Predictors of Adverse Outcomes Following Cleft Palate Repair: An Analysis of Over 2500 Patients Using International Smile Train Data

OBJECTIVE

The objective of this study was to use data from Smile Train's global partner hospital network to identify patient characteristics that increase odds of fistula and postoperative speech outcomes.

DESIGN

Multi-institution, retrospective review of Smile Train Express database.

SETTING

1110 Smile Train partner hospitals.

PATIENTS/PARTICIPANTS

2560 patients.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Fistula occurrence, nasal emission, audible nasal emission with amplification (through a straw or tube) only, nasal rustle/turbulence, consistent nasal emission, consistent nasal emission due to velopharyngeal dysfunction, rating of resonance, rating of intelligibility, recommendation for further velopharyngeal dysfunction assessment, and follow-up velopharyngeal dysfunction surgery.

RESULTS

The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 ± 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased velopharyngeal dysfunction and fistula surgery compared to Asian patients. Palatoplasty technique primarily involved one-stage midline repair.

CONCLUSIONS

Age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train's continual expansion of accessible surgical intervention, nutritional support, and speech-language care.

Systematic Review and Critical Appraisal of the Evidence Base for Nasoalveolar Molding (NAM)

OBJECTIVE

To critically appraise the body of scientific literature supporting the risks and efficacy of nasoalveolar molding (NAM), specifically in contrast to alternative methods of presurgical infant orthopedics (PSIO) or to treatment without PSIO.

MAIN OUTCOME MEASURES

Five outcome domains were considered: nasolabial aesthetics; dentoalveolar relationship; midfacial growth; cost and burden of care; and number of anesthetic events.

DESIGN

MEDLINE, Embase, and Scopus were queried for articles from the first description of the Grayson-Santiago NAM technique (1993) through December 13, 2021. After the application of inclusionary and exclusionary criteria, selected articles were critically appraised using a systematic framework that included risk of bias assessment using the Cochrane RoB 2.0 and ROBINS-I tools.

RESULTS

A total of 88 studies were included. Level-I and -II evidence showed on par or better approximation and alveolar alignment achieved by NAM compared to other PSIO. Level-II and -III evidence showed improved nasolabial aesthetics compared to other PSIOs. Level-II and -III evidence supported no harm to maxillofacial skeletal growth through age 12. Sparse level-III evidence supported a reduced number of labial or nasal revisions following NAM. Level-II and -III evidence showed NAM requiring upfront cost and frequent appointments but reducing caregiver psychosocial burden and reducing long-term costs compared to select alternatives. Many studies carried a high risk of bias.

CONCLUSIONS

Current evidence supports the overall efficacy of NAM regarding short/mid-term outcomes, with a low risk of negative effects on midfacial growth or dental development. The high risk of bias discovered in many papers underscores the need for robust study design in future research.

Assessment of Internal Nasal Dimensions of Individuals With Cleft Lip and Palate and Obstructive Sleep Apnea Syndrome by Computed Tomography

To evaluate nasal cavity (NC) dimensions of individuals with cleft lip and/or palate (CL/P), obstructive sleep apnea (OSA), and primary snoring, by tomographic image analysis, compared to individuals with OSA without CL/P (N-CL/P).

Cross-sectional and retrospective.

Tertiary referral center.

Patients were divided into 2 groups: (G1) CL/P + OSA or primary snoring, n = 11; (G2) N-CL/P + OSA, n = 13.

NC tomographic images were reconstructed using ITK-SNAP software, and measurements were obtained from these three-dimensional models using SpaceClaim software.

Total NC volumes, right and left NC volumes, and volumes of the nostril to the nasal valve (V1) and from the nasal valve to the superior limit of the nasopharynx (V2), cross-sectional areas, and perimeters.

NC volumes (total, right, and left sides), V1, and V2, though smaller in the CL/P + OSA, did not differ significantly from the N-CL/P + OSA. Cross-sectional areas and perimeters of the superior limit of the nasopharynx, in the CL/P + OSA, presented significantly higher values compared to the N-CL/P + OSA (P ≤ .05).

The internal nasal dimensions of patients with CL/P do not seem to be part of the etiopathogenesis, nor constitute a risk factor for OSA with greater severity, in this special group of patients.

Can MRI Replace Nasopharyngoscopy in the Evaluation of Velopharyngeal Insufficiency?

OBJECTIVE

To investigate whether flexible nasopharyngoscopy, when performed in addition to magnetic resonance imaging (MRI), influences the type of surgery selected or success of surgery in patients with velopharyngeal insufficiency (VPI).

DESIGN

Cohort study.

SETTING

A metropolitan children's hospital.

PATIENTS

Patients with non-syndromic, repaired cleft palate presenting for management of VPI.

INTERVENTIONS

MRI and nasopharyngoscopy or MRI alone for preoperative imaging of the velopharyngeal mechanism.

MAIN OUTCOME MEASURES

(1) Surgical selection and (2) resolution of hypernasality. All speech, MRI, and nasopharyngoscopy measurements were performed by raters blinded to patients' medical and surgical history.

RESULTS

Of the 25 patients referred for nasopharyngoscopy, 76% completed the exam. Of the 41 patients referred for MRI, the scan was successfully completed by 98% of patients. Completion of nasopharyngoscopy was significantly (p=0.01) lower than MRI. Surgical selection did not significantly differ (p=0.73) between the group receiving MRI and nasopharyngoscopy and the group receiving MRI alone, nor was there a significant difference between these groups in the proportion of patients achieving resolution of hypernasality postoperatively (p=0.63). Percent total velopharyngeal closure assessments on nasopharyngoscopy and MRI were strongly correlated (r=0.73).

CONCLUSIONS

In patients receiving MRI as part of their preoperative VPI evaluation, the addition of nasopharyngoscopy did not result in a difference in surgical selection or resolution of hypernasality. Routine inclusion of nasopharyngoscopy may not be necessary for the evaluation of velopharyngeal anatomy when MRI is available.

Choosing a Multidisciplinary Cleft and Craniofacial Team: Medical, Surgical, and Social Considerations

Cleft and craniofacial conditions often present with a variety of functional and esthetic sequelae optimally treated by a multidisciplinary approach. Diagnosis of such conditions pre- or postnatally may evoke parental uncertainty and anxiety, and an important primary consideration is the selection of a cleft and craniofacial team. Identifying an optimal team may be particularly important for developing long-term relationships with clinicians who will ideally work intimately with the family from diagnosis to adulthood. While families, parents, and providers should consider several factors, a dearth of evidence-based suggestions preclude critical appraisal of cleft and craniofacial teams. In this article, the authors summarize medical, surgical, and social considerations for selecting a cleft and craniofacial team to optimize patient outcomes and the family/caregiver experience.

Evaluation of Anxiety in Turkish Parents of Newborns with Cleft Palate with or Without Cleft Lip

OBJECTIVE

(1) To compare anxiety between parents of newborns with cleft lip and palate (CLP), isolated cleft palate (CP), and healthy newborns and (2) to evaluate anxiety between parental dyads within these groups.

DESIGN

A cross-sectional study.

SETTING

University Hospital.

PARTICIPANTS

Surveys were completed by 20 mothers and 20 fathers of newborns with CLP, 21 mothers and 21 fathers of newborns with CP, and 23 mothers and 23 fathers of healthy newborns (controls).

