with skeins of catgut (treated by boiling) or thin strips of preserved bull testicle membrane. After this, the flap is placed back and the wound is sutured along the line of the two indicated horizontal incisions.

Thanks to the formation of the two mentioned triangular flaps, moving inward (together with the corresponding moved half of the soft palate), the unhindered convergence and suturing of the underdeveloped halves of the soft palate is largely ensured (without tension in the sutures).

6. Tamponade of the peripharyngeal wound niches with catgut and blind suturing of the wound in the retromolar areas relieves patients from painful dressings, the threat of iodoform intoxication and allergic reactions to it, prevents the formation of scars on the mucous membrane and the development of contracture of the lower jaw. In addition, the data of clinical and experimental-morphological studies conducted by our staff allow us to conclude that tamponade of the interplate fissures (formed as a result of splitting of the pterygoid process plates) and parapharyngeal niches with a slowly absorbable material and their suturing "tightly" (as much as possible) isolate 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 oral cavity, food masses, saliva, with gauze tampons (impregnated, moreover, with a protoplasmic poison - iodoform), which are capable of causing coarse scarring in the lateral parts of the pharynx and thereby reducing to zero the results of mesopharyngoconstriction and retrotransposition of the soft palate achieved by the surgeon. Some authors use brephoplast for tamponade of parapharyngeal niches.
7. Surgical treatment according to any of the options listed below, being a one-stage procedure, does not provide for any preliminary (preparatory) or additional (corrective), pre-planned interventions on the palate; the need for them after the operation arises either as a result of the surgeon’s inept actions or the divergence of the sutures due to the fact that the surgeon did not take into account the “hidden” general somatic contraindications to the operation, which are revealed only during an in-depth examination of the patient, whom the local pediatrician or therapist considered practically healthy and without any doubt referred for such a difficult operation as uranostaphyloplasty.
8. To prevent the development of a significant tissue reaction around the suture canal, all superficial sutures on the mucous membrane in the area of the hard palate and in the retromolar areas are applied from a thin (0.15 mm), soft and most elastic plastic thread (polypropylene, silene, nylon), and in the area of the soft palate - from thin catgut.
9. If there is a significant increase (compared to the norm) in the transverse dimensions of the middle section of the pharynx and the width of the defect, an interlaminar osteotomy is performed, and one or two skeins of catgut or the protein membrane of a bull testicle are introduced into the peripharyngeal niches.

If the general condition of the child and local conditions (correct ratio of jaw fragments, favorable nonunion index) allow early uranostaphyloplasty, then in these cases it is desirable to simultaneously perform cheiloplasty, which reduces the number of surgical interventions by half and provides a significant economic effect, early medical and social rehabilitation of the patient; at the same time, especially vigilant attention of the orthodontist and timely correction of the relationship between the jaws are required.

In cases where we operate on a child for a defect of the palate at an older age, with, as a rule, a significant expansion of the oral part of the pharynx, we always form a triangular flap of the mucous membrane on the cheek (near the extreme teeth at the upper vault of the vestibule of the mouth) according to V. I. Titarev and move it to the wound in the area of the posterolateral part of the hard palate. In the lower vault of the vestibule of the mouth behind the extreme lower tooth, we cut out a flap according to G. P. Mikhailik-Bernadskaya and move it inward, closing the lower-inner part of the wound.

At the end of the operation, we close the suture line with iodoform-gauze tampons (strips) or foam plastic only within the hard palate; the protective plate does not have a tail part, due to which the sutures on the soft palate remain uncovered and the possibility of irritation of the root of the tongue by the plate is excluded.

In cases where the operation is performed on young children or when the protective palatal plate is poorly fixed, the mucoperiosteal flaps are fixed to the hard palate with KL-3 polymer adhesive. The advantages of this method are as follows:

1. the child avoids the unpleasant sensations associated with taking an impression of the upper jaw;
2. the preoperative period is reduced by 2-3 days due to the time required to make a protective palatal plate and wear it during the preoperative period in order to adapt to it;
3. there is no need to use iodoform tampons, which sometimes cause allergic reactions in children;
4. care of the postoperative wound is significantly simplified;
5. the wound formed (after retrotransposition of the palate) in the anterior section, healing by secondary intention under the polymer film, is covered with delicate, flexible scar tissue; this prevents the development of coarse scars that deform the upper jaw;
6. This saves the doctor and dental technician time, as well as the materials needed to make the protective palatal plate.

