Vom Nutzen der Chirurgie und vom Nachteil der Narben

Zusammenfassung

Die chirurgische Versorgung von Patienten mit Lippen-Kiefer-Gaumenspalte hat die Rekonstruktion der anatomischen Verhältnisse, der Funktionalität und der Ästhetik des Gesichts zum Ziel. Bei Kindern mit vollständiger Spalte sind mind. 3 chirurgische Eingriffe erforderlich: Schließen der Lippenspalte, Schließen des harten und des weichen Gaumens sowie Füllen der Spalte im Alveolarfortsatz mit Knochenmaterial. Bei Patienten mit geschlossenen Spalten kommt es zur Störung des maxillofazialen Wachstums in allen 3 Raumebenen, die mit zunehmendem Alter immer deutlicher in Erscheinung treten. Beim Verschluss der Spalte im weichen Gaumen ist die Rekonstruktion der Muskulatur der entscheidende Faktor. Die häufigste Störung nach einer Rekonstruktion des weichen Gaumens ist die velopharyngeale Dysfunktion. Man ist bisher davon ausgegangen, dass die iatrogenen Folgen eines chirurgischen Eingriffs im Gaumen von der Wundkontraktion verursacht werden. Die Bildung von Narbengewebe sowie die damit einhergehende Verbindung des Narbengewebes mit dem Gaumenknochen und den parodontalen Fasern sind jedoch wahrscheinlich die wichtigsten Faktoren. Sie behindern das Oberkieferwachstum und führen zur Kippung von durchbrechenden Zähnen nach palatinal. Die gestörte Muskelregeneration und die Fibrose im weichen Gaumen behindern die funktionelle Rekonstruktion des weichen Gaumens. Neuartige Therapieansätze auf Grundlage von Tissue Engineering könnten neue Perspektiven für die Behandlung von Spaltpatienten eröffnen. Mithilfe von Scaffolds, einer Art Gerüste, die Wachstumsfaktoren kontrolliert freisetzen, lässt sich möglicherweise die Narbenbildung und die Muskelregeneration nach der chirurgischen Korrektur des weichen Gaumens beeinflussen. Zur Entwicklung solcher funktionalisierter Gerüste ist jedoch weitere Forschung erforderlich.

Abstract

Surgical rehabilitation of patients with clefts aims at restoration of the anatomy, function and esthetics of the face. Children with a complete cleft will have at least 3 surgeries: repair of the cleft lip, hard and soft palate closure, and bone grafting of the alveolar process. Patients with a repaired cleft show disturbed maxillofacial growth in all dimensions, which becomes more apparent when they grow older. Muscle reconstruction is considered the most critical component of soft palate repair. The main morbidity associated with reconstruction of the soft palate is velopharyngeal dysfunction. It is hypothesized that the iatrogenic effects of palatal surgery are initially caused by wound contraction, but scar tissue formation and attachment of the scar tissue to the palatal bone and periodontal ligament are probably the most important features. This leads to restriction of maxillary growth and palatal tipping of erupting teeth. Impaired muscle regeneration and fibrosis of the soft palate hamper the functional recovery of the soft palate after repair. Novel therapies based on tissue engineering may offer new perspectives for the treatment of patients with cleft lip and palate. Scaffolds that give a controlled release of growth factors may influence scar formation and muscle regeneration after soft palate surgery. Further research, however, is needed in order to develop these functionalized scaffolds.

Schlüsselwörter

Gaumenspalte - Behandlungsergebnis - Chirurgie - maxillofaziale Entwicklung - Gaumenmuskulatur

Key words

cleft palate - treatment outcome - surgery - maxillofacial development - palatal muscles

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