MAIN OUTCOME MEASURE

The State-Trait Anxiety Inventory (STAI) assessed parental anxiety. Mothers of newborns with a cleft reported on concerns regarding cleft-related issues and facial appearance.

RESULTS

State and trait anxiety were generally in the moderate range for parents of newborns with a cleft, while control parents had low state anxiety and moderate trait anxiety. Mothers of newborns with CP and CLP had significantly higher state and trait anxiety levels than control mothers (p < .05). Fathers of newborns with CLP had a higher state anxiety level than control fathers. When maternal and paternal anxiety was compared within the groups, only trait anxiety scores were significantly higher in mothers of newborns with CLP than that of fathers (p < .05). More than half of mothers of newborns with a cleft were concerned about their newborn's feeding, speech, and palate.

CONCLUSIONS

Parents of children with a cleft may need psychological support in the early postnatal period. It is important for neonatal cleft team providers to help reduce parental anxiety and educate families about cleft care, with a focus on feeding.

Correlation between Cleft Width and Adjacent Teeth Inclination in Patients with Unilateral Cleft Lip and Palate Using CBCT: A Retrospective Study

OBJECTIVES

To evaluate buccolingual and mesiodistal inclination of cleft-adjacent maxillary permanent central incisors (U1) and canines (U3) in patients with unilateral cleft lip and palate (UCLP) in the late mixed dentition and to investigate the correlation between the alveolar cleft width and cleft-adjacent teeth inclination using cone beam computed tomography (CBCT).

DESIGN

Observational cross-sectional retrospective study.

SETTING

Department of Orthodontics, Hama University Dental School.

PATIENTS

32 patients with UCLP (22 boys, 10 girls; mean age = 10.53 ± 1.51 years).

MAIN OUTCOME MEASURE

Buccolingual and mesiodistal inclination of maxillary central incisors and canines were measured on both sides. Then, the cleft and non-cleft sides were compared using the Wilcoxon signed-rank test. Pearson's correlation was used to explore the association between the alveolar cleft width and cleft-adjacent U1 and U3 buccolingual and mesiodistal inclination.

RESULTS

The cleft-adjacent central incisors were significantly inclined lingually and distally compared with their non-cleft antimeres (P = .003, P < .001, respectively). The cleft-adjacent canines were significantly inclined buccally and mesially compared with their non-cleft antimeres (P < .001, for both). A positive correlation was found between the buccolingual inclination of cleft-adjacent U1 and the alveolar cleft width (r = 0.49, P = .004).

CONCLUSIONS

Patients with UCLP demonstrated a significant lingual and distal inclination of cleft-adjacent U1 and a significant buccal and mesial inclination of cleft-adjacent U3. The buccolingual inclination of cleft-adjacent U1 tends to increase with increasing the alveolar cleft width; however, the correlation was weak.

Three-dimensional Analysis of Maxillary Morphology in Infants with Unilateral Cleft Lip and Palate

OBJECTIVE

To three-dimensionally (3D) analyze the maxillary morphology of infants with unilateral cleft lip and palate (UCLP) and preliminarily classify the alveolar arch to assist in personalization of sequence therapy.

DESIGN

Retrospective study.

SETTING

Patients with UCLP referred to outpatients' clinic.

PARTICIPANTS

84 nonsyndromic infants with complete UCLP were recruited (58 boys, 26 girls, mean age 29.48 days).

MAIN OUTCOME MEASURE

Morphometric analysis was conducted on 3D maxillary models. Principal component analysis (PCA) and cluster analysis were combined to classify maxillary phenotypes preliminarily. The Wilcoxon Signed Rank test and the Kruskal-Wallis test were used to compare differences between variables. A P value less than .05 was considered statistically significant.

RESULTS

The maxilla was divided into three types: narrow, homogenous and broad, accounting for 9.52%, 23.81% and 66.67% respectively. The alveolar cleft site (median value) was located in 61% of the total length of the alveolar arch. In the comparison of anterior and total alveolar lengths, the non-cleft side had longer alveolar bone than the affected side, a difference of approximately 2 mm. Pairwise comparisons of variables describing alveolar symmetry revealed significant differences in all subjects; whereas type C had poorer arch symmetry than types A and B, mainly in terms of anterior and overall symmetry.

CONCLUSIONS

In infants with UCLP, the maxillary alveolar arch was inherently asymmetrical with partially bone missing (about 2 mm). Significant differences in alveolar bone morphology and symmetry exist between different types of infants, with individuals with broad clefts (type C, the largest proportion) having the worst maxillary development.

Effect of Veau Class on Levator Veli Palatini Muscle Composition

OBJECTIVE

To examine levator veli palatini muscle composition in patients with nonsyndromic cleft palate and investigate the impact of Veau class.

DESIGN

Prospective cohort study.

SETTING

Tertiary care academic hospital.

PATIENTS/PARTICIPANTS

Thirteen patients with nonsyndromic cleft palate were recruited.

INTERVENTIONS

During primary palatoplasty, a sample of levator veli palatini muscle was excised and prepared for histological analysis.

MAIN OUTCOME MEASURES

Fat and collagen content were determined utilizing Oil Red and Sirius red stains, respectively, while muscle fiber cross-sectional areas were calculated from H&E-stained samples, with analysis using histomorphometric methods. Immunofluorescent staining of myosin heavy chain isoforms was performed.

RESULTS

Patients underwent repair at 10.8 months of age (interquartile range [IQR] 10.2-12.9). Fat content of the levator veli palatini muscle was low in both groups, ranging from 0% to 5.2%. Collagen content ranged from 8.5% to 39.8%; neither fat nor collagen content showed an association with Veau classes. Mean muscle fiber cross-sectional area decreased with increasing Veau class, from 808 µm2 (range 692-995 µm2) in Veau II to 651 µm2 (range 232-750 µm2) in Veau III (P = .02). There was also a nonsignificant decrease in proportion of type I muscle fibers with increasing Veau class (44.3% [range 31.4%-84.4%] in Veau II vs 35.3% [range 17.4%-61.3%] in Veau III).

CONCLUSIONS

Muscle fiber area in levator veli palatini muscles decreases in Veau III clefts in comparison to Veau II. The impact of these differences in velopharyngeal dysfunction requires further analysis of a larger cohort.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE

An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach.

DESIGN

Retrospective single-surgeon study.

PATIENTS

Consecutive nonsyndromic patients (n  =  27) with Veau I cleft palate.

INTERVENTIONS

Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD).

MEAN OUTCOME MEASURES

Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n  =  24) was retrieved for comparison purposes.

RESULTS

Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P  =  .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P  =  .546), age (10.2  ±  1.7 vs 9.6  ±  1.2 months; P  =  .143), rate of lateral incision (18.5% vs 4.2%; P  =  .195), and postoperative complication rate (0% vs 0%).

CONCLUSION

This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Defining the Treatment Gap in Nasoalveolar Molding: Factors Affecting the Utilization of NAM in an Urban Cleft Center

BACKGROUND

Many cleft centers incorporate NasoAlveolar Molding (NAM) into their presurgical treatment protocols. However, there are limited data on eligible patients who do not receive or complete NAM. This study characterizes the demographics associated with non-utilization or completion of NAM.

