Cleft lip and/or palate (CLP) is among the most common congenital anomalies worldwide. While primary surgical repair is essential, comprehensive CLP care also depends on equally important secondary services such as speech therapy, audiologic support, orthodontic care, and revision surgeries. In many low- and middle-income countries (LMICs), these services remain limited or inaccessible, resulting in suboptimal long-term functional, aesthetic, and psychosocial outcomes. Our narrative review searched across PubMed and Embase databases to identify the availability, delivery models, and outcomes of secondary CLP services in LMICs. We found 17 relevant studies and mapped existing evidence, identified key gaps, and explored barriers related to workforce shortages, training, infrastructure, and financial constraints. Our findings highlight the urgent need to strengthen multidisciplinary CLP care pathways beyond primary surgery. Investments in sustainable local capacity, tele-health enabled service models, task-sharing, and community-based interventions are crucial to achieving equitable, high-quality CLP outcomes in resource-limited settings.

ObjectiveTo systematically review advances in surgical techniques for secondary cleft palate repair, emphasizing their impact on velopharyngeal function, speech outcomes, and the methodological validity of speech assessments used in published studies.DesignFollowing PRISMA 2021 guidelines, six electronic databases were searched for articles from January 2012 to February 2025 using MeSH terms related to secondary cleft palate repair, velopharyngeal insufficiency, palatoplasty, and speech outcomes. Eligible studies included clinical reports with ≥10 patients undergoing secondary repair. Data on surgical methods, outcomes, and complications were extracted and qualitatively synthesized due to heterogeneity across studies.SettingAll published clinical studies evaluating secondary cleft palate repair outcomes.Patients/ParticipantsIndividuals presenting with residual velopharyngeal insufficiency, recurrent fistula, or speech dysfunction following primary palatoplasty.Main Outcome MeasuresSpeech resonance and intelligibility, velopharyngeal closure rate, fistula recurrence, donor-site morbidity, and obstructive sleep apnea risk.ResultsFourteen studies met the inclusion criteria. Palate-based re-repair with Furlow double-opposing Z-plasty and buccal myomucosal flaps improved resonance and closure in small to moderate gaps. Pharyngeal flap and sphincter pharyngoplasty achieved satisfactory closure in larger defects but increased the risk of airway obstruction. However, most studies lacked validated speech protocols or controlled for articulatory errors and fistula effects, limiting confidence in the interpretation of outcomes.ConclusionsWhile secondary repairs often improve resonance and velopharyngeal competence, evidence remains constrained by heterogeneity and non-validated assessment methods. Future multicenter research integrating standardized, speech pathologist-verified protocols is essential to establish evidence-based algorithms for secondary cleft palate repair.

Having nasal speech due to velopharyngeal insufficiency (VPI) remains one of the most difficult complications to manage after cleft palate repair. Over early childhood, persistent hypernasality can impede the psychosocial and communicative development of a child. The purpose of this study was to assess the results of secondary soft palate lengthening surgery on children older than five years with a history of primary palatoplasty and persistent nasal speech. In this study, 60 non-syndromic patients with cleft palate whose nasal speech was persistent after cleft palate repair were included from January 2018 to December 2024 at Misurata Medical Center, Libya. Each of them underwent soft palate lengthening, most by intravelar veloplasty, and some by posterior pharyngeal flap. All the patients had preoperative and 12-month postoperative speech evaluation from both perceptual (Pittsburgh Weighted Speech Scale) and instrumental (nasometry) analysis. For statistical analysis, paired t-tests were used, with P < 0.05 considered significant. Of the total, 80% of patients had complete hypernasality correction, and 13.3% had partial correction. There was a significant improvement postoperatively on nasalance scores (48.5 ± 9.2% to 24.1 ± 6.8%, P < 0.001). 85% of the patients had improved speech intelligibility, with more than 86% of parents satisfied with the overall results. 10% had transient snoring and 5% had wound dehiscence, both classified as minor complications and were conservatively managed. For patients older than five years, soft palate lengthening is a secondary procedure that is both safe and effective for persistent nasal speech after cleft palate repair. It shows remarkable positive outcomes in resonance, intelligibility, and psychosocial confidence

