Morphology of isolated cleft palate in children, including Robin sequence, treated with one or two-stage operations

Detailed Cleft Measurements: A Comparison between Isolated Cleft Palates and Cleft Palates Associated with Cleft Lips

Objective

To determine whether there are differences in the anatomical cleft measurements between patients with isolated cleft palate (CP) with or without Pierre Robin sequence (PR) and those with cleft lip and palate (CLP).

Design

Prospective case series.

Setting

Tertiary care university-based medical center.

Patients

From 1993 to 2012, CP and CLP patients were prospectively enrolled in a database.

Main Outcome Measures

Several anatomical cleft parameters were recorded with precise measurements at the time of palatoplasty under general anesthesia.

Results

One hundred twenty-five patients were included in our study: 50 patients in the CP without PR group, 87 patients in the CP with or without PR (CPPR) group, and 38 patients in the CLP group. Patients in the CLP group had increased values for the following parameters compared to patients with CP and patients with CPPR: nasopharyngeal depth ( P = .02 and P = .01, respectively); cleft width at posterior hard palate border ( P < .001 and P < .001); width of the dental arch ( P < .001 and P < .001); and total cleft length ( P < 01 and P < .001). For cleft width at the soft palate level, there was a significant difference between the CP and CLP groups ( P = .005). We found no statistically significant differences between the groups (CLP versus CP and CPPR, respectively) for the length of the soft palate ( P = .74, P = .21) or for the length of the hard palate ( P = .19, P = .08).

Conclusion

There are significant differences in cleft and palate measurements between CLP and CP patients that may be useful to predict the occurrence of velopharyngeal insufficiency or other complications.

Isolated versus Pierre Robin Sequence Cleft Palates: Are They Different?

Objective

To determine if there are any differences in size between isolated cleft palates (CPs) and those associated with Pierre Robin (PR) sequence.

Study Design

Prospective case series.

Settings

Tertiary care hospital.

Subjects and Methods

From 1993 to 2011, nonsyndromic isolated CP and PR sequence cases were classified as severe if the patients had respiratory or feeding difficulties. While patients were under general anesthesia, seven anatomical cleft parameters were prospectively measured in the operating room at the time of palatoplasty.

Results

Fifty-seven patients without the PR sequence and 36 patients with the PR sequence were enrolled. Within the PR group, 61% of cases were mild and 39% were severe. A larger soft palate width was found to be statistically significant in a comparison of the severe PR cases with the isolated clefts ( P < .005) and mild PR ( P < .05), respectively. For the hard palate width, a statistically significant difference was found in a comparison of the narrower isolated cleft cases with the mild PR ( P < .05) and the severe PR cases ( P < .05), respectively. A shorter cleft length was found to be statistically significant in isolated clefts versus both the clefts of the mild PR ( P < .05) and the severe PR cases ( P < .05).

Conclusions

The patients with PR sequence presented statistically significant different cleft characteristics. The increased width of the cleft at the soft palate level showed the greatest correlation with increased airway and feeding problems.

Association between cleft size and crossbite in children with cleft palate and unilateral cleft lip and palate

OBJECTIVE

To investigate the association between cleft size in infancy and crossbite at 5 years of age in children with cleft palate (CP) and unilateral cleft lip and palate (UCLP).

DESIGN

Retrospective study.

SETTING

University Hospital, Uppsala, Sweden.

PATIENTS

Dental study models of 80 consecutive children, 51 children with CP and 29 children with UCLP, born between 1990 and 1999 were analyzed.

INTERVENTIONS

Lip repair at 3 to 4 months in UCLP children. Primary soft palate repair at 6 to 10 months and secondary hard palate closure at 25 to 26 months of age.

MAIN OUTCOME MEASURES

Maxillary arch dimensions and cleft size were measured on infancy dental casts. At follow-up at 5 years, crossbite scores were registered on dental study models.

RESULTS

The cleft dimensions in infancy showed large interindividual variation. Mean posterior cleft width was larger in UCLP children than in children with CP. The UCLP group also had significantly more crossbite at 5 years than the CP group. No significant association was noted between initial cleft size and crossbite scores at 5 years in the CP group. For the UCLP group, larger cleft widths at the level of the cuspid points were significantly associated with less anterior and posterior crossbite.

CONCLUSIONS

The findings support the hypothesis that cleft size in infancy affects early outcome with respect to crossbite in children with UCLP, but not in children with CP.

Mesio-Distal and Buccal-Lingual Tooth Dimensions are Part of the Cleft Spectrum: A Pilot for Future Genetic Studies

Objective : Considering that oral clefts and tooth dimensions may be part of the same phenotypic spectrum, the aim of this study was to investigate tooth dimensions in permanent dentition and dental malformations, including tooth size discrepancies, of subjects born with clefts compared with individuals without clefts. Design : Cross-sectional study. Participants : The cleft group was composed of 66 subjects, and the noncleft group consisted of 66 healthy unrelated subjects. Main Outcome Measures : The mesio-distal and buccal-lingual crown diameter of fully erupted permanent teeth outside the cleft area was measured using a digital caliber. Clinical records and radiographs were used to evaluate the type of clefts and dental anomalies. Results : The lower second premolar was significantly reduced in the CLP and CP groups. The upper lateral incisor was found to be significantly smaller in the CP group, only for mesio-distal dimensions (P < .05). Dental agenesis was found in eight (12%) cleft subjects and supernumerary teeth in two (3%). Conclusions : Subjects born with oral clefts presented size reduction in specific dental groups.