METHODS

A single-institution retrospective review was performed of all patients with cleft lip and alveolus undergoing primary unilateral and bilateral cleft lip repair from 2012-2020. Patients were grouped based on utilization or non-utilization of NAM. Demographic and treatment data were collected, including documented reasons for not pursuing or completing NAM.

RESULTS

Of 230 eligible patients, 61 patients (27%) did not undergo or complete NAM (no-NAM). In this group, 37 (60.7%) received no presurgical intervention, 12 (19.7%) received presurgical nostril retainers, 3 (4.9%) received lip taping, 1 (1.6%) received a combination of taping/nostril retainers, and 8 (13.1%) discontinued NAM. The most common reasons for not receiving NAM were sufficiently aligned cleft alveolus (21.3%), medical complexity (16.4%), late presentation (16.4%), and alveolar notching (18%). Compared to the NAM group, the no-NAM group had significantly lower rates of prenatal cleft diagnosis/consult, and significantly higher proportion of non-married and non-English speaking caregivers. Multivariable analysis controlling for insurance type, primary language, prenatal consult, marital status, and age at first appointment found that age at first appointment is the only statistically significant predictor of NAM utilization (P < .001).

CONCLUSIONS

Common reasons for non-utilization of NAM include well-aligned cleft alveolus, medical complexity, and late presentation. Early presentation is an important modifiable factor affecting rates of NAM utilization.

Orofacial Deformities in 3 Related Rhesus Monkeys (Macaca mulatta) Resembling Human Binder's Syndrome

Binder's syndrome is a rare congenital deformity characterized by midface hypoplasia, particularly around the nasomaxillary area. Genetic etiology or developmental failure caused by prenatal exposure to teratological agents has been considered. In this article, we present 3 related rhesus monkeys born with orofacial deformities similar to those found in infants with the Binder phenotype. For the first time, a primate biomodel for this condition is presented. The clinical description and association with management and environmental factors are discussed. These findings reinforce the knowledge about the relationship between possible vitamin K metabolism interference and Binder's syndrome.

Screening for Academic Risk Among Students With Cleft Lip and/or Palate: Patterns of Risk and Qualities of Effective Tools

This study evaluated the effectiveness of academic screening measures in relation to parent-reported diagnoses.

Multicenter, retrospective cohort study including structured interviews, questionnaires, and chart reviews.

Six North American cleft centers.

Children (n = 391) with cleft lip and/or palate, ages 8 to 10 years of age (192 male) and their guardians were recruited during regular clinic visits.

Parent and child ratings on the Pediatric Quality of Life Inventory (PedsQL) School Scale, child report on CleftQ School Scale, parent report on the Adaptive Behavior Assessment System-Third Edition Functional Academics (ABAS-FA) Scale and Child Behavior Checklist (CBCL) School Competency Scale, parent interview, and medical chart review.

Risk for concerns ranged from 12% to 41%, with higher risk reflected on the CBCL-SC compared to other measures. Males with cleft palate were consistently at the highest risk. Only 9% of the sample had a parent-reported diagnosis of a learning or language disability. Ratings from the ABAS-FA and CBCL-SC had the highest utility in identifying those with language and/or learning concerns.

As cleft teams work to develop standardized batteries for screening and monitoring of patients, it is important to evaluate the effectiveness of measures in identifying those at highest risk. When screening for language and learning disorders, questions related to potential academic struggles, such as increased school effort or increased school distress, are most useful. Referrals for follow-up evaluation are recommended for those identified at high risk.

Sagittal Growth Restriction of the Midface Following Isolated Cleft Lip Repair: A Systematic Review and Meta-Analysis

Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate repair, and is poorly understood. No study has examined the aggregate data on sagittal growth restriction of the midface following repair of the lip, but not palate, in these patients.

A systematic review of 3780 articles was performed. Twenty-four studies met inclusion criteria and 11 reported cephalometric measurements amenable to meta-analysis. Patients with Veau class I-III palatal clefts were included so long as they had undergone only lip repair. Groups were compared against both noncleft and unrepaired controls.

Cephalometrics were reported for 326 patients (31.3% female). Noncleft controls had an average SNA angle of 81.25° ± 3.12°. The only patients demonstrating hypoplastic SNA angles were those with unilateral CLP with isolated lip repair (77.4° ± 4.22°). Patients with repaired CL had SNA angles similar to noncleft controls (81.4° ± 4.02°). Patients with unrepaired CLP and CL tended toward more protruding maxillae, with SNA angles of 83.3° ± 4.04° and 87.9° ± 3.11°, respectively. Notably, when comparing SNA angles between groups, patients with CLP with isolated lip repair had significantly more hypoplastic angles compared to those with repaired CL (P < .0001). Patients with CLP with isolated lip repair were also more hypoplastic than noncleft controls (P < .0001). In contrast, there was no significant difference between the SNA of patients with repaired CL and controls (P = .648).

We found that cleft lip repair only appeared to contribute to MFH in the setting of concurrent cleft palate pathology, suggesting that scarring from lip repair itself is unlikely to be the predominant driver of MFH development. However, studies generally suffered from inadequate reporting of timing, technique, follow-up time, and cleft severity.

Arch Symmetry in Patients Without and With Cleft Lip and Palate After Orthodontic/Rehabilitative Treatment-A Stereophotogrammetry Study

To evaluate and compare the dental arch symmetry of individuals with and without cleft lip and palate after orthodontic/rehabilitation treatment.

Cross-sectional study.

Tertiary cleft center in Brazil.

Fifty-five participants aged between 18 and 30 years were divided into 3 groups according to treatment. Patients that received either a fixed partial denture (FPD) or implant-supported crown (ISC) in the cleft area or only orthodontic treatment, noncleft patients (NC).

An analysis was performed using digitized dental casts scanned by laser and software. The following linear measurements were evaluated: incisor-canine; canine-molar; incisor-molar; surface and volume of the palatal region.

Three-way ANOVA was used to compare the study factors: group (FPD/ISC/NC) and side (right/left) followed by the Tukey test to verify their interaction (α = .05).

The results showed statistically significant differences among groups for the maxillary linear measurements canine-molar and incisor-molar, but not for incisor-canine. No statistically significant differences were found regarding the side for the maxillary measurements, while the factor interaction showed similarity only for incisor-canine. The mandibular measurements showed no statistical differences among groups, sides, or factor interactions. In surface and volume, all values in patients with cleft presented lesser than in without cleft patients.

Regardless of the rehabilitation, arch symmetry can be achieved in the incisor-canine dimension in the cleft area.

"Septoplasty" Performed at Primary Cleft Rhinoplasty: A Systematic Review of Techniques and Call for Accurate Terminology

OBJECTIVE

Primary cleft nasal repair can include septal reconstruction. We hypothesize that primary cleft septoplasty and adult septoplasty have fundamental differences that render these procedures as distinct surgical entities.

DESIGN

Systematic review of the PubMed, Cochrane, and Embase databases performed on pediatric cleft and general adult septoplasty techniques through December 2021. (PROSPERO ID CRD42022295763).

MAIN OUTCOME MEASURES

Collected data included information on septal dissection, septal detachment, and management of the bony and cartilaginous septum.