The aims of the study were to update the current trends in acellular dermal matrix (ADM) utilization during palatoplasty procedures and to evaluate its effectiveness in reducing postoperative oronasal fistula formation. This is a systematic review and meta-analysis. Patients undergoing primary or secondary cleft palate repair. A comprehensive literature search was conducted via PubMed, Embase, Cochrane, and OVID for relevant studies published between July 2016 and June 2024 involving patients undergoing primary or secondary cleft palate repair with ADM versus without. All records were screened by two independent investigators using Covidence. Studies were excluded if they were not published in English, did not use ADM, were nonhuman, or had no reported outcome. Postoperative oronasal fistula formation. Eight studies met the inclusion criteria. This meta-analysis alone found a nonsignificant decrease in relative risk reduction of postoperative fistula formation with the use of ADM; however, when combined with data from the most recent meta-analysis, a statistically significant decrease was found. Overall, the addition of ADM resulted in 47% lower risk of developing fistulas. Furthermore, with the combined data, the pooled proportion of fistula recurrence for primary and secondary palate repair was 6.58%, which is favorable compared to previous studies' rates with the use ADM. This systematic review found a statistically significant decrease in postoperative fistula recurrence when using ADM for both primary and secondary palatoplasty. Therefore, ADM can be considered as a reliable adjunct to palatoplasty for reducing the risk of oronasal fistulas.

Tessier Facial Clefts.

Abstract The cephalic vasculature of turtles has been explored extensively for its evolutionary history. However, the rostral portion of the cephalic vasculature has rarely been investigated compared to that of the basicranial region, despite its unique morphology among diapsids and a wide range of variation within crown turtles. Here, a broad range of diapsid taxa were examined to explore the evolution of the rostral vasculature in turtles. We show that the arrangement of the rostral vasculature specific to extant turtles, bifurcation of the maxillary artery, and the caudally shifted foramen praepalatinum transmitting the palatine artery, could at least be traced back to the mesochelydians based on osteological evidence. Although one of the oldest testudinatans Proganochelys quenstedtii had a medially shifted maxillary artery as in crown turtles, its rostral vasculature likely retained the ancestral diapsid condition, consistent with the generally plesiomorphic morphology of the cranium. The crownward evolution of the rostral vascular patterning is likely related to associated rostral morphological changes, such as the keratinous beak, nasolacrimal duct, and medial nasal gland. In addition, variations of the osteological correlates for the maxillary and palatine arteries were found in crown turtles. Trionychians have a unique large opening termed foramen intermaxillaris instead of the paired foramina praepalatina on the floor of the nasal cavity, but they were shown to be homologous based on the shared palato-nasal neurovascular pattern. Chelonioids exhibited the most deviation from the generalized turtle rostral vascular patterning. Those deviations within crown turtles are likely associated with the relevant anatomical changes of the rostrum, such as the secondary palate of cheloniids.

Nonsyndromic oral clefts (NSOC) result from disruptions in the development of the primary and secondary palate and are categorized into cleft lip (CL), cleft lip and palate (CLP) and cleft palate (CP). NSOC is acondition with complex genetically heterogeneous backgrounds for that several genes might be involved. Thus, this study investigated whether functional single nucleotide polymorphisms (SNPs) in genes that potentially influence the vitaminD levels and parathyroid hormone (PTH) levels are associated with NSOC. Brazilian individuals with NSOC-presenting cleft lip (CL), cleft lip and palate (CLP) and cleft palate (CP)-and acomparison group were selected. Individuals' DNA was obtained from epithelial cells of the oral mucosa. Nine SNPs in five genes (VDR, CYP27B1, CYP24A1, SEC23A and PTH) were selected. Genotyping was performed by real-time polymerase chain reaction (PCR). The association between NSOC and vitaminD related polymorphisms was analyzed by Χ2test at asignificance level of p < 0.005 (after Bonferroni correction). The sample consisted of 274 individuals: 154 NSOC individuals and 120 controls. Atotal of 43(27.9%) had CL, 91 (59.1%) had CLP and 20 (13.0%) had CP. After Bonferroni correction, none of the SNPs were associated with NSOC (p > 0.005). None of the studied SNPs in vitaminD related and parathyroid hormone genes were associated with NSOC.

