Palate Deformities Research Articles

Prosthetic Rehabilitation of Postsurgical Nasomaxillary Hypoplasia for a Patient Following Reconstructive Surgery: A Clinical Report

Repairs of the cleft nose, lip, and palatal deformity remain challenging endeavors for reconstructive surgeons. Postsurgical nasomaxillary hypoplasia is a common finding in patients with extensive clefts. This complex deformity has a pronounced impact on the social behavior and self image of the subject. Esthetic and functional rehabilitation of this postsurgical defect is scarcely reported in the literature. Support in the form of prostheses or stents to prevent tissue collapse is usually required in these patients following surgery. This clinical case presentation discusses the fabrication of an internal nasal stent for a cleft nose, lip, and palate patient following surgical reconstruction. Two prostheses using two prosthetic materials (Polymethyl methacrylate, flexible resin) were prepared to compare their efficacy. The final prostheses improved the patient's appearance, making the postsurgical defect less conspicuous.

Determining the osteotomy pattern in surgically assisted rapid maxillary expansion in a unilateral palatal cleft: A finite element model approach

To evaluate the stress pattern in the craniofacial skeleton in a patient with unilateral cleft deformity of the secondary palate and alveolus in response to various techniques of surgically assisted rapid maxillary expansion (SARME). Three patient-specific composite skull models were developed for finite element model analysis. The details of the modeling procedure have been described in Part I of this series. The finite element analysis was performed on each model with a specified SARME technique in combination with RME using Abaqus (6.7). The ideal form of surgery in SARME for patients with unilateral cleft deformity of the secondary palate and alveolus would be complete unilateral LeFort I with pterygoid dysjunction in combination with midpalatal split, followed by isolated midpalatal split and zygomatic buttress osteotomies. A more invasive SARME technique can significantly reduce the resultant stresses. However, this benefit should be weighed against the risk of increasing complications associated with more extensive surgeries. When a more conservative surgical technique is selected, it would be preferable to perform a midpalatal split rather than zygomatic buttress osteotomies, as indicated by the stress-strain distribution and displacement pattern associated with different SARME techniques.

Biomechanical response of the maxillofacial skeleton to transpalatal orthopedic force in a unilateral palatal cleft

To assess the skeletal and dental effects of rapid maxillary expansion in a patient with unilateral cleft deformity of secondary palate and alveolus using the finite element method. A patient-specific composite skull model was developed from a patient computed tomographic scan and a surface scan of the patient's maxillary cast using MIMICS imaging analysis software. For volumetric meshing and the finite element analysis, Abaqus (6.7) was used. The typical wedge-shaped opening that occurs after RME, seen in non-cleft patients, is not seen in cleft patients. A clockwise rotation of the maxilla as a result of maxillary expansion was evident. The areas of maximum stress were the intact primary palate region, inferior orbital foramen of the non-cleft and the cleft sides, and the zygomatic buttress of the cleft side. During expansion, the intact primary palate showed high stress and acted as a region of major resistance, followed by the zygomatic buttress on the cleft side. Clinicians should consider a need for customization of expansion therapy for cleft patients depending on the patient's age, the type of cleft present (primary or secondary palate), and the desired area of expansion (anterior or posterior).

An overview of Cleft care in Nigeria

This is an overview of the present state of cleft lip and palate care in Nigeria. The aim is to stimulate further discussions on the need to improve standard of care and quality of life in patients with cleft lip and palate deformities. The number of cleft surgeries and surgeons involved in cleft repairs across Nigeria is increasing due to availability of free treatment grants provided by non-governmental organisation; therefore, it has become imperative to assess the quality of surgery and quality of cleft care. It is expected that as the number of repaired cleft lip/palate increases, more patients will require secondary repair, speech therapy, and orthodontics therapy and orthognathic surgery. The following recommendations are made to improve the standard of cleft care in Nigeria: establishment of multidisciplinary team approach, formulation of policy on quality control, establishment of fellowship training in cleft care and establishment of regional specialised cleft care centre.

Changing Patterns in Demography of Cleft Lip–Cleft Palate Deformities in a Developing Country: The Smile Train Effect—What Lies Ahead?