RESULTS

Twenty-eight pediatric cleft septoplasty and 229 adult septoplasty studies were included. Dissection in primary cleft septoplasty was limited to the anterocaudal septum, while secondary cleft septoplasty and adult septoplasty techniques entailed wide exposures of the cartilaginous septum with or without exposure of the perpendicular plate of the ethmoid. In primary cleft septoplasty, detachment of the septum was mostly limited to the nasal spine and anterior base of the cartilaginous septum, while secondary cleft septoplasty and adult septoplasty included detachment from the vomer, and ethmoid. In the few reports of cartilage excision during primary cleft septoplasty, removal was limited to the anterior inferior border of the septum, while secondary cleft septoplasty and adult septoplasty included excision of the cartilaginous and bony septum.

CONCLUSION

Primary cleft septoplasty is distinct from septoplasty performed on facially mature patients. More specifically, septal dissection and detachment are limited to the anterior caudal area during primary lip repair, with rare removal of cartilage or bone. Given these differences, the authors suggest the term "septal reset" to describe septoplasty performed during primary cleft nasal repair.

A Rare Case of Cleft Palate Associated With Tongue Hamartoma: A Case Report and Systematic Review

INTRODUCTION

Palate development involves a genetic regulation through a complex molecular mechanism that may be disrupted by environmental factors, resulting in impaired fusion and cleft palate formation. An encounter with a case of cleft palate due to dorsal tongue hamartoma prompted us to perform this systematic review.

OBJECTIVE

To review the clinical profile and management approach for a case with cleft palate and tongue hamartoma.

DESIGN

A systematic literature search was conducted using keywords related to cleft palate and tongue hamartoma in PubMed, Scopus, MEDLINE, and Scielo databases through December 2021, with no time or language restrictions.

PATIENTS, PARTICIPANTS

Studies reporting patients with cleft palate and tongue hamartoma were included.

MAIN OUTCOME MEASURE(S)

Information related to clinical profile, diagnostic tests, histopathology, management, and outcomes were extracted.

Fourteen relevant publications were identified with 16 cases reported so far. Among them, thirteen patients were females (81.25%), and 3 were males (18.75%). The age of presentation varied from birth to 19 years. Oral-facial-digital syndrome (type II) was the most commonly associated syndrome.

Congenital tongue hamartoma with cleft palate is a rare presentation, which can present as an isolated entity or part of a syndrome. Genetic evaluation is warranted, particularly for multiple hamartomatous lesions. The preferred treatment is immediate excision of hamartoma while following a standard timeline for palatoplasty.

Presurgical Cleft Management of Infants: A Survey of ACPA Approved and International Cleft Palate and Craniofacial Teams

OBJECTIVE

To characterize the presurgical infant orthopedics (PSIO) and gingivoperiosteoplasty (GPP) protocols across the American Cleft Palate-Craniofacial Association (ACPA) approved and international cleft palate (CP) and craniofacial teams.

DESIGN

Cross-sectional survey.

SETTING

ACPA approved and international CP and craniofacial teams.

RESULTS

Respondents from 115 out of 215 ACPA approved and international CP and craniofacial teams permitted to contact (out of a total of 259 total teams) completed the survey (response rate  =  53.5%). There were 89 (77.4%) ACPA approved teams and the remaining international teams were mainly located in Europe (13.0%). Seventy-eight CP and craniofacial teams (67.8%) provided PSIO and 65 (83.3%) of these teams used alveolar molding (AM). Twenty-two CP and craniofacial teams (19.1%) provided GPP. A mean of 9.5  ±  2.6 different specialists were on the cleft team with the most common being orthodontists (97.4%), speech therapists (96.5%), and plastic/craniofacial surgeons (90.4%).

CONCLUSIONS

Most ACPA approved and ACPA registered international CP and craniofacial teams provided PSIO techniques by orthodontists using lip taping (LT) and AM, while few provide GPP.

Review of Diet Protocols Following Orthognathic Surgery and Analysis of Postoperative Weight Loss

INTRODUCTION

Orthognathic surgery is routinely practiced, yet little comparative data exists to evaluate post-orthognathic surgery diet protocols.

OBJECTIVE

To evaluate which postoperative diet protocols are recommended and to quantify post-orthognathic surgery weight changes in our institutional cohort.

METHODS

An internet search was carried out on Google for "orthognathic surgery diet" and the postoperative diet recommendations from centers worldwide were quantified. Additionally, a retrospective analysis of patients that underwent orthognathic surgery at our institution was performed, and their preoperative and postoperative weights were recorded.

RESULTS

The internet search yielded 58 centers that met our inclusion criteria. Most centers were in the United States (n = 37, 63.8%) and were oral and maxillofacial surgeon (OMFS)-led centers (n = 39, 67.2%). Postoperative diets were categorized into 7 distinct protocols, ranging from most to least restrictive-the most popular was liquid diet for 2 to 4 weeks followed by soft diet for 2 to 6 weeks. There were no significant patterns observed across different geographical regions or specialties.In our institution, 135 patients were identified. Overall, there was an average maximum weight loss of 4.1 kg by week 4, followed by a gradual increase in weight. Linear regression analysis showed that patients with greater preoperative body mass index (BMI) lost more weight postoperatively than patients with lower BMI (R2 = 0.25, P < .001).

CONCLUSION

There is a significant variability in recommended postoperative diets following orthognathic surgery. Following a moderately restrictive diet at our institution, patients returned to their preoperative weight after approximately 4 months.

Ten-Year Cephalometric Comparison of Patients With Cleft Palate who Received Treatment With Active or Passive Pre-surgical Orthopedic Devices

BACKGROUND

Pre-surgical orthopedic (PSO) devices can be used in the management of patient with cleft lip/palate (CL/P) to narrow the alveolar gap (AG) prior to lip surgery. There are few studies comparing these 2 devices. The objective of this work was to compare the effects of active and passive PSO devices on facial growth in a single surgeon's cohort of patients with CL/P over a 10-year period.

METHODS

A retrospective review of all patients with CL/P in a single surgeon's practice from 2002 to 2018 was performed. Preoperative measurements of AG size were done using electronic calipers on patient molds. Patient radiographs were taken at 5 and 10 years of age and cephalometric landmarks were plotted using specialized software. Independent sample t-tests were used to compare means for maxillary, mandibular, vertical, and dento-alveolar growth parameters.

RESULTS

Twenty patients with an active device and 23 patients with a passive device were included. No differences were observed in the basic demographic information between the two groups. At the time of lip repair, patients with a passive device had significantly larger horizontal AGs (P < .01), but by the time of palate repair, there was no difference between the two groups (P = .94). There was no significant difference in any growth measurements between the active and passive device groups at 5 and 10 years.

CONCLUSIONS

Despite closing the AG more quickly, patients treated with an active device have no significant difference in facial growth at 10 years compared to patients treated with a passive device.

Impact of Syndromes on Sleep-Disordered Breathing in Children After Cleft Palate Repair

OBJECTIVE

Prior research suggests that children with cleft palate (CP) are at increased risk of obstructive sleep-disordered breathing (SDB). However, few studies differentiate the effects of CP repair on SDB based on syndrome status. The goal of this study was to evaluate differences in SDB after palatoplasty among children with nonsyndromic CP, syndromic CP, and isolated Robin sequence (RS).

DESIGN

Retrospective chart review.

