Cleft lip and palate in Norway. I. Registration, incidence and early mortality of infants with CLP

Household and context-level determinants of birth registration in Sub-Saharan Africa

While according to the United Nations birth registration is a human right, in sub-Saharan Africa (SSA) only half of new-born children currently have their birth registered. To gain insight into the reasons behind this low registration rate, we study the role of determinants at the household, sub-national regional and country level, using self-reported birth registration data on 358,842 children in 40 SSA countries. While most of the variation in reported birth registration is due to factors at the household level, context factors are found to play an important role as well. At the household level, poverty, low education, restricted autonomy of women, and belonging to a traditional religion are associated with lower odds of being registered. Lack of professional care during pregnancy, delivery, and early life also decrease the odds of being registered. Important factors at the context level are the average number of prenatal care visits in the local area, living in an urban area, the kind of birth registration legislation, decentralization of the registration system, fertility rates, and the number of conflicts. To improve registration, the complex dynamics of these factors at the household and context level have to be taken into account.

Norwegian Orthodontists' Experience and Challenges With Treatment of Patients With Cleft Lip and Palate

Background:

Patients born with cleft lip and/or palate (CL/P) have orthodontic treatment challenges due to maxilla deficiency, malocclusions, and dental abnormalities. In Norway, orthodontic treatment is done by centralized CL/P teams. Due to traveling restrictions, this treatment might be done locally in the future. The experience of Norwegian community orthodontists in managing such patients has not been investigated previously.

Objective:

To assess Norwegian orthodontists’ management of patients with CL/P and need for further education.

Material and Methods:

All orthodontists in Norway were sent a questionnaire about their experience, challenges, and knowledge and asked about their need of further theoretical education and clinical training in the management of patients with CL/P.

Results:

Norwegian orthodontists’ standard of knowledge of CL/P treatment is adequate. However, few respondents have treated a high number of cleft patients. Eighty-six percent of the participants believed that treating CL/P patients involves challenges, such as time-consuming treatment and technical difficulties. Increased perceived need for more education was revealed among participants stated unpreparedness during education (4 folds), encountered challenges, and lack of knowledge (almost 3 folds).

Conclusions:

The study revealed that community orthodontists in Norway lack experience and acknowledged the challenges in treating patients with CL/P. Most of the respondents perceived a need for additional education and clinical training to treat CL/P patients competently. The findings suggested more focus on patients with CL/P management in the curricula and more collaboration between centralized CL/P teams and community orthodontists.

The Influence of Consanguinity on Familial Clefting Among Palestinians

INTRODUCTION

Orofacial clefts (OFC) are the most common congenital craniofacial anomaly. The relationship between intermarriage (consanguinity) and positive family history for OFC is not well described. Consanguinity rates in developed countries are <1% but are considerably higher in the Middle East (45%). Familial clefting rates in developed countries are under 20% but in the Middle East are reported at 30% or higher.

OBJECTIVE

To determine OFC demographics and to clarify the relationship between consanguinity and familial clefting among Palestinians.

DESIGN

The Palestinian Congenial Anomalies Database is based on a 700-question survey administered to mothers of children with congenital anomalies. Orofacial clefts were diagnosed in 540 children. All demographic data were analyzed using χ² tests with a level of significance at α < .05.

RESULTS

Demographics for OFC among Palestinians were similar to other published reports. Overall consanguinity rate was 53% and familial clefting rate was 49%. Parental rates of consanguinity were significantly different for patients with cleft palate. Patients with consanguineous parents had a higher rate of positive family history of clefting (67%). Recurrence of clefts in siblings was significantly higher among those born to consanguineous parents (73%) when compared to nonconsanguineous parents.

CONCLUSION

Consanguinity rates for Palestinians with OFC were higher than those reported in the Middle East. Familial clefting and sibling recurrence rates were also higher than expected. The risk of OFC may be mitigated with improved education about anticipated genetic consequences of consanguinity in high-risk populations such as the southern West Bank.

Pattern of clefts and dental anomalies in six-year-old children: a retrospective observational study in western Norway

OBJECTIVES

Clefts of the lip and/or palate (CL/P) are the most common congenital disorders of the head and neck. In Norway, the incidence is 1.9/1000 live births. The aim of this study was to investigate the frequency and distribution of various types of clefts and dental anomalies in patients treated by the cleft lip and palate (CLP) team in Bergen, Norway.

