Presurgical Nasoalveolar Molding Techniques for a Complete Unilateral Cleft Lip and Palate Infant: A Case Report

The purpose of this article was to present a modified protocol and devices of presurgical nasoalveolar molding techniques to improve deformity of lip, nose and alveolus at Department of Orthodontic, Khon Kaen University (KKU). This new protocol was developed in order to address nasal problems as early as possible with a new extra-oral type of nasal molding device, "forehead type of nasoalveolar molding device". Extra-oral strapping was applied to approximate lip segments and also help to reduce alveolar cleft rapidly. The remaining alveolar cleft was reduced till completely, using alveolar molding plate with traction screw. The forehead type of nasal molding device could be used continuously after cheiloplasty to maintain nasal configuration until the secondary palate repaired. A case of complete unilateral cleft lip and palate girl was presented to clearly demonstrate treatment steps and results of lips, nose and alveolus after being treated with this new presurgical nasoalveolar molding protocol and devices for a period of four months.

Emanuel Syndrome (ES): new case-report and review of the literature

Multiple congenital anomalies and craniofacial dysmorphism are characterizing the so-called Emanuel or supernumerary der(22)t(11;22) syndrome (OMIM609029). Mental and developmental retardation are major clinical features. The der(22) may arise from a parental balanced t(11;22)(q23;q11.2) or can be created de novo. Here we present a 2 years old boy with normal prenatal history, cyanotic at delivery and with ear anomalies, a preauricular tag, high-arched palate and micrognathia. There were neither microcephaly, nor heart or kidney defects. Psychological and motor testing at the age of 2 years confirmed significant mental and developmental delay. In addition, the child had seizures and an abnormal electroencephalogram. Cytogenetic and molecular analyses revealed a karyotype 47,XY,+der(22)t(11;22)(q23;q11.2). As parents refused further tests it could not be determined if the der(22) arose de novo or was parentally derived. Overall the present report should alert physician to offer cytogenetic and/or molecular diagnostics in comparable cases.

Analysis of skeletal maturity of children with cleft palate in terms of healthy children by the CVM method

BACKGROUND

For many years, the analysis of bone age X-rays have been used for the hand and wrist, which were assessed on the basis of changes in the various centers of ossification. These images, however, do not constitute a diagnostic element of cleft defects, leading to additional exposure of the patient to X-rays. The problem was solved by using lateral head films, which enabled the interpretation of the morphological changes in the cervical spine to evaluate skeletal development stages.

OBJECTIVES

The objective of this work is to define the differences between the skeletal age and chronological age of children with malocclusion and congenital craniofacial disorders - primary and secondary palate cleft.

MATERIAL AND METHODS

The study material comprised 90 lateral cephalometric radiographs of patients at the age of 7 to 16 (45 lateral head radiographs of patients with various occlusion disorders and 45 lateral head radiographs of patients with various types of primary and secondary palate cleft). Then, all the lateral cephalometric radiographs were analysed in terms of the shape of the 2nd, 3rd and 4th cervical vertebra in line with the Cervical Stage method (CS), developed by Baccetti et al. in 2005.

RESULTS

Patients with malocclusions without malformations achieved various stages of bone development at an earlier chronological age compared with patients with primary and secondary palate. An exception was the phase CS 3 (early growth spurt) development disorders, in which patients with different types of cleft had lower chronological age compared with patients with malocclusion.

CONCLUSIONS

The method that allows for an assessment of the development of skeletal maturity is the analysis of the shape of the cervical vertebrae in lateral head film.

[A neonate who could not open her eye]

We present a case of a female neonate who was born with a string between the eyelids of one eye. There were no other dysmorfic features. She had an isolated ankyloblepharon filiforme adnatum, a rare congenital malformation of the eyelid.

Verbal competence in narrative retelling in 5-year-olds with unilateral cleft lip and palate

BACKGROUND

Research regarding expressive language performance in children born with cleft palate is sparse. The relationship between articulation/phonology and expressive language skills also needs to be further explored.