SETTING

Tertiary academic children's hospital.

PATIENTS/PARTICIPANTS

A total of 145 children who underwent primary CP repair from 2014 to 2021.

MAIN OUTCOME MEASURE

Post-palatoplasty SDB is defined as parent-reported symptoms and/or evidence of obstructive sleep apnea (OSA).

RESULTS

Median age at palatoplasty was 11.1 [IQR 10.2-13.6] months. Most patients (61.4%) had nonsyndromic CP, 26.9% had a syndrome, and 11.7% had RS. Children with syndromic CP and RS had more post-palatoplasty SDB symptoms (56.4% vs 58.8% vs 30.3%, P = .006) and higher rates of OSA (25.6% vs 29.4% vs 5.6%, P = .001) compared to children with nonsyndromic CP after palatoplasty. Children with syndromic CP and RS had nearly 3 to 4 higher odds of post-palatoplasty SDB than children with nonsyndromic CP (adjusted odds ratio [aOR] 2.88, 95% CI 1.29-6.47, P = .010; aOR 3.73, 95% CI 1.19-11.70, P = .024).

CONCLUSION

This study showed that children with CP experience higher rates of SDB after palatoplasty than the general pediatric population. Within the cohort, children with syndromic CP and isolated RS were more likely to have obstructive sleep disorders than nonsyndromic children after palatoplasty. Clinicians should counsel caregivers accordingly and closely monitor these groups for SDB after palate repair.

Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network

OBJECTIVE

To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings.

DESIGN

Cross-sectional analysis of prospectively collected data from 2019-2022.

SETTING

Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol.

PARTICIPANTS

714 English-speaking children and adolescents with non-syndromic cleft lip/palate.

INTERVENTION

Routine multidisciplinary care and systematic outcomes measurement by cleft teams.

OUTCOME MEASURES

Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress.

RESULTS

12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes.

CONCLUSIONS

This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

The First Hybrid International Educational Comprehensive Cleft Care Workshop

OBJECTIVE

Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance.

DESIGN

Cross-sectional survey-based evaluation.

SETTING

International comprehensive cleft care workshop.

PARTICIPANTS

Total of 489 participants.

INTERVENTIONS

Three-day simulation-based hybrid comprehensive cleft care workshop.

MAIN OUTCOME MEASURES

Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance.

RESULTS

The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01).

CONCLUSION

Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Comparison of Cleft Lip Nasal Deformities Between Lesser-Form and Incomplete Cleft Lips: Implication for Primary Rhinoplasty

OBJECTIVE

This study investigated various manifestations of nasal deformities in lesser-form cleft lips, including the minor-form, microform, and mini-microform, by photogrammetric comparison with incomplete cleft lips.

DESIGN

Retrospective study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A total of 160 patients with unrepaired unilateral incomplete cleft lips ranging from lesser-form to two-thirds way clefts.

MAIN OUTCOME MEASURES

The severity of nasal deformities was assessed by photogrammetric measurements of linear and angular variables. The symmetry ratio between the cleft and non-cleft sides was obtained by measuring various nasal parameters and comparing them among the different labial cleft groups.

RESULTS

The degree of nasal deformities increased with the extent of labial clefts among the 3 labial cleft groups (lesser-form, halfway, and two-thirds way clefts) in terms of alar base width ratio (1.102, 1.197, 1.309; P < .05), nostril width ratio (1.287, 1.387, 1.551; P < .05), and columellar angle (11.5, 14.45, 18.197; P < .05). Each parameter indicated lesser-form, halfway, and two-thirds way clefts, respectively. However, only the lateral lip height ratio (0.942, 0.851, 0.87; P < .05) and nostril width ratio (1.207, 1.35, 1.29; P < .05) significantly differed among the 3 subgroups. Each parameter indicated mini-microform, microform, and minor-form, respectively.

CONCLUSIONS

The cleft nasal deformities in lesser-form cleft lip present comparable severities among its subtypes, which implies that the extent of the labial cleft is not correlated with nasal deformities. Each nose in the lesser form cleft should be individually assessed for primary rhinoplasty and requires tailored correction.

Long-term Outcome for Two-Stage Palatal Closure With Different Timings for Hard Palate Surgery: Craniofacial Growth and Dental Arch Relation

OBJECTIVE

The aim was to evaluate dental arch relation and craniofacial growth for individuals born with unilateral cleft lip and palate (UCLP), who had two-stage palatal surgery, with hard palate closure (HPC) at the ages of 3 or 8 years.

DESIGN

Longitudinal cohort study.

SETTING

Ceft lip and palate team in Gothenburg, Sweden.

PATIENTS

The inclusion criteria were nonsyndromic individuals born with complete UCLP who were consecutively operated according to two different surgical protocols; soft palate closure at 6 months followed by hard palate closure at the age of 3 years (HPC3) or at the age of 8 years (HPC8). In this evaluation, 28 individuals had HPC3 and 59 individuals had HPC8.

INTERNVENTIONS

The main outcome, longitudinal series of dental casts and lateral radiographs from the ages of 5, 10, 16, and 19 years, were evaluated using GOSLON Yardstick and cephalometric analysis.

RESULTS

At the age of 10 years, 78% of the individuals with HPC3 demonstrated GOSLON scores of 1 and 2 and 86% in HPC8. At the age of 19 years, 54% of the individuals exhibited GOSLON scores of 1or 2 when compared with 74% in HPC8. A statistical significant difference for SNA was observed at the age of 5 years (P  =  .004), with a lower SNA in HPC3, but not at the ages of 10, 16 and 19 years. At the final age, SNA was 75.2° for HPC3 and 76.8° for HPC8.

CONCLUSIONS

The decrease in age for HPC did not have an adverse effect on long-term dental arch relationship or craniofacial growth.

Evaluation of Facial Esthetics Following NAM Versus CAD/NAM in Infants With Bilateral Cleft Lip and Palate: A Randomized Clinical Trial

OBJECTIVE

The aim is to compare the facial esthetics following nasoalveolar molding (NAM) versus computer-aided design NAM (CAD/NAM) in patients with bilateral cleft lip/palate (CLP).

DESIGN

The trial is a randomized comparative trial with a 1:1 allocation ratio.

PARTICIPANTS

Thirty infants with bilateral complete cleft lip and palate were recruited.

INTERVENTIONS

Patients were randomized between NAM and CAD/NAM groups. The treatment steps described by Grayson were followed for the NAM group. In the CAD/NAM group, digitized maxillary models were made to create a series of modified virtual models, which were used to fabricate the molding plates using 3-dimensional printing technology. The nasal stents were then added to the intraoral plates following the Grayson method. The study lasted for 4 months.

MAIN OUTCOMES

The assessment of the changes observed in the interlabial gap and nasolabial esthetics was done using standardized 2-dimensional photographs. The correlation between dental arch changes and extraoral facial esthetics was studied.

RESULTS

Both modalities showed improvement in nasolabial esthetics before the lip surgery. No statistically significant difference was found between NAM and CAD/NAM groups in any of the assessed variables.

CONCLUSIONS

Both interventions were effective in the management of infants with bilateral CLP.