ObjectiveTo assess the relationship between neighborhood-level social disadvantage, as measured by Area Deprivation Index (ADI) and Childhood Opportunity Index (COI), and postoperative outcomes and follow-up care after primary or secondary cleft palate repair.DesignRetrospective cohort study.SettingAcademic tertiary care center.PatientsPediatric patients with cleft palate with or without cleft lip (CP ± L).InterventionsPrimary palatoplasty, revision palatoplasty, or closure of oronasal fistula.Main outcome measuresPostoperative complications and clinic follow-up adherence.ResultsA total of 244 patients were included in the study. Among all patients, there was only a moderate correlation between patients' ADI and COI quintiles (R2 = 0.465, P < .001). In patients undergoing primary palatoplasty, greater ADI neighborhood deprivation was significantly associated with a greater number of no-show (P = .011) and cancelled (P = .025) clinic appointments. In patients undergoing revision palatoplasty, greater ADI neighborhood deprivation was significantly associated with higher rates of postoperative complications (P = .016) and a greater number of no-show clinic appointments (P = .036). Greater COI disadvantage was associated with significantly higher rates of hospital readmission (P = .049) and fewer cancelled clinic appointments (P = .049) in revision palatoplasties. Neighborhood disadvantage was not predictive of any oronasal fistula repair postoperative outcomes, follow-up adherence, or patient characteristics at surgery.ConclusionsNeighborhood-level social disadvantage indices are predictive of suboptimal surgical outcomes and follow-up adherence in patients undergoing cleft palate surgery and could be used to identify patients who may benefit from additional clinic outreach and support.

The impact of low socioeconomic status (SES) on access to secondary speech procedures following cleft palate (CP) repair remains poorly understood. This study examined the association between SES-related diagnoses and the likelihood of undergoing secondary speech surgery among patients with CP and a history of hypernasality who had previously received primary palatoplasty. On April 8, 2025, the de-identified global network database TriNetX was queried for patients with CP using ICD-10 and CPT codes. Patients were categorized based on the presence or absence of lower SES-related ICD-10 codes. Outcomes included rates of secondary speech procedures such as palate revision, pharyngeal flap, and secondary palate lengthening. Propensity score matching was used to adjust for covariate differences. Out of 10,363 patients with CP and hypernasality who underwent palatoplasty between 2010 and 2024, 2,207 (21.3%) had an SES-related diagnosis. Patients identifying as African American/Black (P<0.0001) and Hispanic/Latino (P=0.0460) were significantly more likely to have SES-related diagnosis codes. Rates of secondary palate lengthening (P<0.036) and palatoplasty with pharyngeal flap (P<0.0001) were significantly lower among patients with lower SES-related diagnoses compared with those without. These findings highlight significant disparities in access to secondary speech surgery based on socioeconomic disadvantage. Patients with lower SES were less likely to receive procedures that may improve speech outcomes, underscoring the need for targeted efforts to promote surgical equity in cleft care.

The buccinator musculomucosal flap was found to be a useful alternative for palatal fistula and velopharyngeal insufficiency repair. This surgical technique has become increasingly common in the surgical management of secondary cleft palate deformities during the last years; however, few studies have been published documenting associated postoperative complications.The present study was carried out to present a case series and describe observed surgical complications associated with this technique used by the authors. This is a retrospective outcome study of patients with sequels after primary cleft palate repair (palatal fistulas, flap necrosis, or velopharyngeal insufficiency) admitted to our center and operated by a single surgeon using the buccinator flap from 2017 to July 2024.A review of the literature for studies published until November 2024 was performed to evaluate postoperative complications after using this technique. A total of 42 cleft palate patients with postoperative sequels have been operated using the buccinator musculomucosal flap by a single surgeon (P.R.P.) from 2017 to 2024.The most common cleft palate sequel after primary cleft palate repair in this series was the mucoperiosteal flap necrosis 10/42 (23.8%), velopharyngeal insufficiency 21/42 (50%) and palatal fistula 11/42 (26.19%).The most common complications after buccal myomucosal flap surgery were flap dehiscence and partial flap necrosis in 13 (30.95%) and 8 (19.04%) of patients, respectively. Buccinator (buccal) flap is an alternative for reconstruction of cleft palate sequels; however, their potential complications are not rare and should be prevented.