MATERIAL AND METHODS

The material comprised the records of patients 6 years of age, examined by the CLP team in Bergen from spring 1993 to autumn 2012, incomplete records were excluded. The records of 989 patients were analysed, using frequencies and Chi-square test to compare differences in percentages between groups.

RESULTS

The gender distribution was 58.8% male and 41.2% female. Isolated cleft palate (CP) was the most common condition (39.5%). Clefts of the lip, jaw and palate (CLP) constituted (30%) of cases and (30.5%) had isolated cleft lip (CL). The frequencies of agenesis, supernumerary and peg-shaped teeth were (36.5%), (17.8%) and (7.5%), respectively. Over 50% of the study population were diagnosed with one or more malocclusion. Of the CLP patients, 61.4% had Angle Class III occlusion. Statistical analysis disclosed a positive association of agenesis with Class III occlusion (OR =1.8, p≤ 0.001).

CONCLUSIONS

The findings supported the hypothesis that the distribution of dental anomalies and occlusal disorders varied among patients with CL, CP and CLP. In patients with cleft, there is a twofold chance to get Class III malocclusion in the presence of agenesis.

A descriptive epidemiology study of cleft lip and palate in Northern Finland

OBJECTIVE

The aim of this study was to determine the incidence of cleft lip and/or cleft palate in a population uniquely from Northern Finland.

MATERIALS AND METHODS

The records of a total of 214 cleft patients treated between 1998-2011 at the Oulu Cleft Lip and Palate Center at the University of Oulu were assessed on a retrospective basis. Data regarding cleft type, sex and side of cleft was collected and analyzed. Family history of clefting was investigated.

RESULTS

Cleft palate (68.7%) was most frequently found, followed by cleft lip and palate (18.7%) and cleft lip with or without alveolus (12.6%). Cleft palate occurred more frequently in females (63.3%) and cleft lip and palate was more frequently found in males (62.5%). The left side was more frequently affected in both male and female patients. Left-sided clefts were observed in 82% of patients compared to right-sided clefts in 18%. A family history of clefting was detected in 20.1% of patients.

CONCLUSION

The incidence of clefts in Northern Finland is higher than the corresponding incidence in other European countries. Cleft palate was the most frequent cleft type and it was more frequent in females. In males, cleft lip and palate was more frequent. The left side was more frequently affected in both genders. One fifth of the patients had a family history of clefts.

Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India

Objective:

To assess the incidence of cleft lip and palate defects in the state of Andhra Pradesh, India.

Design Setting:

The study was conducted in 2001 in the state of Andhra Pradesh, India. The state has a population of 76 million. Three districts, Cuddapah, Medak and Krishna, were identified for this study owing to their diversity. They were urban, semi-urban and rural, respectively. Literacy rates and consanguinity of the parents was elicited and was compared to national averages to find correlations to cleft births. Type and side of cleft were recorded to compare with other studies around the world and other parts of India.

Results:

The birth rate of clefts was found to be 1.09 for every 1000 live births. This study found that 65% of the children born with clefts were males. The distribution of the type of cleft showed 33% had CL, 64% had CLP, 2% had CP and 1% had rare craniofacial clefts. Unilateral cleft lips were found in 79% of the patients. Of the unilateral cleft lips 64% were left sided. There was a significant correlation of children with clefts being born to parents who shared a consanguineous relationship and those who were illiterate with the odds ratio between 5.25 and 7.21 for consanguinity and between 1.55 and 5.85 for illiteracy, respectively.

Conclusion:

The birth rate of clefts was found to be comparable with other Asian studies, but lower than found in other studies in Caucasian populations and higher than in African populations. The incidence was found to be similar to other studies done in other parts of India. The distribution over the various types of cleft was comparable to that found in other studies.

Congenital Anomalies Associated with Cleft Lip and Palate—An Analysis of 1623 Consecutive Patients

Objective

To document the frequency and nature of associated anomalies in cleft lip and/or palate patients from a craniofacial center in India.