The Role of Postoperative Nasal Stents in Cleft Rhinoplasty: A Systematic Review

OBJECTIVE

To evaluate the role of postoperative nasal stenting in preserving nasal shape and preventing nostril stenosis in cleft rhinoplasty, and to develop a classification system for postoperative nasal stents.

DESIGN

Systematic review.

METHODS

Electronic and manual searches of scientific literature were conducted from 3 databases (PubMed, SCOPUS, OVID). Primary evidence that described postoperative nasal stenting in cleft rhinoplasty were included. Exclusion criteria included secondary evidence, non-English articles, and studies focusing on preoperative nasal stents.

PATIENTS AND PARTICIPANTS

Patients with cleft lip/nose of any type were included.

MAIN OUTCOME MEASURE(S)

Role in preservation of nasal shape & symmetry, role in prevention of nostril stenosis, complications with the use of postoperative nasal stent.

RESULTS

Of the 13 articles, 9 papers described the preservation of nasal shape with nasal stents and three studies with a control group showed improved symmetry score. No studies evaluated the prevention of nostril stenosis; however, 2 studies reported improvement of nostril stenosis in secondary cleft rhinoplasty. The results of the included studies had significant heterogeneity. Nasal stents were classified into five types: Type I-spare parts assembled, Type II-prefabricated commercial, Type IIIa-patient specific 3D-printed static, Type IIIb-patient specific dynamic, and Type IV-internal absorbable. Total complications were 6.0%, including irritation (0.9%), infection (0.3%), and stent loss (4.6%).

CONCLUSION

Despite the lack of consensus with postoperative nasal stents, this review suggests its safety and role in preserving shape and improving stenosis. Our classification system highlights variability and the need for better quality studies to determine the efficacy of nasal stents.

Disability Caused by Cleft Lip and Palate: A Systematic Review and Critical Valuation Appraisal

OBJECTIVE

Measuring disability as a concept of impaired global function enables beneficiaries of treatment, the impact of treatment, and targets of health system investment to be rigorously assessed. Measures of disability are not well established for cleft lip and palate. This study aims to systematically review disability weight (DW) studies pertaining to orofacial clefts (OFCs) and identify methodological strengths and shortcomings of each approach.

DESIGN

Systematic literature review of studies that met the following criteria: (1) peer-reviewed publication, (2) focus on disability valuation, (3) mention orofacial clefts, and (4) publication January 2001-December 2021.

SETTING

None.

PATIENTS/PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Disability weight method of valuation and the value itself.

RESULTS

The final search strategy yielded 1,067 studies. Seven manuscripts were ultimately included for data extraction. The disability weights used in our studies, including those newly generated or taken from the Global Burden of Disease Studies (GBD), ranged widely for isolated cleft lip (0.0-0.100) and cleft palate with or without cleft lip (0.0-0.269). The GBD studies limited their consideration of cleft sequelae informing disability weights to impact on appearance and speech-related concerns, while other studies accounted for comorbidities such as pain and social stigma.

CONCLUSIONS

Current measures of cleft disability are sparse, inadequately reflect the comprehensive impact of an OFC on function and socialization, and are limited in detail or supporting evidence. Use of a comprehensive health state description in evaluating disability weights offers a realistic means of accurately representing the diverse sequelae of an OFC.

Epidemiologic Characteristics, Time Trend, and Seasonality of Orofacial Clefts in São Paulo State, Brazil. 2008-2019

OBJECTIVE

To characterize the epidemiology, identify trends in prevalence, seasonality, and risk factors for orofacial clefts (OFC), selecting the São Paulo state (SPS) population database.

DESIGN

A population-based study to estimate the OFC prevalence trends in recent years, stratified by maternal age and SPS geographical clusters.

SETTING

All live births (LB) with OFC in SPS from 2008-2019.

PATIENTS

5342 cases of OFC among 7 301 636 LB.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

OFC prevalence trends, annual percent change (APC) with a 95% confidence interval, and seasonality.

RESULTS

We found an OFC prevalence of 7.3/10 000LB in SPS, Brazil. Among all the cases, the majority were male (57.1%), Caucasian (65.4%), 77.8% born at term, 75.8% weight >2500 g, 97.1% singleton, and 63.9% of births were by cesarean section. From 2008-2019, SPS presented a stationary OFC prevalence trend; in São Paulo city, the highest APC was observed (0.05%); the maternal age group with the highest OFC prevalence rate was ≥35 years (9.2/10 000LB). We identified the existence of seasonal variation based on the conception date in the final months of the year, corresponding to the spring season (P < .001).

CONCLUSION

OFC had a stationary prevalence trend in recent years, with the highest prevalence in the Central North Cluster and ≥35 years maternal age group. Seasonality was observed in the spring season, and congenital malformation of lips was the most common associated pathology. This population-based study is the first to summarize the current epidemiology of OFC in SPS.

To Operate or Not to Operate? Reconstructive Surgical Burden and Quality of Life of Pediatric Patients with Facial Differences

OBJECTIVE

The Craniofacial Condition Quality of Life Scale (CFC-QoL) was used to evaluate the relationship between surgical burden and quality of life (QoL).

DESIGN

Patient-parent dyads completed the CFC-QoL which queries the following QoL domains: Bullying, Peer Problems, Psychological Impact, Family Support, Appearance Satisfaction, and Desire for Appearance Change. Stepwise multivariate linear regressions were performed for each QoL domain.

SETTING

Urban tertiary care center.

PATIENTS, PARTICIPANTS

Pediatric patients with facial differences, and their parents.

INTERVENTION

Survey study.

MAIN OUTCOME MEASURE(S)

Demographic, diagnostic, and surgical characteristics were collected. Surgical burden was calculated as the standard deviation from the mean number of surgeries per diagnostic cohort.

RESULT

Patients (N  =  168) were majority female (57.1%) and Hispanic (64.3%). Diagnoses were cleft lip and/or palate (CLP,n  =  99) or other craniofacial conditions (CFC,n  =  69). Average patient age was 2.3  ±  5.6 years at first reconstructive surgery and 12.3  ±  3.4 years at study enrollment. Patients received an average of 4.3  ±  4.1 reconstructive surgeries.Worse Bullying was associated with higher surgical burden. Worse Peer Problems was associated with higher surgical burden, but only for children with non-CLP CFCs. Worse Family Support was associated with CFC diagnosis, female sex, and higher surgical burden. Worse Psychological Impact was associated with higher surgical burden. Worse Appearance Satisfaction was associated with younger age and with lower surgical burden. Greater Desire for Appearance Change was associated with older age, higher surgical burden, CLP diagnosis, female sex, and non-Hispanic ethnicity. Socioeconomic status did not predict QoL per patient self- or parent-proxy report.

CONCLUSIONS

Higher surgical burden was associated with worse QoL outcomes in multiple domains.

Translation, Validation, and Cultural Adaptation of CLEFT-Q© for use in Indonesia

OBJECTIVE

To translate and validate CLEFT-Q^©, patient-reported outcome measure for patients with cleft lip and/or palate (CL and/or P), into Indonesian. CLEFT-Q^© covers the domains of appearance, facial function, health-related quality of life and consists of scales describing outcomes after cleft surgery.

DESIGN

The CLEFT-Q^© instrument was translated according to the International Society of Pharmacoeconomics and Outcomes Research guidelines, including translation, cognitive debriefing, and field-testing.