The cleft palate-associated gene Midline1 plays a role in mouse palatal development by regulating MMP8 and Snail proteins.

Cleft lip and palate significantly impact a child's speech and facial appearance. Children undergo cleft repairs in infancy, but poor results from these initial repairs often lead to secondary surgery. In the late 1990s, cleft care provision in the UK was centralised to approximately 11 managed clinical networks or centres. This centralisation has been associated with improvements in speech and aesthetic outcomes, but little is known about the effect of centralisation on the use of secondary surgery. The purpose of this study was to compare the cumulative incidence of secondary cleft surgeries before and after centralisation and the proportion of children achieving good clinical outcomes without secondary surgery. Retrospective, cross-sectional. Two cross-sectional studies of 5-year-old children with non-syndromic unilateral cleft lip and palate were conducted, one precentralisation and one postcentralisation. The cumulative incidence of secondary surgery from birth through age 5 was compared precentralisation and postcentralisation using Fisher's exact test, as were facial appearance and speech outcomes at age 5. Risk ratios (RR) were estimated using log-binomial multivariable regression models that adjusted for sex and age at evaluation. Postcentralisation, the proportion of children achieving good or excellent facial appearance increased from 16% to 42% (p<0.0001), good speech outcomes improved from 82% to 90% (p=0.02) and those avoiding secondary surgery rose from 45% to 67% (p<0.0001). The risk of secondary surgery decreased by 40% (RR: 0.60; 95% CI: 0.48 to 0.74), with notable reductions for secondary lip, palate and nose surgeries (RR: 0.19, 0.54 and 0.13, respectively; p<0.0001). The proportion of children achieving an ideal surgical outcome-good facial appearance, good speech and no secondary surgery-increased from 7% precentralisation to 28% postcentralisation (p=0.01; 4.1-fold increase). Centralisation of cleft care was associated with improved outcomes of primary lip and palate repairs and a corresponding reduction in secondary surgery.

The International Mouse Phenotyping Consortium (IMPC) has generated thousands of knockout mouse lines, many of which exhibit embryonic or perinatal lethality. Using micro-computed tomography (micro-CT), the IMPC has created and publicly released three-dimensional image data sets of embryos from these lethal and subviable lines. In this study, we leveraged this data set to screen homozygous null mutants for anomalies in secondary palate development. We analyzed optical sections from 2987 embryos at embryonic days E15.5 and E18.5, representing 484 homozygous mutant lines. Our analysis identified 44 novel genes implicated in palatogenesis. Gene set enrichment analysis highlighted biological processes and pathways relevant to palate development and uncovered 18 genes jointly regulating the development of the eye and the palate. These findings present a valuable resource for further research, offer novel insights into the molecular mechanisms underlying palatogenesis, and provide important context for understanding the etiology of rare human congenital disorders involving malformations of the palate and other organs.