Setting

Craniofacial Surgery & Research Centre, SDM College of Dental Sciences & Hospital, Dharwad, India.

Patients/Participants

A total of 1623 consecutive patients with cleft lip and/or cleft palate treated in a 40-month period.

Main Outcome Measure

Frequency and nature of associated anomalies, analyzed according to the cleft type and principal organ system and/or area affected.

Results

The overall male to female ratio was 1.8:1. Unilateral cleft lip with cleft palate (41%) was the most frequent cleft subtype, followed by cleft lip and/or cleft alveolus (33%); isolated submucous cleft palate (1%) was the least frequent. A total of 240 (14.8%) patients had associated anomalies, and these were more frequent in males (M:F = 1.4:1). Per patient, anomalies were most frequent in the submucous cleft group (mean, 0.53) and least common in the cleft lip with or without cleft alveolus (mean, 0.14). Anomalies were most frequent in the facial region (21%), followed by the ocular (17%), central nervous (15%), gastrointestinal (3%), and urogenital (2%) systems. Thirty-four patients (2%) had recognized nonchromosomal syndromes; this was more common in the cleft palate group.

Conclusions

Associated anomalies are not uncommon in patients with cleft lip and/or palate, though the frequency varies with the cleft type and organ system affected.

Maxillary arch width in unoperated adult bilateral cleft lip and alveolus and complete bilateral cleft lip and palate

OBJECTIVES

To study maxillary arch width in adult patients with bilateral cleft lip and alveolus (BCLA) or with complete bilateral cleft lip and palate (BCLP), who have not had any surgery. SETTING AND SAMPLING POPULATION: Eighteen patients with BCLA, 13 patients with BCLP, and 24 controls from remote areas of Indonesia collected over 10 years.

MATERIALS AND METHODS

Dental casts were digitized three-dimensionally using an industrial coordinate measuring machine (CCM) (Zeiss Numerex; Carl Zeiss, Stuttgart, Germany). Transversal distance between molars was measured on the tip of the distobuccal cusp and the tip of the mesiobuccal cusp, and for premolars and canines, the tip of the buccal cusps was recorded. Means and standard deviations were calculated for all variables. t-Test was used to determine whether the mean values of the cleft groups showed significant differences from each other and from the controls. Level of significance was set at p < 0.05.

RESULTS

Transversal arch dimensions in the BCLA group were comparable to the controls except at the canine level. Intercanine distance, which is close to the alveolar cleft, was 4.3 mm (SE 1.4) smaller in the BCLA group (p = 0.002). In the BCLP group, a comparable pattern was found. At the canine level, mean transversal width was 7.2 mm (SE 1.9) smaller compared to the control group, but no significant differences were found in the other transversal dimensions.

CONCLUSIONS

Small differences are found in transversal dimensions in patients with BCLA and BCLP compared to a control group. Differences are most outspoken in the area near the cleft.

The embryonic origins of left-right asymmetry

The bilaterally symmetric body plan of vertebrates features several consistent asymmetries in the placement, structure, and function of organs such as the heart, intestine, and brain. Deviations from the normal pattern result in situs inversus, isomerisms, or heterotaxia (independent randomization), which have significant clinical implications. The invariance of the left-right (LR) asymmetry of normal morphology, neuronal function, and phenotype of several syndromes raises fascinating and fundamental questions in cell, developmental, evolutionary, and neurobiology. While a pathway of asymmetrically expressed signaling factors has been well-characterized in several model systems, very early steps in the establishment of LR asymmetry remain poorly understood. In particular, the origin of consistently oriented asymmetry is unknown. Recently, a candidate for the origins of asymmetry has been suggested: bulk transport of extracellular morphogens by rotating primary cilia during gastrulation. This model is appealing because it 'bootstraps' morphological asymmetry of the embryo from the intrinsic structural (molecular) chirality of motile cilia. However, conceptual and practical problems remain with this hypothesis. Indeed, the genetic data are also consistent with a different mechanism: cytoplasmic transport roles of motor proteins. This review outlines the progress and remaining questions in the field of left-right asymmetry, and focuses on an alternative model for 'Step 1' of asymmetry. More specifically, based on wide-ranging data on ion fluxes and motor protein function in several species, it is suggested that laterality is driven by pH/voltage gradients across the midline, which are established by chiral movement of motor proteins with respect to the cytoskeleton.