SETTING

Dr. Cipto Mangunkusumo Hospital, Indonesia; independent CL and/or P support groups.

PATIENTS

Patients ages 8-29 with a history of repaired CL and/or P were grouped based on age. Those unable to complete the questionnaire independently were excluded.

INTERVENTIONS

The primary objective was reliable translation of the CLEFT-Q® instrument. Each scale was assessed for its internal consistency (Cronbach's alpha) and validity (inter-item correlation), and sub-group analyses were performed based on age group.

RESULTS

Forward and back translation revealed 25(13.3%) and 12(6.3%) of items were difficult to translate. Cognitive debriefing revealed 10(5.3%) items were difficult to understand, with the lowest reliability on the facial appearance scale (α=0.27). Other scales demonstrated acceptable to excellent reliability (α=0.53-0.68). Field testing revealed acceptable reliability and validity of the translation (α = 0.74-0.92; 69% ideal range of inter-item correlation). Sub-group analyses revealed patients in the <11y.o. and >18y.o. groups had the lowest scores on the "cleft lip scar" scale while those 11-18y.o. had the lowest scores on the "nostrils" scale.

CONCLUSION

Iterative translation and cultural adaptation of CLEFT-Q^© into Indonesian demonstrated reliability and validity of the tool, supported by acceptable to excellent internal consistency and ideal inter-item correlation.

Seasonal, Geographic, and Ethnic Influence on the Prevalence of Orofacial Clefts in Kuwait: A Nationwide Study

OBJECTIVE

Accurate nationwide epidemiological evidence is vital to study the seasonal, geographic, and ethnic influence on the trends of orofacial cleft prevalence in Kuwait.

DESIGN

Data obtained from the National Center for Health Information and Ministry of Health Hospital digital records were reviewed retrospectively to identify patients with orofacial clefts (OFC) using the ICD-10 diagnostic codes. The Jonckheere-Terpstra test was used to assess the trend of birth prevalence across the different years. The associations of types of OFC with ethnic and geographic influences were tested with chi-square or Fisher's exact tests, while the strength of that association was tested with multi-nominal logistic regression.

RESULTS

Birth prevalence in Kuwait ranged from 0.75-2.55 per 1000 live births (0.73- 2.73 among Kuwaitis, 0.60-3.27 among non-Kuwaitis), with no statistically significant change observed during the past 28 years. The risk of unilateral cleft lip and palate was eight times higher during summer compared to Autumn, while the risk of cleft lip and palate remained lower during winter. Jahra (OR-7.76, CI- 1.51-39.80), Farwaneya (OR-6.65, CI- 1.34-33.06), and Hawalli (OR-6.72, CI- 1.26-35.98) governorates had higher odds of bilateral cleft lip when compared to Mubarak Alkabeer.

CONCLUSIONS

The study outcome is an indicator to improve patient care and customize healthcare infrastructure in the Ministry of Health. It also provides insight to develop projections of future needs. Future studies should focus on understanding the factors that might be a potential contributor to the seasonal change observed in the prevalence of OFC.

Evaluation of Radiographic Outcomes of Alveolar Graft Associated with Premaxillary Osteotomy Performed with rhBMP-2

OBJECTIVE

To evaluate the influence of filling material and timing of surgery on radiograph outcomes of alveolar grafting with premaxillary osteotomy. The null hypothesis was that radiographic outcomes would be similar with both rhBMP-2 (rhBMP-2G) and cancellous bone from the iliac crest (IG), regardless of the timing of surgery.

DESIGN

Cross-sectional study with consecutive sampling of 56 periapical or occlusal radiographs taken 12 months after surgery.

SETTING

A single tertiary craniofacial center.

PATIENTS/PARTICIPANTS

Twenty-eight patients with complete bilateral cleft lip and palate and mean age of 13 years. The individuals underwent bilateral alveolar grafting associated with premaxillary osteotomy (AG + PO) with rhBMP-2 or cancellous bone from the iliac crest.

INTERVENTIONS

Experienced maxillofacial surgeons used the same surgical technique in both groups. AG + PO were assigned as success or failure by 3 blinded raters based on modified Bergland and SWAG scales.

MAIN OUTCOME MEASURES

The influence of filling materials and timing of surgery on radiographic outcomes was verified by Fisher's exact test and chi-square test (P < .05).

RESULTS

There was no significance variation between the mean age of participants in the rhBMP-2G and IG (P = .471). Scales showed almost perfect reliability (agreement rate = 96.4%; K = 0.85). rhBMP-2G and IG had similar success rates with modified Bergland scale (85.7% and 82.1%) and SWAG scale (92.9% and 82.1%), respectively. However, only modified Bergland scale found influence of age on radiographic outcomes (P = .025).

CONCLUSIONS

AG + PO performed with rhBMP-2 and iliac crest bone showed similar radiographic success rates, regardless of the timing of surgery.

Geospatial and Socioeconomic Factors Interact to Predict Management and Outcomes in Cleft Lip and Palate Surgery: A Single Institution Study of 740 Patients

OBJECTIVE

Determine interactions between geospatial and socioeconomic factors influencing cleft lip and/or cleft palate (CL/P) management and outcomes.

DESIGN

Retrospective review and outcomes analysis (n = 740).

SETTING

Urban academic tertiary care center.

PATIENTS

740 patients undergoing primary (CL/P) surgery from 2009 to 2019.

MAIN OUTCOMES MEASURES

Prenatal evaluation by plastic surgery, nasoalveolar molding, cleft lip adhesion, and age at CL/P surgery.

RESULTS

Prenatal evaluation by plastic surgery was predicted by the interaction between higher patient median block group income and shorter patient distance from the care center (OR = 1.07, p = 0.022). Nasoalveolar molding was also predicted by the interaction between higher patient median block group income and shorter distance from the care center (OR = 1.28, p = 0.016), whereas cleft lip adhesion was predicted by higher patient median block group income alone (OR = 0.41, p < 0.001). Lower patient median block group income predicted later age at cleft lip (β = -67.25, p = 0.011) and cleft palate (β = -46.35, p = 0.050) repair surgery.

CONCLUSIONS

Distance from the care center and lower median income by block group interacted to significantly predict prenatal evaluation by plastic surgery and nasoalveolar molding for patients with CL/P at a large, urban, tertiary care center. Patients living farthest from the care center who received prenatal evaluation by plastic surgery or who underwent nasoalveolar molding had higher median block group income. Future work will determine mechanisms perpetuating these barriers to care.

Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients

OBJECTIVE

Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients.

SETTING

An academic tertiary pediatric care center.

METHODS

Retrospective cohort study.

PATIENTS

Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL).

OUTCOME MEASURES

The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS).

RESULTS

97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05).

CONCLUSION

Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.

Surgical Repositioning of the Premaxilla: Incidence, Indications and Growth Study About a 189 Bilateral Cleft Lip ± Palate Population

OBJECTIVE

We aimed to evaluate the rate of patient requiring Surgical Repositioning of the Premaxilla in a population carrying BCL  ±  P, retrieve age and operative indication. Our secondary objective was to present further facial growth characteristics.

SETTINGS

This was a retrospective, single-center cohort study conducted in Nantes University Hospital, Oral and Maxillofacial Surgery department, tertiary cleft center.