The past decade has seen tremendous changes in the management of cleft deformities with the advent of the Smile Train project. The present study evaluates the effect of the Smile Train project on the demographics of cleft deformities. Data collected over the past three decades were studied retrospectively. The number of cases, age at presentation, and relative proportion of cleft lip-cleft palate patients were analyzed. Thirty patients operated on at the authors' institute for cleft lip deformity were evaluated for their awareness of cleft deformities, and the results were compared with those of 22 patients operated on elsewhere in camp settings. The numbers of patients with cleft deformities treated at the authors' institute from 1980 to 1989, 1990 to 1999, and 2000 to 2009 were 1189, 1050, and 374, respectively. However, the number with cleft palate has remained nearly constant over the three decades. The mean age of reporting for treatment of cleft palate was 16 months after being operated on for cleft lip at the authors' institute and 41 months after being operated on elsewhere in camps. All patients operated on at the authors' institute expressed awareness of holistic treatment of cleft deformities. Of the 22 patients operated on at other camps, 16 were ignorant about the time scale and 19 were unaware of the consequences of nonadherence to the treatment protocol. Nineteen of the 22 patients felt that enough information was not provided to them at initial surgery. The authors recommend that cleft counseling, continued cleft care for the complete complex of deformities, and responsible behavior by the initial operating team should be the goals for the future.

Multicenter plastic surgery outreach services for underserved Ghanaian communities

This paper describes the efforts of one plastic surgery team composed of Ghanaians from one of the major metropolitan areas in Ghana to meet the plastic surgery needs of rural Ghanaian communities. The aim was to analyze retrospectively the cases managed by the team, the difficulties which arose over a 14-year period, and the provision of recommendations for such future work. This study reviewed the medical records of patients treated during 86 outreach visits to nine centers from October 1995 to September 2009. The team, drawn from three hospitals, comprised a plastic surgeon and surgical support staff. They mostly treated Buruli ulcers, postburns scar contractures, chronic ulcers, facial clefts, tumors, and breast diseases. In all, 2,284 patients were managed during the period under review, giving an average of 163 patients per year and 254 per center. Buruli ulcers accounted for the largest group of cases treated during the outreaches (41%). Other common diagnoses were postburn scar contractures and cleft lip and palate deformities. This paper provides an example of the possibilities for surgical outreach work that exist and how challenges that come up during surgical outreach visits can be handled effectively. It also highlights the need for outreach medical work in developing countries like Ghana, especially since there is a reduction in foreign outreach medical missions. The authors encourage all stakeholders involved in health care delivery to initiate and support local medical outreach teams to provide care to rural communities.

Effects of phenytoin onSatb2andHoxa2gene expressions in mouse embryonic craniofacial tissueThis paper is one of a selection of papers published in this special issue entitled “Second International Symposium on Recent Advances in Basic, Clinical, and Social Medicine” and has undergone the Journal's usual peer review process.

Cleft lip and cleft palate are common congenital craniofacial birth defects in humans. Phenytoin (PHT) is a risk factor of cleft palate formation; however, the molecular mechanisms by which phenytoin exerts its teratogenic effects resulting in cleft palate remain unknown. The Satb2 gene mutation is associated with cleft palate. Satb2-deficient mice exhibit cleft palate deformity and an up-regulation of Hoxa2 in the fronto-nasal region. In this study, phenytoin was administered intraperitoneally to pregnant C57BL/6 mice on the 10th day of gestation. Real-time PCR results showed that the expressions of Satb2 and Hoxa2 in craniofacial tissues of mouse embryos were obviously different at different time points. The Satb2 gene was down-regulated and the Hoxa2 gene was up-regulated in phenytoin-treated mouse embryonic craniofacial tissue. We conclude that phenytoin may regulate the expression of these two genes in C57BL/6 mice and it may also be involved in the formation of cleft palate.

Beak necrosis in Hungarian partridges (Perdix perdix) associated with beak-bits and avian poxvirus infection

Proliferative growth, consistent with poxvirus infection, encapsulated plastic beak-bits and covered the dorsal portion of the upper beak and nares of adult male and female captive-raised Hungarian partridges. Three representative birds were submitted to the Wisconsin Veterinary Diagnostic Laboratory for necropsy. Lesions in the necropsied birds extended through the nares, where the plastic bit ends are designed to rest. The lesions also variably extended caudally into the oropharynx and cranially within the beak epithelium, and included palate deformity and beak necrosis. Poxvirus was diagnosed in all of the birds examined based on histopathology, electron microscopy, and polymerase chain reaction amplification and sequencing. This report is the first to describe avian pox lesions associated with the application of beak-bits and the resulting beak and oral pathology.