Cleft palate, transforming growth factor alpha gene variants, and maternal exposures: Assessing gene-environment interactions in case-parent triads

We have previously reported a threefold risk of cleft palate only (CPO) among children homozygous for the less common allele A2 at the TaqI marker site of the transforming growth factor alpha gene (TGFA) (Jugessur et al. [2003a] Genet. Epidemiol. 24:230-239). Here we assess possible interaction between the child's TGFA TaqI A2A2 genotype and maternal cigarette smoking, alcohol consumption, use of multivitamins and folic acid. This was done by comparing the strength of genetic associations between strata of exposed and unexposed case-parent triads. We also looked for possible gene-gene interaction with the polymorphic variant C677T of the folic acid-metabolizing gene MTHFR. We analyzed a total of 88 complete CPO triads selected from a population-based study of orofacial clefts in Norway (May 1996-1998). No evidence of interaction was observed with either smoking or alcohol use. The risk associated with two copies of the A2 allele at TGFA TaqI was strong among children whose mothers did not use folic acid (relative risk=4.5, 95% confidence interval=1.3-15.7), and was only marginal among children whose mothers reported using folic acid (RR=1.4, 95% CI=0.2-12.7). Although the interaction between the child's genotypes at TGFA TaqI and MTHFR-C677T was not statistically significant, the effect of the TGFA TaqI A2A2 genotype appeared to be stronger among children with either one or two copies of the T-allele at C677T (RR=4.0, 95% CI=1.1-13.9) compared to children homozygous for the C-allele (RR=1.7, 95% CI=0.2-15.7). In conclusion, we find little evidence of interaction between the child's genotypes at TGFA TaqI and various exposures for cleft palate, with the possible exception of folic acid intake.

An audit of the Yorkshire Regional Cleft Database

This study assessed the validity of the Yorkshire regional orofacial cleft database by comparing the computer-based records with locally collated records of primary surgical events for babies born over a 2-year period (1994-1995). One-hundred-and-thirty-two infants with clefts (excluding submucous cleft palate) were identified from the latter source with an equal proportion of unilateral cleft lip/palate and isolated cleft palate births. However, only 62 per cent of cases were recorded on the database and the reporting rate of individual cleft units was highly variable (43-85 per cent). In addition, there was a significant under-reporting of both cleft lip and isolated cleft palate cases (42 and 50 per cent ascertainment, respectively). Consequently, the database figures understated the prevalence of all cleft births, but especially of these two cleft subtypes. Conversely, the relative frequency of combined cleft lip and palate cases was exaggerated. The reasons for such discrepancies and possible improvements to data collection are discussed.

Asymmetry of left versus right unilateral cleft impairments: an experimental study of face perception

OBJECTIVE

Previous psychosocial studies of adults born with cleft lip and palate have provided circumstantial evidence that surgically repaired right-sided unilateral clefts may be more disfiguring than left-sided clefts. The present study asked if such asymmetries are physiognomic asymmetries or arise "in the eye of the beholder," representing perceptual processes in face recognition.

DESIGN

Color slides of 160 children (6 years of age) and young teenagers (16 years of age) were rated by subjects for perceived disfigurement. Sixty of the subjects had unilateral complete cleft lip and palate (30 had a right-sided cleft and 30 had a left-sided cleft), 60 had unilateral cleft lip/alveolus (30 right-sided and 30 left-sided clefts), 32 children had bilateral cleft lip and palate, and 8 children had cleft palate only. Faces were shown in normal and in mirror-reversed versions; the order in which faces were shown was randomized, as were other stimulus factors such as cleft type, age, and gender.

SETTING

The study was conducted as a classroom-type experiment at the Vision Laboratory, Department of Psychology, Oslo, Norway.

PARTICIPANTS

Thirty-seven students of psychology at the University of Oslo, who were ignorant of the purpose of the study, acted as subjects.

MAIN OUTCOME MEASURE

Subjects rated perceived disfigurement using a visual analog scale.