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

1. Is there unilateral or bilateral alveolar ridge non-union?
2. What is the distance between the edges of the defect in the gingival (alveolar process) area and the anterior third of the hard palate?
3. Are the right and left clefts located symmetrically in a bilateral alveolar ridge defect?
4. What is the relationship of the edges of the hard palate defect to the vomer?
5. Is it possible to cut out flaps from the mucous membrane of the nasal cavity floor?
6. What is the degree of underdevelopment of the soft palate and widening of the oral part of the pharynx (mesopharynx)?
7. How large is the anterior-posterior extent of the defect?
8. Is there a hidden cleft of the hard, soft palate or uvula?
9. What is the relationship between the latent and manifest parts of nonunion?

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

• I - unilateral obvious non-union of the alveolar process, gum tissue and the entire palate;
• II - bilateral obvious non-fusion of the alveolar process and the entire palate;
• III - obvious non-union of the entire soft palate, combined with obvious or hidden non-union of all or part of the hard palate;
• IV - obvious or hidden non-unions of the soft palate only;
• V - all other non-unions, i.e. the most rare (including hidden - submucosal), which are combined or not combined with non-union of the lips, cheeks, forehead or chin.

The first four classes are divided into subclasses. Each subclass of nonunion corresponds to a specific variant of the operation, 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 parts of the defect is actually much greater.

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

/ class. Unilateral non-union of the alveolar process, gum tissue, and the entire hard and soft palate.

Subclass 1/1. In the anterior section, the edges of the defect are sufficiently distant from each other, which allows for the cutting out of two mucoperiosteal flaps, called anterior palatal, within the gum and the anterior third of the hard palate and their epithelial surface to be turned 180° into the nasal cavity. The vomer is not fused with the edges of the defect along its entire length, which allows for the cutting out of two symmetrical, identical in length, so-called posterior palatal flaps from the mucous membrane of the nasal cavity floor and then sutured together. If the small width of the defect does not allow for the turning out of two anterior palatal flaps into the nose, one flap should be cut out using the method of V. I. Zausaev or B. D. Kabakov.

A new, so-called "method of gentle cheilouranostaphyloplasty" is proposed for defects related to subclass 1/1. Its main stages are as follows: cutting out, separating and turning down the main and additional mucoperiosteal flaps, removing the vascular-nerve bundles coming from the large palatine openings, removing the tendon m.tensor veli palatini from the hamulus, freeing 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 sphenoid bone.

The flaps are separated from the nasal mucosa at the border of the hard and soft palate. The mucosal incisions in the retromolar spaces are extended beyond the alveolar process, the submucosal layer is dissected in this area and the hook of the pterygoid process is exposed, from which the flap is separated in the layer of the interfascial space without changing the attachment site of the pharyngeal-palatine muscle. The mobility of the flaps is ensured by separating the tissues from the inner surface of the inner plate of the pterygoid process of the sphenoid bone to the lower pole, where the pharyngeal-palatine muscle is attached. The edges of the nonunion are refreshed and sutures are applied layer by layer with catgut and polyamide thread, after which KL-3 polymer glue is applied to the sutured flaps and horizontal plates of the palatine bone. Wounds in the pterygomaxillary spaces are sutured with catgut taking into account the retrotransposition of the palate. The defect in the anterior part of the palate is closed using either mutually tilting flaps by 180°, or flaps of M. D. Dubov, B. D. Kabakov, or a flap on a pedicle from the side of the mucous membrane of the upper lip.

Subclass 1/2 differs from the first in that the vomer is fused along its entire length with one of the edges of the defect, which makes it possible to cut out one fairly long and one very short posterior-palatal flap in the area of the bottom of the nasal cavity. A mid-palatal flap can be cut out on the vomer and sutured to the aforementioned long posterior-palatal flap.

When performing uranostaphyloplasty in children with unilateral through nonunions of the palate, L. V. Kharkov noted that some elements of this operation require improvement. Firstly, when performing uranostaphyloplasty (for defects of subclass 1/2), two main mucoperiosteal flaps are cut out, which are always of different sizes and are located on fragments of the jaws of different areas and shapes: the small fragment is always underdeveloped, shorter in length, while the large fragment is “turned out” in the opposite direction from the nonunion and is located significantly distal to the midline. Secondly, the main palatine mucoperiosteal flaps, being displaced after retrotransposition and fixed to the bone, expose the lateral sections of the hard palate, in which the wound always heals by secondary intention.

An analysis of literature data and experimental, clinical studies conducted by L. V. Kharkov showed that in cases of removal of vascular-nerve bundles from the large palatine openings according to P. P. Lvov, scarring of the lateral sections of the palate is one of the main reasons for the development of deformation in the postoperative period. Thirdly, the most frequent place of formation of postoperative defects of the palate is the border of the hard and soft palate, where the flaps experience the greatest tension, and, in addition, the place above the area of non-union, where there is no underlying tissue.