ABSTRACT Cryptodontia is a diverse and widespread group of Permian dicynodonts, although its exact membership has been a subject of uncertainty in recent phylogenetic analyses. Cryptodont fossils were first reported from the Lopingian Usili Formation (Ruhuhu Basin, Tanzania) in 1932, with the current composition of the Usili cryptodont assemblage emerging from taxonomic revisions in the mid-2000s. Here we describe a new cryptodont, Mdomowabata trilobops, gen. et sp. nov., from the Usili Formation. Diagnostic characters of M. trilobops include: transversely expanded caniniform process of the maxilla that has a bluntly rounded ventral tip; paired nasal bosses; hatchet-shaped exposure of the postfrontal on the dorsal surface of the skull; parietals that are widely exposed dorsally; intertemporal portion of the postorbital that is oriented vertically with a concave lateral surface; triangular exposure of the postparietal on the skull roof; low, close-set anterior median palatal ridges; large palatine pad with a rugose posterior section and a smoother anterior section that is flush with the premaxillary secondary palate; transversely broad and anteroposteriorly short symphyseal region of the mandible; and prominent, round muscle scar anterior to the external mandibular fenestra. The plow-shaped snout and evidence of increased facial sensitivity suggest that Mdomowabata used its snout to interact with the substrate. A phylogenetic analysis recovers M. trilobops within a monophyletic Cryptodontia, on the stem leading to a clade comprising Oudenodontidae and Rhachiocephalidae. However, persistent problems in recovering stable relationships suggest that a critical reassessment of the character data underlying current dicynodont phylogenies is needed.

During secondary palate formation, bilateral palatal shelves grow vertically to a horizontal position. This morphological change of the palatal shelves, defined as the palatal shelf elevation, occurs from embryonic day (E)-13.5 to E14 in mice. Palatal shelves show regional differences in elevation patterns along the anterior-posterior (AP) axis; however, the underlying mechanisms remain unclear. Material properties of the lingual/nasal and buccal/oral surfaces, especially stiffness, possibly contribute to different elevation patterns. Indentation test using atomic force microscopy was performed to measure the stiffness at the epithelial surface of the palatal shelf. Measurement of palatal shelf stiffness along the AP axis before and after elevation revealed that the lingual/nasal surface was softer than the buccal/oral surface in the posterior region before elevation and that the palatal shelf was stiffer after elevation than before elevation. Moreover, the thickness of epithelial cells on the lingual/nasal side was lower than that on the buccal/oral side before elevation. Overall, our results suggest that epithelial cell thickness affects epithelial surface stiffness, causing regional differences in elevation patterns.

Cleft palate is one of the most common congenital abnormalities and one of the main symptoms of Stickler syndrome. Secondary palate development is a complex multi-step process that involves raising the palatal frame from a vertical to a horizontal position. Lysyl oxidase-like 3 (LOXL3), a member of the lysyl oxidase family responsible for the crosslinking in collagen, is also one of the mutated genes detected in Stickler syndrome. Loss of Loxl3 causes delayed palatal shelf elevation, which in turn resulted in cleft palate. However, the precise mechanisms of palatal shelf delayed elevation remain unclear. In this study, we deeply investigated the mechanism of Loxl3 induced delayed elevation in palatal shelves. We found that Loxl3 deficiency caused reduced cell proliferation in both medial and posterior palatal mesenchyme through BrdU labeling and Western blot analysis (p < 0.05, p < 0.01), decreased migration of palatal mesenchymal cells through cell scratch assay (p < 0.05), and decreased expression of genes associated with proliferation through Western blot analysis (p < 0.05, p < 0.01) at E14. We found that the specific deletion of Loxl3 in the palatal mesenchyme resulted in delayed elevation but normal fusion of palatal shelves, also reduced cell proliferation and collagen fibers deposition in medial palatal mesenchyme through BrdU labeling and histological analysis (p < 0.05, p < 0.01). Thus, our data suggest that Loxl3 regulates cell proliferation and collagen fibers deposition in the palatal mesenchyme, thus controlling palatal shelf elevation.