AIMS

To investigate verbal competence in narrative retelling in 5-year-old children born with unilateral cleft lip and palate (UCLP) and its possible relationship with articulation/phonology at 3 and 5 years of age.

METHODS & PROCEDURES

A total of 49 children, 29 with UCLP treated according to three different procedures for primary palatal surgery and a comparison group of 20 children (COMP), were included. Longitudinally recorded audio files were used for analysis. At ages 3 and 5, the children were presented with a single-word test of word naming and at age 5 also the Bus Story Test (BST). The BST was assessed according to a test manual. The single-word test was phonetically transcribed and the percentage of consonants correct adjusted for age (PCC-A) was calculated. Differences regarding the BST results within the UCLP group were analysed. The results were compared with the results of the COMP group, and also with norm values. In addition, the relationship between the results of the BST and the PCC-A scores at ages 3 and 5 years was analysed.

OUTCOMES & RESULTS

No significant group differences or correlations were found. However, 65.5% of the children in the UCLP group had an information score below 1 standard deviation from the norm value compared with 30% in the COMP group.

CONCLUSIONS

A larger proportion of children in the UCLP group than in the COMP group displayed problems with retelling but the differences between the two groups were not significant. There was no association between the BST results in the children with UCLP and previous or present articulatory/phonological competence. Since group size was small in both groups, the findings need to be verified in a larger study.

Review: Facial endophenotypes in non-syndromic orofacial clefting

Cleft lip and/or palate (CL/P) is one of the most frequent congenital malformations, with a frequency of 1 in 700 live births. Non-syndromic orofacial clefting is a multifactorial condition, with both a genetic and an environmental component. Although numerous studies have been published addressing the genetic etiology of CL/P, this factor remains incompletely understood. A promising approach to find candidate gene regions for CL/P is the investigation of endophenotypes, which are characteristics associated with a certain condition and that can be an expression of underlying susceptibility genes. This review focuses on the known facial endophenotypes in CL/P (such as distortion of the orbicularis oris muscle and facial features in non-affected relatives of patients with CL/P) and genes that could be associated with these characteristics. Possibilities for further endophenotype-related studies in the field of non-syndromic CL/P are discussed.

MEGALENCEPHALY, POLYMICROGYRIA, POLYDACTYLY AND HYDROCEPHALUS (MPPH) SYNDROME: A NEW CASE WITH OCCIPITAL ENCEPHALOCELE AND CLEFT PALATE

The megalencephaly, polymicrogyria, polydactyly, and hydrocephalus (MPPH) syndrome is quite rarely seen. The four main findings in this syndrome may be accompanied by severe psychomotor retardation, blindness, hypotonia, convulsions, and facial dysmorphism. In this paper, we present a female newborn at 39 weeks gestational age born to parents who are first degree cousins. Beside the facial dysmorphism and four main features of the MPPH syndrome, the findings on the physical examination of the patient were, hypertonicity, occipital encephalocele, cleft palate, and multiple polyps in the tongue. The presence of occipital encephalocele, cleft palate, and polyps in the tongue in this patient was not reported previously in the literature.

Cleft lip and/or palate: review

AIM

Aim of the review was to provide a literature overview of the birth defects of cleft lip and/or cleft palate (CL/P).

METHODS

Through the use of the PubMed database items were collected that would provide information about the condition, leading to the discussion of the following topics: epidemiology, anatomical features, genetics, environmental factors, diagnosis and treatment.

RESULTS

According to these data, the CL/P are the most common congenital malformations of the craniofacial region. There are different phenotypes and clinical features of this malformation, which differ according to the anatomical structures involved: cleft lip, cleft lip and cleft palate. The etiology is multifactorial and includes both genetic factors and environmental factors. For proper diagnosis and treatment it is important to complete a multidisciplinary approach to guide the patient from birth to the end of growth. Among the outstanding figures for the care of the anomaly are: the gynecologist, the pediatrician, the maxillofacial surgeon and orthodontist. Individuals with a cleft lip and/or cleft palate may experience problems in feeding, pronunciation, hearing and social integration, which can be corrected to a different extent by surgery, dental treatment, speech therapy and psychosocial interventions.