In connection with these circumstances, L. V. Kharkov (1986) developed a technique for the operation, which included the following stages: cutting out and separating the main palatine mucoperiosteal flap only on the larger fragment of the palate, removing the vascular-nerve bundle from the pterygopalatine canal and cutting off the flap from the posterior edge of the hard palate, bluntly separating it from the hook and freeing it from the medial surface of the inner plate of the pterygoid process of the sphenoid bone; refreshing the edges of the non-union, separating the mucoperiosteal flap on a small fragment no more than 0.5 cm wide from the bone edge of the non-union, cutting out two triangles in the area of the border of the hard and soft palate for Z-plasty, freeing the soft palate from the posterior edge of the hard palate on a small fragment from the side of the nasal mucosa, eliminating the defect of the palate by layer-by-layer suturing with catgut and nylon thread, cutting out and separating a tongue-shaped flap on a pedicle on the cheek with a base in the pterygomaxillary space in the area of a larger fragment, moving it to the palate and suturing from the distal side with the main palatal flap moved to the center and back.

According to L. V. Kharkov’s observations, the described technique has the following advantages:

1. by cutting out and separating only one mucoperiosteal flap on the hard palate, the duration of the operation is halved and gross trauma to the underdeveloped small fragment of the palate is eliminated, which has a beneficial effect on its further development;
2. the maximum tension of the flaps at the border of the hard and soft palate is completely eliminated or leveled by dispersing the suture line using two mutually moving triangles, which makes it possible to significantly prevent the occurrence of postoperative or so-called “secondary” defects of the palate in this area;
3. symmetry of the soft palate tissues along the length is achieved by releasing the soft palate tissues in 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 area of the anterior and middle sections of the defect is facilitated by the fact that the suture line is located on the bone base, and not in the middle of the defect of the palate, that is, between the cavities of the mouth and nose;
5. by moving the flap of mucous membrane on a stalk from the neck with the base in the pterygo-maxillary space, where (according to thermovisiography data) the area of the most intensive blood circulation is determined, the zone of wound healing by secondary intention in the area of the base of the alveolar process is significantly reduced, which eliminates the formation of coarse scars.

The listed factors contribute to the correct and early formation of the dome of the palate, accelerated normalization of the function of the hard and soft parts of the palate, prevention of postoperative underdevelopment of the upper jaw and, as a consequence, incorrect relationship of the teeth of the upper and lower jaws.

Since 1983, L. V. Kharkov has been using a new method of uranostaphyloplasty for unilateral through non-unions of the palate, related to subclass 1/2. According to this method, the defect of the hard palate is eliminated by a vomer flap. The operation involves the sequential implementation of the following stages:

1. cutting out and separating the mucoperiosteal flap on the vomer with a base on a larger fragment; in this case, the size of the flap should exceed the size of the defect of the hard palate;
2. dissection of the mucous membrane to the bone in a small fragment parallel to the edge of the defect of the hard palate with a 3-4 mm deviation from it; in this case, a narrow strip is separated downwards - it will cover the suture line from the side of the nasal cavity, and the soft tissues of the opposite side will be sutured with the vomer flap;
3. suturing the vomer flap with the raised edge of soft tissue on the opposite side along the entire edge of the palate defect;
4. at the lower pole of the vomer fragment, a “lining” flap is cut out and turned 180°, which is stitched in the same plane as the vomer;
5. at the border of the hard and soft palate, two angular mucoperiosteal flaps are cut out and separated, which are freed from the posterior edge of the hard palate, the hook and the medial surface of the inner plate of the pterygoid process of the sphenoid bone;
6. refresh the edges of non-union in the area of the soft palate and uvula;
7. Sutures are applied layer by layer in the area of the uvula, soft palate, vomer flap and at the border of the soft and hard palate

Postoperative period

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

Operations for congenital nonunions in the maxillofacial area cause significant disturbances in the functions of the body in infants operated on under local anesthesia; they manifest themselves both during the operation and in the immediate postoperative period. In older children and adults, in whom plastic surgery of the palate is performed 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 hemodynamic shifts associated with the operation, as a rule, are leveled out no later than the third day after it, then compensation for shifts in the respiratory system usually drags on for up to two weeks. A study of the erythropoietic function in connection with surgical blood loss showed that the body of these patients copes with the loss of red blood cells in the same time frame as the body of healthy individuals. However, the restoration of iron reserves in the body, especially in infants with impaired proper feeding, is slow and requires special therapy. Therefore, the author believes that blood transfusions in excess of the lost volume - 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 - serve as an effective means of replenishing iron reserves in the patient's body. Replenishment of blood loss and oxygen therapy in the postoperative period help the body of these patients compensate for respiratory disorders and help prevent acute postoperative respiratory failure.

