Rebuilding the Roof of the Mouth
Why does closing the take more than just sewing the hole shut, and why do surgeons argue about which technique is best?
💡 must close the oronasal hole AND rebuild the levator sling; a closed with a misdirected muscle is a hole filled but a valve that cannot work.
Prerequisite check
- The defining lesion of a lip is the interrupted ring, whose fibers insert abnormally on the cleft margins instead of crossing the .
- Every technique shares the same goals: release the misdirected muscle, rebuild a continuous ring, level the Cupid's bow, and restore and nasal symmetry.
What you will learn
Goal: Explain that must do two jobs at once (close the and reconstruct the levator sling), and compare how named techniques achieve them.
- Job 1 is closing the in layers; Job 2 (the harder one) is rebuilding the into a working sling.
- In a the levator ran the wrong way and inserted onto the back of the ; imaging shows it stays abnormal even after repair, worst in children who still leak air.
- von Langenbeck closes the lining but does not reliably reposition the levator; is the muscle repair; the Furlow Z-plasty reorients the muscle and lengthens the soft .
- Adding the Furlow element to the Sommerlad method raised velopharyngeal competence from 57.9% to 70.5% in a 1254-patient series, with a 4.3% fistula rate.
Model: Two jobs, and what each technique does about the muscle
A has two problems, and a good repair must solve both. Job 1: close the . The hole between mouth and nose is closed in layers (nasal lining, then muscle, then oral mucosa) so food and air no longer pass straight through. Job 2 (the hard one): rebuild the into a working sling. In a cleft the levator never formed its sling; its fibers run front to back and insert abnormally onto the back of the . Imaging confirms the levator stays abnormal in thickness, length, and even after repair, with the worst abnormality in children who still leak air. So a palate that is closed but whose muscle still runs the wrong way is a hole filled, but a valve that cannot work.
Named techniques differ in how much they do about the muscle. von Langenbeck closes the lining in the but does not reliably reposition the levator. Bardach two-flap closes the and is usually paired with an (IVVP), the muscle repair that dissects the levator off its wrong and rebuilds the sling. The Furlow uses two mirror-image Z-flaps to reorient the muscle transversely AND lengthen the soft ; it succeeded in 82.1 percent of submucous clefts. In a 1254-patient study, a modified Sommerlad-Furlow technique reached higher velopharyngeal competence than the Sommerlad method alone (70.5 percent versus 57.9 percent), with a postoperative fistula rate of 4.3 percent.
Explore (work the model before reading on)
- Write the two jobs a repair must do.
- Which named technique closes the hole but does not reliably fix the muscle?
- The von Langenbeck repair does not reposition the levator. Predict what could still go wrong for a child after that kind of repair, and connect it to the muscle.
- The Furlow technique both reorients the muscle and lengthens the soft . Why might a longer, properly oriented soft palate matter for a valve that has to reach the back wall of the throat?
- Adding the Furlow element raised competence from 57.9 to 70.5 percent. What one trade-off would you want to know about before always adding it?
Guided notes
Two jobs
- Job 2 reconstructs the into a ____, because in a the muscle ran the wrong way and inserted onto the back of the .
- A that is closed but whose muscle still points the wrong way is a hole filled but a valve that cannot ____.
What each technique does
- von Langenbeck closes the lining but does not reliably move the ____.
- The Furlow reorients the muscle transversely AND ____ the soft .
One number
- Adding the Furlow element to the Sommerlad method raised velopharyngeal competence from 57.9 percent to ____ percent, with a 4.3 percent fistula rate.
Reading the Research
- Skim the title and abstract first to get the gist.
- Circle the one sentence that states the main claim.
- Box the evidence the authors give for that claim.
- Mark one sentence that confuses you, and move on.
Vocabulary (the same words your classes use)
Vetted readings for this lesson
Track your progress today
Check these off as you work through the lesson, then submit. This tells Mr. Mendoza how you're doing so he can help the class. It does not replace turning in your producible.
Use the code Mr. Mendoza gave you, not your name. Saved on this device.
- Read the Model and answered the Explore questions.
- Filled in the guided notes in my own words.
- Defined the new vocabulary with an example.
- Built the producible: Present Mateo's palate-repair plan in four sentences: (1) state the two jobs and which is harder, citing the muscle source, (2) name the technique or combination you will use and tie it to the muscle, (3) cite one real number that supports paying attention to the muscle, and (4) end with a clear plan. Show you know the difference between closing a hole and building a valve.
- Wrote my Claim, Evidence, and Reasoning exit ticket.
Exit ticket (Claim, Evidence, Reasoning)
- Claim: A successful repair is judged by the muscle, not just by whether the hole is closed.
- Evidence: Cite the levator finding and one technique-comparison number.
- Reasoning: Explain why two children with closed palates could still have very different speech.
| Criterion | Proficient | Developing | Beginning |
|---|---|---|---|
| Complete | Every required part of the artifact is present and filled in. | Most parts are present, but one is missing or left blank. | Several parts are missing. |
| Accurate | The science and data are correct and match the evidence. | Mostly correct, with a small factual slip. | Key science or data is wrong. |
| Scientific reasoning (CER) | States a claim, backs it with specific evidence, and explains the reasoning. | Has a claim and evidence, but the reasoning is thin or missing. | Gives an answer with no evidence or reasoning. |
| Professional communication | Clear, organized, and labeled the way a clinician or scientist would write it. | Readable but disorganized or missing labels. | Hard to follow. |
| Submitted | Turned in the right way (Schoology for routine work) and confirmed. | Turned in, but in the wrong place or unconfirmed. | Not turned in. |
- CompleteProficient: Nothing is left blank: the model fills every part of "Present Mateo's palate-repair plan in four sentences: (1) state the two jobs and which is harder, citing the muscle source, (2) name the technique or combination you will use and tie it to the muscle, (3) cite one real number that supports paying attention to the muscle, and (4) end with a clear plan. Show you know the difference between closing a hole and building a valve.".
- AccurateProficient: Every number and claim matches the case evidence.
- Scientific reasoning (CER)Proficient: It names a claim, cites the specific evidence, and explains the reasoning, not just the answer.
- Professional communicationProficient: It is organized and labeled like a real chart note.
- SubmittedProficient: It would be turned in on Schoology and confirmed.
Where this leads: careers
What's next: We closed Mateo's and rebuilt the levator sling. But two children can have the very same closed palate, repaired the very same way, and one speaks clearly while the other does not. Part of that may be the calendar. When should the lip and palate each be repaired, and could timing itself help decide whether Mateo speaks clearly? We chase that next time.