CONCLUSION

Today the optimal treatment is difficult to find, because of the large variability of malformations and the subjective response of each patient to therapy.

Evaluation of speech errors in Putonghua speakers with cleft palate: a critical review of methodology issues

Speech errors associated with cleft palate are well established for English and several other Indo-European languages. Few articles describing the speech of Putonghua (standard Mandarin Chinese) speakers with cleft palate have been published in English language journals. Although methodological guidelines have been published for the perceptual speech evaluation of individuals with cleft palate, there has been no critical review of methodological issues in studies of Putonghua speakers with cleft palate. A literature search was conducted to identify relevant studies published over the past 30 years in Chinese language journals. Only studies incorporating perceptual analysis of speech were included. Thirty-seven articles which met inclusion criteria were analyzed and coded on a number of methodological variables. Reliability was established by having all variables recoded for all studies. This critical review identified many methodological issues. These design flaws make it difficult to draw reliable conclusions about characteristic speech errors in this group of speakers. Specific recommendations are made to improve the reliability and validity of future studies, as well to facilitate cross-center comparisons.

Pre-linguistic children with cleft palate: growth of gesture, vocalization, and word use

Children with cleft lip and/or palate show early delays in speech and vocabulary development that may have an impact on later communication and social development. While delays in the complexity of babbling may put children at risk for later delays in speech and language development, there is considerable variability in development. This study focused on the rate of children's communication acts, canonical vocalizations, and word use as they made the transition from the pre-linguistic to linguistic development. The study included 15 children with non-syndromic cleft lip and/or palate who were seen at three time points between 17-34 months age. Communication rates were calculated from parent-child language samples collected during play activities. Assignment to linguistic stages was based on the children's expressive vocabulary, as reported on the MacArthur Communicative Development Inventory: Words and Sentences. From the pre-linguistic to linguistic level, the children's average rate per minute of: communicative acts overall increased significantly from 1.49 to 3.07 per minute; canonical vocalizations from 0.21 to 0.90 per minute; and word use from 0.16 to 3.61 per minute. Rates of communicative acts were associated with later word use. It appears that children with clefts rely on non-verbal communicative acts when verbal development is delayed.

Use of the buccinator musculomucosal flap for bone coverage in primary cleft palate repair

BACKGROUND

Cleft palate is one of the most common congenital malformations in the maxillofacial region. After a cleft palate repair, surgeons must deal with the transverse growth restriction and palatal fistulas caused by scar tissue on the raw bone surface around the hard palate. This report describes the technique of the buccinator musculomucosal flap procedure performed together with repair of the cleft palate. The objective is to cover exposed bone areas of the hard palate to decrease scar contraction and subsequent transverse maxillary growth restriction, as well as tension at the closure.

METHODS

From August 2009 to February 2012, 15 patients underwent the buccinator musculomucosal flap procedure. First, the cleft palate was repaired by mucoperiosteal flaps, resulting in wide and raw bone surfaces around the hard palate. The outline of the flap was marked on the buccal mucosa. Grounding on the exposed bone areas around the hard palate, the authors designed widths of flaps ranging from 1.5 to 2.5 cm. These flaps were elevated from the buccopharyngeal fascia and turned 90° to cover the raw hard palate bone surfaces. The donor sites were closed by direct suture.

RESULTS

The follow-up period was 1-26 months (average, 10 months). No complications were found in any patient who underwent the procedure, and no fistulas occurred in the midline of the palate. No patients experienced complications related to the donor sites. No trismus or other dysfunction related to mouth movement was observed.