Observations are convincing:

• compensation for surgical and postoperative blood loss should be carried out not according to the “volume for volume” principle, but until the normalization of central and peripheral hemodynamics;
• the use of droperidol and xanthinol allows to eliminate vomiting and hiccups, eliminate psychoemotional instability of patients and create good conditions in the wound area for its favorable outcome;
• It is highly advisable to use parenteral nutrition in the early postoperative period after uranostaphyloplasty, which includes protein preparations in combination with a glucose solution (providing the body's energy needs), as well as hormones, vitamins and insulin, regulating metabolism and increasing the digestibility of the administered protein hydrolysates. This method of nutrition creates peace for the operated palate, eliminates the pain factor associated with food intake, the wound is not infected with food, it is possible to carry out full-fledged nutrition and thereby contribute to the fastest normalization of metabolic processes, the normal course of the postoperative period. If the protective palatal plate is poorly fixed on the teeth, it should be rebased using quick-hardening plastic. We resort to fixing the protective plate on a head cap only in exceptional cases (when there are no teeth on the upper jaw or very few).

After surgery under endotracheal anesthesia or local potentiated anesthesia, the patient may vomit, which should be reported to the person caring for him.

If nasal breathing is difficult, use an airway or a rubber tube with a diameter of 5-6 mm (M.D. Dubov recommends splitting the end of the tube protruding from the mouth and spreading it out like a slingshot).

For several hours and even the first day after the operation, a mucous-bloody fluid may be released from the mouth and nose, which should be blotted 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: jelly, liquid semolina porridge, sweet tea with lemon, various fruit and vegetable juices (up to 0.5-1 glass in total).

During the first 24 hours after the operation, being in a sedated state under the influence of narcotic drugs, the patient is usually able to take liquid food; however, the next day he usually refuses to drink or eat because of sharp pain when swallowing (caused by swelling of the pharynx, palate, and pharynx that lasts for several days). As clinical studies have shown, due to trauma, forced "defensive" starvation and insufficient feeding with a spoon or through a sippy cup, the protein composition of the blood in the body of the child undergoing surgery changes (decrease in the level of albumins and increase in a1- and a2-globulins), and the nitrogen balance and water-electrolyte metabolism are disrupted. Therefore, during the first 3-4 days, the patient should be fed through a thin tube inserted into the stomach before or during the operation. Nutritional mixtures should be liquid, high-calorie and fortified with vitamins (jelly, porridge, broths, juices, tea with lemon, raw eggs, etc.). A detailed description of diets for tube feeding is presented below.

If after the operation there is profuse bleeding from under the plate, it should be removed, the bleeding vessel should be found, compressed and bandaged. It is not recommended to use a tight tamponade under the protective plate, as it can cause a circulatory disorder in the formed palate. At the same time, 10 ml of 10% calcium chloride solution should be administered intravenously.

During the dressing, the tampons, which are abundantly soaked with blood, are changed. After removing them, the palate is irrigated with a thin stream of hydrogen peroxide solution; the foam, oxidizing the flaps, washes away blood clots and mucus. After removing the foam with gauze balls, the palate is covered with fresh iodoform strips and the protective palatal plate is put back on.

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

At high body temperature (39-40°C) antipyretic drugs are prescribed.

Dressings are changed every 2-3 days, alternating irrigation with a 3% solution of hydrogen peroxide and a 1:5000 solution of potassium permanganate and removing plaque from the palate (detached epithelial cells, food, exudate).

Pediatric patients complain of pain when swallowing for the first 1-2 days; in adults, the pain is more severe and lasts longer. Therefore, analgesics are prescribed if necessary.

The stitches are removed on the 10th-12th day after the operation. By this time, they have partially cut through and fallen off.

Immediate anatomical outcomes of surgical treatment

The anatomical outcome of palate surgery is determined by the completeness of preoperative preparation, the choice of the required surgical option, the surgeon's surgical technique, postoperative treatment and care of the patient, as well as the behavior of the patient himself.

When evaluating the results of the operation, the authors usually do not take into account intentionally left defects in the anterior part of the palate. But even without taking them into account, the number of cases of suture divergence after the operation and the occurrence of postoperative defects varies from 4 to 50%. According to the available data, among the complications of primary uranoplasty, the most common are rupture of the entire uvula or its perforation, perforation of the vault of the palate, rejection of the pharyngeal flap, etc.