RESULTS

Modest but highly consistent hemifacial asymmetries in judged disfigurement were found, with left-sided unilateral clefts rated as less disfiguring than right-sided unilateral clefts. Unilateral clefts were judged as being less disfiguring than the bilateral clefts, and cleft lip/alveolus was judged as being less disfiguring than cleft lip and palate. The patterns of facial judgments were almost identical in the normal and reversed-slides conditions.

CONCLUSIONS

Asymmetries between left- and right-sided clefts reside in physiognomic factors rather than in hemispheric asymmetries controlling the perceptual process of face judgment.

Incidence of cleft lip and palate and risks of additional malformations

OBJECTIVE AND METHODS

Children with cleft lip and/or palate (n = 251) born between 1991 and 1995 in the county of Stockholm, Sweden, were studied with reference to incidence and rate ratios (RRs) of different types of clefts, gender, birth weight, mother's age, and length of pregnancy. Children who had clefts and additional malformations were compared with children who had clefts but no additional malformations.

RESULTS

The incidence of clefts was 2.0/1000 live births, and it was higher among males than among females. The RR, an index of relative risk, was 1.58. The main groups, children with isolated cleft lip, children with cleft lip and palate, and children with isolated cleft palate, showed similar incidence values (0.6-0.7/1000 live births). Children with bilateral clefts had an incidence of 0.3/1000 live births. Additional malformations were found in approximately every sixth newborn with a cleft when children with Robin sequence were excluded. There was a tendency for newborns with bilateral clefts to have additional malformations (RR = 1.36; confidence interval = 0.74-2.49). Children with clefts and additional malformations had lower birth weight and were born earlier than children with clefts only.

CONCLUSION

Preterm cleft children with low birth weight should be screened for the presence of other birth defects.

Birth prevalence of cleft lip and palate in Colorado by sex distribution, seasonality, race/ethnicity, and geographic variation

An epidemiologic study was designed to describe the association of potential risk factors with the occurrence of cleft lip and palate (CL/P) births in Colorado for the years 1982-1988. There were 307 children out of 381,175 live births identified, through birth certificate data, with a diagnosis of cleft palate or cleft lip with or without cleft palate. For this period, the birth prevalence was 0.81/1000. Male gender [odds ratio (OR) = 1.62, 95% confidence interval (CI) = 1.28, 2.04], white race (OR = 2.87, 95% CI = 1.52, 5.44), and non-metropolitan residence (OR = 1.59, 95% CI = 1.23, 2.05) were each associated with an excess risk of having a cleft abnormality of any type at birth. No differences in the occurrence of cleft lip and palate were observed by month of birth, altitude of county of residence, or in Hispanic compared with non-Hispanic newborns. Using information from the 1989 Colorado Registry for Children with Special Needs, there was little evidence of ascertainment bias on major factors of interest for the birth certificate data. Further studies are required to define the factors associated with excess risk of CL/P in non-metropolitan areas.

[Cleft lip and palate: case-control study]

This study relates to a case-control analysis for the purpose of verifying the association between oral clefts and possible risk factors. The analysed variables were: place of mother's residence (urban/rural), pollution, parental diseases, mother's diseases during the first four months of pregnancy, intake of drugs related to this period, heredity, smoking habits, alcohol consumption and X-ray examinations during pregnancy or X-ray examinations prior to pregnancy. There were 450 cases of clefts of whom 354 had a cleft lip with or without cleft palate and 96 had a cleft palate. The relative risk (RR) for each variable by was estimated points and at a 95% of confidence interval and multivariate analysis was applied. As regards cleft lip with or without cleft palate, the risk factors are heredity (RR = 4.96), epilepsy in the mother (RR = 2.39) and the intake of drugs such as anti-inflammatory substance in the first four months of pregnancy (RR = 2.59). Related to cleft palate, the risk factors are heredity (RR = 2.82) and pollution (RR = 2.58).

Prevalence of a soft tissue bridge in a sample of 2014 patients with complete unilateral clefts of the lip and palate

This study examines the prevalence of a soft tissue bridge (Simonart's band) on 2014 Brazilian Caucasian patients with unilateral complete cleft lip and palate (UCLP). A soft tissue bridge occurred in 19.6% of the subjects; 94.9% of the soft tissue bands had skin coverage. The presence of soft tissue bridges was unrelated to gender and the laterality of the cleft.