Nutritional and haematological parameters of cleft lip and/or palate patients in Lagos, Nigeria.

Introduction: Cleft Lip and Palate (CLP) deformities are the most common congenital abnormalities of the orofacial structures. The deformity is associated with certain peculiar problems including feeding disorders and recurrent infections. These may combine to affect the nutritional status of the patients. This study was carried out to assess the prevalence of malnutrition among patients with CLP deformities in Lagos, review the prevalence of anaemia and the burden of bacterial infections.Materials/methods: Serum albumin levels of patients with CLP invited for surgical intervention in Lagos between 2006 and 2008 were assessed to determine the nutritional status, the Packed Cell Volume for the presence of anaemia and total White Cell Count (WBC) to screen for the possibility of bacterial infection.Results: Two hundred and twenty five patients were studied comprising of 112 males and 113 females. Mean age was 5.05 ± 7.73 years. One hundred and one (44.89%) patients had complete cleft of the lip and palate, 27.22% had cleft lip, 13.78% had cleft of the lip and hard palate, while 7.11% had cleft of the soft palate alone. Various types of rare cleft deformities occurred in 8.88% patients out of which macrostomia or lateral cleft constituted 6.67%. Forty-eight (21.3%)patients had malnutrition. The type of CLP deformities was found to have no significant effect on the serum albumin level (p = 0. 089). Sixty-eight (30.2%) patients had anaemia. There was an association between the types of CLP deformities and the PCV levels (P=0.001). Twenty-two (9.8%) patients showed haematologic evidences of on-going bacterial infections with raised total WBC count.Conclusion: The prevalence of anaemia in patients with CLP is however higher than that of the general population. Patients with CLP require nutrition support and continuous medical monitoring.

Presurgical Nasoalveolar Molding Assisted Primary Reconstruction in Complete Unilateral Cleft Lip Palate Infants

Various methods have been described for the primary surgical reconstruction of the unilateral cleft lip and palate deformity (UCLP) in infants. There have been several attempts at restoring the normal anatomy of the nose at the time of lip repair in the affected individuals with varying degrees of success. Presurgical nasoalveolar molding (PNAM) is a presurgical infant orthopedic procedure that attempts to target the nasal deformity leading to a more esthetic surgical repair. At our center we aimed to use PNAM to help in providing the surgical team with a better foundation for an easier and more esthetic single stage repair at the level of nose in addition to the lip and alveolus. The infant nasal cartilages are amenable to correction in the first few weeks of life when they retain their plasticity. Three infants with complete unilateral cleft lip palate (CUCLP) were operated upon after a course of PNAM. No nasal stents were use after repair to retain the results. PNAM reduced the extent of the cleft deformity and improved the anatomic relationship between the affected structures. Postoperative recovery was uneventful. Subjective evaluation immediate post surgery and at the time of palate repair reveals adequate nasolabial esthetics. Long-term results of PNAM assisted repair are to be ascertained. The use of PNAM enables in reducing the severity of the deformity the surgical team has to tackle thereby enabling in a better and esthetic primary repair.

Presurgical nasoalveolar moulding for a unilateral midfacial cleft: A case report

Although surgical correction remains the mainstay of treating unilateral/bilateral cleft lip and/or palate deformities, some inadequacies still remain like scarring of the nasolabial complex, multiple interventions to achieve desired results, etc. Presurgical nasoalveolar moulding consists of selective repositioning by active moulding of the alveolar segments as well as the surrounding soft tissue. Clinical case of unilateral mid-facial cleft treated by the same, showed significant reduction in the defect size and improved contour of the columella-philtrum region for superior postsurgical esthetics.