Modified Von Langenbeck cleft palate repair using an anterior triangular flap: decreased incidence of anterior oronasal fistulas

OBJECTIVE

A complication following cleft palate surgery is the development of oronasal fistulas. Despite recent advances aimed at addressing this concern, rates of postoperative fistulas have remained unchanged and are reported at between 3% and 60%. Oronasal fistulas commonly occur between the hard and soft palate and at the anterior portion of the cleft. These fistulas lead to functional problems with nasal emission, hypernasal speech, and food regurgitation through the nose. For clefts of the secondary palate, we developed a modification of the Von Langenbeck technique in which an anterior triangular flap is used to decrease the incidence of postoperative fistulas.

METHOD

A triangular flap composed of oromucosa was designed for isolated clefts of the secondary palate only. It is based at the anterior margin of the cleft and is used as a turnover flap to allow closure of the often very tight anterior nasal side. A retrospective chart analysis was performed from 2000 to 2007. All patients who had isolated clefts of the secondary palate and had undergone a modified Von Langenbeck procedure were included in the study. Patients were evaluated 4 to 8 weeks postoperatively for the presence of oronasal fistulas.

RESULTS

With the introduction of the anterior triangular flap, we show that 0 of 182 patients developed a postoperative oronasal fistula.

CONCLUSIONS

This modification of the standard Von Langenbeck uses an anterior triangular flap and confers the advantage of assisting in nasal side closure of the anterior margin of the cleft; in doing so, it reduces the rate of fistula formation.

Prevalência de fissuras labiopalatais no município de Campos dos Goytacazes-RJ, 1999-2004

O objetivo deste estudo foi determinar a prevalência de fissuras labiopalatais no município de Campos dos Goytacazes-RJ, Brasil, em crianças nascidas entre 01/01/1999 e 31/12/2004. Foram considerados a faixa etária, tipo de fissura, sexo e raça da criança, além do estado civil, grau de escolaridade e procedência da mãe do portador na época do parto. Deste modo, foram verificados os prontuários de pacientes inscritos em serviços de referência em tratamento de anomalias craniofaciais, com o objetivo de selecionar os nascidos e/ou domiciliados no município de Campos dos Goytacazes. Após seleção inicial, foi realizada busca no Sistema de Informações sobre Nascidos Vivos (SINASC), definindo o universo do estudo, a saber: nascidos vivos entre 1999 e 2004, cujas mães eram residentes em Campos dos Goytacazes. Neste período, o número de nascidos no município, por residência da mãe, foi de 46.707, dos quais 63 possuíam algum tipo de fissura labiopalatal, representando uma prevalência de 1,35 casos por 1000 nascidos vivos. A análise dos dados revelou que 55,6% dos pacientes eram do sexo masculino. Os tipos de fissuras mais encontrados foram o de lábio e palato e o de palato isolado (34,9% cada). Embora a raça branca tenha representado 61,3% dos indivíduos estudados, o percentual de casos por raça não diferiu estatisticamente em relação à distribuição de nascidos na população. Com relação à mãe do portador, a maior parte das mães era solteira ou casada, possuindo como característica o baixo grau de escolaridade.

Dental occlusion after Veau-Wardill-Kilner versus minimal incision technique repair of isolated clefts of the hard and soft palate

OBJECTIVE

To compare the Veau-Wardill-Kilner technique with a technique similar to the minimal incision technique described by Mendosa et al. on the basis of surgical complications and dentoalveolar status in the deciduous dentition.

DESIGN

Retrospective study of medical and dental records and casts.

PATIENTS

A consecutive series of 129 Caucasian children born with isolated cleft palate between 1980 and 1992.

MAIN OUTCOME MEASURES

From medical records, the variables of time for surgery, blood loss, complications in the immediate postoperative period, and frequency of fistulas were evaluated. On dental casts, the variables of sagittal, transversal, and vertical relations; structure of the palatal mucosa; and height of the palatal vault were studied.

RESULTS

Time for surgery was shorter in the extensive clefts repaired with a Veau-Wardill-Kilner technique. Blood loss was higher using the Veau-Wardill-Kilner technique. The width of the upper jaw was significantly narrower in the Veau-Wardill-Kilner group, compared with the minimal incision group. Scar tissue and pits of the palate were more frequently found in the Veau-Wardill-Kilner group.

CONCLUSIONS

The minimal incision technique in this study has been shown to result in better development of the upper jaw with a better dental occlusion and palatal mucosa with significantly less scar tissue.

Maxillofacial pathology and management of Pierre Robin sequence

Pierre Robin sequence affects 1:8500 newborns and is characterized by cleft palate, micrognathia, and airway obstruction. Evolution in the understanding of the causes and pathogenesis of this condition is reviewed. Clinical findings and treatment options are also addressed. An overview of syndromes commonly associated with Pierre Robin sequence is provided.