CONCLUSIONS

The buccinator musculomucosal flap is a convenient and safe flap procedure with fewer donor-site complications. This procedure also has significant potential for improving maxilla growth and reducing the secondary complications that often can result from cleft palate repair.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Otitis media with effusion in children with cleft lip and palate: a narrative review

OBJECTIVE

Repair surgery of cleft lip and palate (CLP) can produce satisfactory cosmetic results but the problem of recurrent otitis media with effusion (OME) secondary to CLP may persist. This can cause long-term hearing loss and affect linguistic, academic, and personal development. The aim of this review is to provide the most recent information regarding OME in children with CLP.

METHODS

All papers referring to children with CLP and OME were identified from searches in Medline, PubMed, Cochrane Library, and Web of Science. Abstracts were read and relevant papers were obtained. Additional studies were obtained from the references of the selected articles.

RESULTS

Both current and previous research on OME in children with CLP focused on the controversy over treatment strategies. Evidence on the optimal treatment for OME in CLP children was lacking. Ventilation tube surgery using the same anesthetic as lip or palate procedures was not well-supported. After summarizing the literature review, a flowchart of management guidance for such patients is also recommended. Updated reviews such as this will provide clinicians and patients/parents with a valuable reference.

CONCLUSIONS

The lack of evidence on the optimal treatment for OME in children with CLP should prompt a relatively conservative approach. However, only a consensus between patients/parents and surgeons regarding the most suitable treatment strategy for OME can ensure the greatest benefit to individual patients.

Towards a new procreation ethic: the exemplary instance of cleft lip and palate

The improvement of ultrasound scan techniques is enabling ever earlier prenatal diagnosis of developmental anomalies. In France, apart from cases where the mother's life is endangered, the detection of "particularly serious" conditions, and conditions that are "incurable at the time of diagnosis" are the only instances in which a therapeutic abortion can be performed, this applying up to the 9th month of pregnancy. Thus numerous conditions, despite the fact that they cause distress or pain or are socially disabling, do not qualify for therapeutic abortion, despite sometimes pressing demands from parents aware of the difficulties in store for their child and themselves, in a society that is not very favourable towards the integration and self-fulfilment of people with a disability. Cleft lip and palate (CLP), although it can be completely treated, is one of the conditions that considerably complicates the lives of child and parents. Nevertheless, the recent scope for making very early diagnosis of CLP, before the deadline for legal voluntary abortion, has not led to any wave of abortions. CLP in France has the benefit of a exceptional care plan, targeting both the health and the integration of the individuals affected. This article sets out, via the emblematic instance of CLP, to show how present fears of an emerging "domestic" or liberal eugenic trend could become redundant if disability is addressed politically and medically, so that individuals with a disability have the same social rights as any other citizen.

Diagnostic/genetic sreening - approach for genetic diagnoses and prevention of cleft lip and/or palate

The treatment, research and volunteer work for cleft lip and/or palate (CL/P) has been led for over 30 years by our team. Within this period, more than 4,000 cases of CL/P were treated and at the same time, and approximately 400 papers were published as the first or partner researcher in Nature Genetics, New England Journal of Medicine and others. In addition, with $20 million that was donated from companies and laypeople, and the grant from the Japanese government, CL/P centres in many countries and in Japan, the oral and craniofacial congenital anomaly gene bank in our CL/P centre was established by our leadership. In the bank there are genes from approximately more than 8,000 cases. The genes were mapped with Professor Jeffery Murray of Iowa University in the United States, the findings about genetic syndromes such as Van der Woude Syndrome and basal cell nevus syndrome were applied in clinical settings. The genetic counselling section that specialises in the oral and maxillofacial field was established by our effort for the first time in Japan. In this review, our clinical experience and approach for genetic diagnoses and prevention of cleft lip and/or palate will be discussed.

Bamforth syndrome: is porencephaly a new finding?

Bamforth syndrome is a rare inherited condition whose main features are congenital hypothyroidism due to thyroid dysplasia, cleft palate, and spiky hair, with or without choanal atresia and bifid epiglottis. This syndrome is caused by mutations in the gene encoding thyroid transcription factor 2 (TTF-2). Here we report on a newborn with facial dysmorphism, cleft palate, spiky hair, congenital hypothyroidism and that are observed with Bamforth syndrome. This is the first case with Bamforth syndrome in which porencephaly has been observed.