ObjectiveCleft palate (CP) is a common congenital malformation with numerous popular and effective techniques described for operative repair. Despite this, the fistula rate following primary as well as secondary palate repairs remains high with reports ranging between 15% and 55% fistula rate. We conducted a systematic meta-analysis review to evaluate the effect of platelet rich products (PRPs) on rate of fistula formation given its well documented association with accelerated wound healing.DesignMeta-analysis systematic review.SettingArticles identified through MEDLINE, Embase, Pubmed, Google Scholar, Web of Science, Scopus, Cochrane, References, related articles.Patients, ParticipantsPatients in randomized controlled trials undergoing primary or secondary CP repair.InterventionsPRP vs no PRP.Main Outcome MeasureRate of fistula formation.ResultsFive articles with a total of 164 patients were identified and included in our final meta-analysis. There were 82 patients in each experimental and control groups. A total 22 patients experienced a fistula. Fistula rates in PRP and non-PRP groups were 4.9% (n = 4) and 22.0% (n = 18). The difference of fistula rates between PRP and non-PRP groups was statistically significant (pooled risk ratio: 0.32 (0.12-0.82, p = .02) on our overall pooled meta-analysis.ConclusionIn our meta-analysis review, PRP was found to significantly reduce fistula rates after primary or secondary palatoplasty in CP repair. PRP may represent an effective intra-operative adjunct to conventional surgical management and repair of CP to reduce the risk of fistula formation. Further investigation is required to explore the impact of the use of PRP on other post-operative parameters for CP.

Introduction: Primary cleft palate repair is associated with significant psychosocial burdens for patients and their families. The abundance of operations and appointments create financial and non-financial hardships for the patient and health care system alike. Therefore, the financial implications of cleft care have become an area of focus in craniofacial surgery. The purpose of this study was to evaluate the financial implications of utilization of the buccal fat pad flap (BFPF) during primary cleft palate repair. We hypothesized that utilization of the BFPF as vascularized soft tissue filler would decrease the need for secondary speech operations, therefore decreasing the financial burden of cleft care on patients and the health care system. Methods: A retrospective cohort study was performed that included 146 patients who underwent primary cleft palate repair between 1996 and 2022. Medicare.gov national average costs were utilized to establish standardized direct secondary cleft palate procedural costs, and the total direct and indirect financial cost associated with secondary speech operations was also determined. Results: It was found that usage of the BFPF resulted in a reduction of roughly $1000 in direct secondary procedural costs and a reduction of roughly $3000 in total financial secondary procedural costs for patients. Furthermore, the BFPF’s role in reducing a patient’s need for a secondary speech procedure was reaffirmed with a 15% absolute risk reduction for BFPF patients. Discussion: Overall, cleft palate patients treated with BFPF at the time of initial surgery benefited due to the decreased likelihood of requiring a secondary speech operation as this resulted in a reduction in financial and non-financial costs associated with cleft palate repair, reducing financial toxicity as a whole.

Combined Fiberoptic and video Laryngoscopic intubation for difficult airway management in a child with turner syndrome and isolated secondary cleft palate

Introduction: This study aimed to examine the transforming growth factor (TGF)-β signaling pathway during secondary palate fusion by transfecting single and double small interfering RNA (siRNAs) for TGF-β2 and -β3. This investigation also focused on understanding the phenotype of palatal development. Methods: siRNAs targeting TGF-β2 and -β3 were used in an organ culture model of fusion of the secondary palate of 13-day embryonic ICR mice cultured for up to 72 h. The palatal shelves were collected at different times following the initiation of organ culture and were examined for TGF-β2 and -β3 gene expression. Downstream signaling was characterized using Western blotting and PCR. Results: In the double siRNA-treated palatal shelves, approximately 90% (91% anterior, 89% posterior with phenotype A) showed fusion failure in hematoxylin and eosin staining. Phosphorylation of Smad-dependent and -independent signaling showed a significant reduction in phosphorylation in double knockdown palate organ cultures when compared to single knockdown cultures. Although, the expression of matrix metalloproteinase 13 and TIMP2 were small influenced by siTGF-β2, the extracellular matrix and transcription factor expressions showed to be significantly reduced in double knockdown palate compared to single knockdown palates. Conclusions: This study demonstrates that double siRNAs targeting TGF-β2 and -β3 results in phenotypes during secondary palatal fusion and that they could be affected phosphorylation of Smad-dependent and -independent signaling synergistically compared to single knockdown of TGF-β2 and -β3. The results of this study demonstrate important functions during secondary palatal fusion and will contribute to our understanding of the etiology of cleft palate.