Three-dimensional geometric morphometrics applied to the study of children with cleft lip and/or palate from the North East of England

This prospective cross-sectional, case-controlled morphometric study investigated three-dimensional facial morphological variation among and between 8- and 12-year-old children [40 with a unilateral cleft lip and palate (UCLP), 23 with a unilateral cleft lip and alveolus (UCLA), 19 with a bilateral cleft lip and palate (BCLP), and 21 with an isolated cleft palate (ICP)]. Eighty gender- and age-matched individuals comprised the control group. The mean shape of each group was computed using generalized Procrustes analysis (GPA). Differences in shape between group means were assessed using multivariate analysis of variance and permutation tests, and shape differences were visualized for interpretation using warpings of the grand mean shape and transformation grids computed using thin plate splines (TPA). Statistically significant differences between the mean facial shapes and forms (shape plus size) of all groups were found. The greatest difference was in the BCLP group and the second greatest in the UCLP group. The study of asymmetry indicated different degrees and differences in the nature of asymmetry that characterize different cleft lip and palate (CLP) deformities. Principal component analyses (PCA) of form space and of means, plus reflected means, were informative with respect to the differences in facial size and shape and asymmetry between these groups. The results highlight differences in the aetiology of ICP and CLP groups and underline the potential value of statistical shape analysis in assessing the outcomes of CLP treatment.

Cleft deformities in adults and children aged over six years in Nigeria: Reasons for late presentation and management challenges

Cleft deformities in adults and children aged over six years in Nigeria: Reasons for late presentation and management challenges Wasiu L Adeyemo1, Mobolanle O Ogunlewe1, Ibironke Desalu2, Akinola L Ladeinde1, Bolaji O Mofikoya3, Michael O Adeyemi4, Adegbenga A Adepoju4, Olufemi O Hassan41Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, 2Department of Anaesthesia, 3Department of Surgery, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria; 4Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos, NigeriaAbstract: In developing countries, untreated cleft lips and palates are found with increasing frequency and patients often present to the surgeon far past the optimal time for closure of the cleft deformities. A prospective study was conducted between March 2007 and September 2009, to identify the reasons and treatment challenges of delayed presentation of cleft lip and palate deformities at the Lagos University Teaching Hospital, Nigeria. Out of a total of 150 patients with cleft defects during the period, 43 (28.7%) were adults and children aged over six years. The mean age of these patients at the time of presentation was 17.3 years. The most common reasons for late presentation were lack of money (56.7%), lack of health care services nearby (18.4%), and lack of awareness of treatment availability (13.3%). Common challenges in these patients included surgical, orthodontic, speech, anesthetic, and psychological. Although adult clefts were significantly enlarged in three dimensions the anatomic landmarks were easier to discern than in an infant. However, extensive soft tissue dissection in adult cleft lip repair resulted in significant postoperative edema. Closure of wide palatal cleft often required the use of adjunct intraoral flaps. Despite late presentation, surgical outcome of these patients was satisfactory and comparable to cleft repair in infants.Keywords: cleft deformities, adults, adolescents, late presentation, management, challenges

Secondary Alveolar Bone Grafting: Outcomes, Revisions, and New Applications

Cleft lip and palate deformities are one of the most common birth defects. The alveolar cleft requires bony repair to allow proper eruption of dentition. The purpose of this study is to evaluate success in the repair of alveolar clefts and examine whether the addition of allogenic materials improves outcomes. One hundred three patients with cleft lip and palate were identified retrospectively after institutional review board approval was obtained. The authors reviewed their medical records, surgical complication rate, need for revision surgery, and whether allogenic materials were used. The data were then compared using analysis of variance. The average patient age was 16.6 years (range, 7 to 25 years). There were 59% unilateral clefts and 41% bilateral clefts identified. The average age at palate repair was 17.5 months. The average age at alveolar bone grafting (ABG) was 8.9 years (range, 5 to 15 years). Allogenic material was used in 22 primary ABGs and 10 revision ABGs. The revision rate of unilateral ABGs was 18%, which was statistically different from the 32% revision rate of bilateral ABGs. The use of allogenic material during ABG repair did not affect the revision rate. Secondary alveolar bone grafting is necessary for complete rehabilitation of the cleft alveolus. The patients undergoing ABG had an overall 23% revision rate, 18% for unilateral and 32% for bilateral clefts. The use of allogenic materials during ABG did not show a statistical benefit in this study, but future review including more patients may be useful.