Cleft lip and palate, scoliosis, skeletal and cardiac malformations and other dysmorphic features in a child. Case report

A girl aged 3 1/2 years presented with cleft lip and palate, facial asymmetry, brachycephaly, persistent ductus arteriosus, vertebral defects, and progressive scoliosis. There was, however, no significant mental and growth retardation.

A study of facial growth in patients with bilateral cleft lip and palate treated by the Oslo CLP Team

Lateral and frontal cephalometric analysis of a mixed longitudinal survey of 90 individuals with complete bilateral clefts of the lip and palate from the Oslo Growth Archive is described. All subjects were treated and followed-up by the Olso CLP Team according to strictly defined protocols for treatment and documentation. Craniofacial form in this sample is generally similar to that reported for Caucasian subjects treated for this condition elsewhere.

A study of facial growth in patients with unilateral cleft lip and palate treated by the Oslo CLP Team

Lateral and frontal cephalometric analysis of a mixed longitudinal survey of 257 individuals with complete unilateral cleft lip and palate from the Oslo CLP Growth Archive is described. All subjects were treated and followed up by the Oslo CLP Team according to strictly defined protocols for treatment and documentation. Craniofacial form for this sample is generally similar to that reported for Caucasian children treated for this condition elsewhere.

Characteristics of premaxillary hyperodontia. A radiographic study

Among 63,029 patients admitted to Department of Oral Radiology, University of Oslo, 900 had a total of 1153 supernumerary teeth located to the premaxillary region. Characteristics of the supernumeraries were predominance in males, predominance in the permanent dentition, predominant location in the central incisor region, and predominant position palatally to the dental arch, vertically oriented, half of them inverted. Interference with the normal dentition included malposition, diastema, maleruption, and resorption. Sequelae included widened follicular space, dentigerous cyst formation, dental pulp necrosis, pulp canal obliteration, root resorption, and ankylosis. Nearly 60% of the patients had radiographic or clinical signs of interference with the normal dentition or of associated complications.

Cleft lip and palate in Finland in 1948-75: correlations to infections, seasonal and yearly variations

Comparison of the patient records of the Finnish Red Cross National Cleft Center and the Central Register of Congenital Malformations showed a statistically significant yearly fluctuation as well as an increasing trend in the incidence of both cleft lip (and palate) and isolated cleft palate during the period 1948-1975. Almost significant difference was found in the monthly incidence of CL(P) with the peak in children born in April, while no such difference could be noticed in CP or both groups combined. The rapid increase and similarity of the incidence curves of both CL(P) and CP is suggestive of the action of simultaneous and similar exogenous agents in the pathogenesis of both types. In patients with CL(P) the etiological factor was considered to have been active 35 weeks and in CP 31 weeks before delivery. The monthly number of clefts was compared to the number of serologically verified infections (influenza A, respiratory syncytical, mumps, measles, rubeola, parainfluenza, adenoviruses as well as Mycoplasma pneumoniae) in the years 1971-75. No statistically significant correlation was found in this respect.

Increasing incidence of clefts in Finland: reliability of hospital records and central register of congenital malformations

The treatment of cleft lip and/or palate [CL(P), CP] in Finland has been centralized to one unit since 1947. Since 1963 all congenital malformations are reported to a central register. Comparison of these two materials showed that altogether 3928 children with clefts, born from 1948 to 1975, were registered in a total of 2 258 850 live born children in Finland, corresponding an incidence of 1.74%. There was a constant registered rise in the incidence from 1.31% in 1948-52 to 2.16% in 1969-75, indicating a corrected "true" increase in the incidence by 33% in 28 years, or approximately by over one percent per year. Of all registered clefts born 1963-75 23.5% were lacking from the Register of Congenital Malformations, and 10.3% from the hospital records. In 1948-75 55.8% of the clefts belonged to the group CP and 44.2% to CL(P). The incidence of CP increased from 0.78% in 1948-52 to 1.21% in 1969-75, and that of CL(P) from 0.53 to 0.95%. An average of 13,8% of the CP-cases were submucous clefts. Their registered incidence in all live born children increased from 0.08% in 1948-52 to 0.19% in 1969-75.