In our opinion, firstly, the number of unsuccessful operations should include all those cases in which there is a need for repeated closure of a deliberately left defect in the anterior part of the nonunion. Secondly, we consider it completely unacceptable to evaluate the immediate anatomical outcome of the operation without taking into account the type (extent) of the fissure defect.

According to our clinic, favorable anatomical outcomes of operations using the method of Yu. I. Vernadsky were observed in 93-100% of cases, which is due to the following factors: individualization of surgical intervention for each patient; quite sufficient retro-transposition and mesopharyngoconstriction, provided by the intersection of the vascular-nerve bundles and wide detachment of the bridging retromolar flaps; the one-stage and radical nature of the operation for any of its main variants; careful attitude to the main mucoperiosteal flaps, which are held with silk "holders" and are not injured with tweezers. It is necessary to avoid the imposition of very frequent and tight sutures, as this can lead to tissue necrosis along the suture line, where the blood supply is already insufficiently developed.

In the postoperative period, a favorable outcome is facilitated by such factors as the correct position of the flaps, ensuring their rest with a well-fitted (before the operation) protective palatal plate. Iodoform-gauze tampons should be placed evenly, not tightly (loosely) on the operated palate. In cases where the child falls ill with an acute infectious disease after the operation (scarlet fever, measles, flu, tonsillitis), a complete divergence of the sutures may occur. This complication indicates an insufficient preoperative examination of the child.

Remote anatomical results of operations

A study of remote anatomical results of operations in patients who underwent surgical treatment using the methods of Yu. I. Vernadsky and L. V. Kharkov shows that due to the creation of a duplication of the mucous membrane in the posterior third of the hard palate and on its border with the soft palate, tamponade of the peripharyngeal niches with biological (absorbable) material, introduction of xenocolloid between the plates of the pterygoid processes, as well as tight suturing of peripharyngeal wounds and the absence of traditional vertical dissection of the mucous membrane in the retromolar region (according to the Ganzer method) and other features of the methods used, it is possible to achieve high functional capacity of the soft palate. This is due to the fact that the palate either does not shorten at all during the wound healing process or shortens insignificantly.

Experimental morphological data indicate that the introduction of allo- or xenobone into the interlaminar space provides a more stable result of interlaminar osteotomy than the introduction of iodoform gauze between the plates. Gradually resorbing, the interposed allo- or xenobone is replaced by newly formed bone tissue, which firmly fixes the plate displaced inward in the position specified for it (during the operation). Filling the peripharyngeal niches with biological absorbable material (catgut coils) ensures less rough scarring of the wound than under the cover of iodoform tampons. This explains the more stable anatomical result of the operation (long soft palate, pharynx narrowed to normal), which, in turn, determines a higher functional outcome of the treatment, i.e. the patient clearly pronounces all sounds. This is also significantly facilitated by the formation of the palate (first by a stensile and then a plastic protrusion layered on the protective palatal plate) and speech therapy training of the patient before and after surgical treatment.

Remote functional (speech) results of uranoplasty and uranostaphyloplasty

Unfortunately, there are no generally accepted criteria for assessing pronunciation after uranostaphyloplasty. In order to objectify the assessment of the functional effect of palate plastic surgery, the method of spectral speech analysis 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 hearing in the patient, dental and jaw deformities or shortening of the frenulum of the tongue; speech therapy training and exercise therapy, etc.); therefore, it is possible to judge the effectiveness of the operations themselves by the quality of speech only by comparing all other factors that affect speech function.

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

As shown by the results of spirometry conducted after 6 months of exercise therapy, in the majority of children operated on for through-and-through non-fusions of the palate, air loss through the nose during exhalation is absent or significantly reduced, and in those operated on for isolated defects of the soft palate, air leakage is absent altogether.

To assess the functional state of the palatine tissues during surgery and predict the outcome of surgical treatment, a method for taking into account the values of heat flow in the palatine tissues is used. This method, unlike the generally accepted rheographic ones, is easy to implement, does not require significant time and expensive equipment, 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 terms of speech restoration, it is necessary to eliminate associated defects of the maxillofacial region - shortening of the frenulum of the tongue, absence of teeth, especially the front ones, cicatricial deformation and shortening of the lips, cicatricial adhesions in the nose, etc.

To reduce the number of postoperative purulent-inflammatory complications, it is recommended to carry out immunocorrective therapy before the operation and prescribe antibiotics, sulfanilamide drugs, furazolidone after the operation. Immunization with staphylococcal anatoxin also contributes to the normalization of the composition of the microflora of the oral cavity, pharynx and nasal part of the pharynx.