Cleft deformities in adults and children aged over six years in Nigeria: Reasons for late presentation and management challenges

In developing countries, untreated cleft lips and palates are found with increasing frequency and patients often present to the surgeon far past the optimal time for closure of the cleft deformities. A prospective study was conducted between March 2007 and September 2009, to identify the reasons and treatment challenges of delayed presentation of cleft lip and palate deformities at the Lagos University Teaching Hospital, Nigeria. Out of a total of 150 patients with cleft defects during the period, 43 (28.7%) were adults and children aged over six years. The mean age of these patients at the time of presentation was 17.3 years. The most common reasons for late presentation were lack of money (56.7%), lack of health care services nearby (18.4%), and lack of awareness of treatment availability (13.3%). Common challenges in these patients included surgical, orthodontic, speech, anesthetic, and psychological. Although adult clefts were significantly enlarged in three dimensions the anatomic landmarks were easier to discern than in an infant. However, extensive soft tissue dissection in adult cleft lip repair resulted in significant postoperative edema. Closure of wide palatal cleft often required the use of adjunct intraoral flaps. Despite late presentation, surgical outcome of these patients was satisfactory and comparable to cleft repair in infants.

Isolated Lower Lip Fistulas in Van der Woude Syndrome

Van der Woude syndrome (VWS) is a dominantly inherited disease of orofacial region. Characteristic features of this syndrome are bilateral lower lip sinuses along with cleft lip or palate deformity. However, isolated lower lip pits in VWS without any cleft syndrome is uncommon. Lip pits in VWS are usually asymptomatic; however, patients may complain of watery drainage and/or infection. In this report, asymptomatic isolated lower lip sinuses without any cleft syndrome in a patient and his father are presented.

Unilateral Cleft Lip and Nasal Repair: The Rotation–Advancement Flap Technique

The comprehensive treatment of cleft lip and palate deformities requires thoughtful consideration of the anatomic complexities of the deformity, and the delicate balance between intervention and growth. The surgical reconstruction of clefts requires that the surgeon maintain a cognitive understanding of the complex malformation itself, the varied operative techniques employed, facial growth considerations, and the psychosocial health of the patient and family. This article describes the overall reconstructive approach for repair of the unilateral cleft lip and nose deformity using the rotation-advancement repair technique modified from the original description by Millard, still the most common version of unilateral cleft lip and nose repair in the world. Several other techniques exist and are used in various forms by most surgeons. To date, no technique has definitively been proven to produce the best results.

S321: Secondary Management of Cleft Lip/Cleft Palate Deformities in Both Soft and Hard Tissues

The management of the primary cleft lip and palate deformities often may be followed by several secondary sequelae in different areas: nose, lip, alveolar ridge, hard and/or soft palate and also dentofacial discrepancies.

L519: Comprehensive Surgical Treatment of Cleft Lip and Palate Patients—Evidence- Based Discussion

Oral and maxillofacial surgeons play a critical role in the treatment of cleft lip and palate deformities. There are many controversies in the literature pertaining to different treatment modalities. This includes efficacy of presurgical orthopedic appliances, primary gingivoperiosteoplasty, the effect of different palatal repair techniques on speech production, the timing of alveolar bone grafting, and the role of distraction osteogenesis in this patient population. This eye-opener will explore these topics through a review of the pertinent literature.

Le Fort III Bipartition Osteotomy to Treat a Rare Craniofacial Anomaly

Frontofacionasal dysplasia or dysostosis (Mendelian Inheritance in Man 229400) is composed of cranial, ophthalmic, nasal, and lip and palate deformities. It is a rare and separate entity because it contains none of the extracranial defects seen in frontonasal dysplasia and related syndromes. Four patients with frontofacionasal dysplasia were treated in Hacettepe University between 2000 and 2007. A new surgical approach, less invasive and risky than an intracranial procedure and more effective and quicker than an orthodontic molding/distraction therapy, was developed during the treatment course of this group of patients. Le Fort III bipartition osteotomy was performed to reduce the distance between maxillary segments in very wide cleft lip and palate repair. No surgical complication was encountered, and all the patients healed well and were discharged from the hospital without a problem. Craniofacial deformities of the patients with frontofacionasal dysplasia should be repaired to have a socially acceptable facial appearance. We suggest Le Fort III bipartition osteotomy in selected cases to reduce the distance between maxillary segments in patients with very wide clefts.