A case report of Gordon's syndrome in a 20-year-old male with free medical family history

Gordon's syndrome is a rare autosomal dominant disease that manifests in childhood. It is characterized by hypertension, hyperkalemic hyperchloremic metabolic acidosis, low renin and usually normal aldosterone levels, and it is sensitive to thiazide diuretics. A 20-year-old male with a history of diagnosed Gordon's syndrome was referred to a nephrology clinic for evaluation. The patient, who was under treatment with hydrochlorothiazide, had been diagnosed with Gordon's syndrome at the age of 11, when he presented hypertension and episodes of hyperkalemic hyperchloremic metabolic acidosis. However, none of his relatives had been diagnosed with this syndrome. Therefore, we assume that our patient might be a case of de novo gene mutation.

[The clefts as inborn defects]

The article refers usual facial clefts, which are not rare anomalies. Relation to other forms of so-called midline defects (limb clefts) is indicated. Syndromic and unusual clefts are rarer than isolated non-syndromic clefts. Clinical features, including minimal symptomatology, etiopathogenesis and population frequency are discussed. From the diagnostic point of view specific, prenatal, postnatal and differential diagnostic approaches are recognized. Preventive aspects, therapy and management of the disease (for cleft lip and palate defects, median cleft palate, broad spectrum of neural tube defects including anencephaly, limb clefts etc.) are important. We estimated the empiric risk of the recurrence and suggest methods for preconceptional preventive care.

Ectrodactyly-ectodermal dysplasia-cleft syndrome (EEC syndrome) with a developmental delay caused by R304W mutation in the tp63 gene

Ectrodactyly-ectodermal dysplasia-cleft syndrome (EEC) results from a simultaneous developmental abnor-caused by mutations of the tp63 gene. Five mutations: 204, 227, 279, 280, and 304 account for most cases of this syndrome. A case with R304W mutation, characterized by the presence of all major (ectrodactyly, ectodermal dysplasia, cleft lip and palate) and two minor (lacrimal duct obstruction, developmental delay) clinical symptoms of the syndrome is presented. This severe case improves the existing knowledge concerning the genotype-phenotype correlations in EEC syndrome.

[Clinical evaluation of the five-digit numerical recording system for classification of cleft lip and palate deformities]

OBJECTIVE

To evaluate the five-digit numerical recording system (LAPAL system) for classification of cleft lip and palate.

METHODS

Fourteen young doctors took part in the study after receiving one-hour instruction twice for the LAPAL system. Photographs of 200 cases of untreated cleft lip and palate were used for the evaluation. The diagnostic codes of the patient were recorded and compared with the teacher's standard diagnosis. The basic criterion of the LAPAL system was that the clefts were arranged in five anatomical components in order of right lip (L), right alveolus and primary palate (A), secondary palate (P), left alveolus and primary palate (A), and left lip (L). The degrees of the cleft severity were recorded with Arabic number 0 for the intact, 1 for the subcutaneous or submucous cleft, 2 for clefts smaller than half of a component, 3 for clefts larger than half of a component, 4 for complete clefts.

RESULTS

The rate of the diagnostic coincidence was 88% (2475/2800) totally. The higher coincidence appeared in degree 4 of cleft lip and in degree 4 of cleft alveolar and cleft primary palate as 99% (707/714) and 100% (546/546), respectively. The lower coincidence appeared in degree 2 and degree 3 of clefts of the alveolus and primary palate as 70% (98/140) and 82% (103/126), respectively. Among the 17 types of possible cleft combination, 14 types were found in the present study.

CONCLUSIONS

The LAPAL system is easily understood and grasped in a short time. Clefts on the border of adjoin degrees may cause confusion in diagnosis. More training or simplified modification is suggested.