PATIENTS

Patients with BCL  ±  P born between 1980 and 2019 treated at Nantes University Hospital were included.

MAIN OUTCOME MEASURE

Our primary outcome measure was the rate of patient requiring SRP.

RESULTS

Over the whole period, 189 patients with BCL  ±  P were identified. Three patients (1,58%) underwent SRP. Patients who underwent SRP all had BCLP. SRP was performed during their primary dentition period. The indication for surgical repositioning was always premaxilla vertical overgrowth with an overbite over 10 mm. Facial growth features in the three patients were mostly comparable with a population carrying BCLP who had no premaxillary surgery.

CONCLUSION

Our results showed a low incidence of SRP. No SRP was necessary during early infancy (ie, before lip repair) or during adulthood. Surgical repositioning of the premaxilla is beneficial for patient with orthodontically uncorrectable vertical premaxillary excess, even more since facial development compared with other patients with BCLP appears comparable.

Effect of Acellular Dermal Matrix on Long-Term Speech Outcomes in Primary Palatoplasty with Radical Intravelar Veloplasty

OBJECTIVE

This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included.

MAIN OUTCOME MEASURES

A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated.

RESULTS

The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency.

CONCLUSION

The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood.

Managing Chronic otitis media with Effusion in Children with non-Syndromic Cleft Palate: Short-Term Ventilation Tubes Versus Surveillance

OBJECTIVE

To compare the effectiveness of short-term ventilation tubes compared to surveillance on conductive hearing loss in children with non-syndromic orofacial clefting involving the muscular palate.

INTRODUCTION

Chronic otitis media with effusion is a common finding in children with cleft palate. The accepted convention is insertion of short-term ventilation tubes at the time of palate repair, but some centres are choosing conservative management. Each approach has its advantages but there is currently no consensus on the most appropriate management in children with non-syndromic cleft palate.

INCLUSION CRITERIA

Children <18 years with cleft lip and palate, or isolated cleft palate, not associated with a genetic syndrome, who have been diagnosed with chronic otitis media with effusion.

METHODS

A systematic search of MEDLINE, CINAHL, Embase and Scopus databases was conducted. Grey literature searches were conducted through Central Register of Controlled Trials, Clinicaltrials.gov and ProQuest. Two reviewers screened the studies, conducted critical appraisal, assessed the methodological quality, and extracted the data. Where possible, studies were pooled in statistical meta-analysis with heterogeneity being assessed using the standard Chi-squared and I2 tests.

RESULTS

Four studies met the inclusion criteria but were of low quality with a moderate risk of bias. Only data on hearing thresholds could be pooled for analysis which found no statistically significant difference. Other outcomes were presented in narrative form. Certainty of evidence for all outcomes was deemed low to very low using GRADE criteria.

CONCLUSIONS

No definitive conclusions can be drawn regarding most effective management at improving conductive hearing loss. Missing data and inconsistent reporting of outcomes limited capacity for pooled analysis.

Repeat Buccal Flaps Successfully Reduce Hypernasality in a Patient with Cleft Palate

Surgical intervention can contribute to the development of velopharyngeal insufficiency (VPI) leading to hypernasality and regurgitation. In this case, a patient with a history of bilateral buccal flaps used for her primary CP repair presented to clinic with hypernasality and VPI as assessed by speech exam and imaging. She underwent repeat bilateral buccal flap palatal lengthening with division of the pedicles 3 months later. Three months after her division, her hypernasality score improved from moderate to mild and her posterior gap decreased. This study concluded buccal flaps can be used a second time for patients needing palatal revisions for VPI.

Impact of Illustrated Postoperative Instructions on Knowledge and Retention During a Cleft Lip and Palate Surgical Mission

OBJECTIVE

To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention.

DESIGN

Prospective study with all participants receiving an educational intervention.

SETTING

Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020.

PARTICIPANTS

A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery.

INTERVENTION

Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points.

MAIN OUTCOME MEASURE

Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up.

RESULTS

Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based.

CONCLUSIONS

In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.

Submucous Cleft Palate (SMCP): Indications and Outcomes of Radical Muscle Dissection Palatoplasty in Children Under 4 Years of Age

To delineate the indications, referral sources and outcomes of radical muscle dissection palate repair in the first 4 years of life for patients with submucous cleft palate (SMCP).

This study presents a retrospective analysis of a single surgeon's management.

All children were treated at Great Ormond Street Hospital, United Kingdom.

Twenty-three children with nonsyndromic SMCP were included in this study.

All participants underwent radical muscle dissection repair before their fourth birthday.

Parameters analyzed included: referral sources, indications for referral, extent of anatomical abnormality, and postoperative outcomes.

Paediatricians provided the largest proportion of referrals to the cleft lip and palate clinic (39%) due to the presence of cleft lip/palate on prenatal scans or during neonatal examination. Over half (n = 12, 52%) of patients had severe anatomical anomalies being in grade IV (score 8-9), with the classical triad present to some extent in all but 2 of the patients. The main indication for surgery was nasal regurgitation of food and liquid (n = 9, 35%) followed by hypernasality (n = 6, 21%), difficulty feeding (n = 3, 8%), and severe anatomical defect (n = 2; 4%). Postoperatively, the presenting complaint improved in the majority of cases.

Nonsyndromic SMCP is often missed, though may present with nasal regurgitation, feeding problems, and/or hypernasality, though may be missed in nonsyndromic children. Early radical muscle dissection repair in the first 4 years of life is safe and effective, facilitating normal speech development.

Early Secondary Alveolar Bone Grafting and Facial Growth of Patients with Complete Unilateral Cleft Lip and Palate

OBJECTIVE

To investigate the craniofacial growth outcomes of early secondary alveolar bone grafting(ABG) around 6 years of age.

DESIGN

Retrospective cohort study.

SETTING

1 North-American and 5 Northern-European cleft centers.

SUBJECTS

33 subjects with CUCLP consecutively treated with secondary ABG around 6 years of age were compared to 105 subjects from 4 centers treated with late secondary ABG and 19 subjects from 1 center with primary ABG.

METHODS

Preorthodontic standardized lateral cephalometric radiographs taken after 12 years of age were traced and analyzed according to the Eurocleft Study protocol. Fourteen angular and two proportional measurements were performed. Measurement means from the Study Center(SC) were compared to 5 Northern-European centers using analysis of variance and Welch's modified t-tests, and P < .05 was considered statistically significant.

RESULTS

For the SC, the mean age ± SD at the time of bone graft was 5.85 ± 0.71 years and the mean age at the time of the lateral cephalogram was 13.4 ± 1.8 years. The sagittal maxillary prominence of the SC was favorably comparable to the 5 Northern-European centers. The mean SNA (78.1 ± 4.3) for the SC was significantly higher compared to 4 of the 5 Northern-European centers(all P < .05), and the mean ANB angle was comparable to 4 of the 5 centers. Similarly, the mean soft tissue ANB angle was not significantly different to the 5 centers. The soft tissue vertical proportions compared favorably to all 5 Northern-European centers(all P < .01).

CONCLUSIONS

Craniofacial growth outcomes of early secondary ABG around 6 years compare favorably to the outcomes of late secondary ABG.

Clinical and Descriptive Study of Orofacial Clefts in Colombia: 2069 Patients From Operation Smile Foundation

OBJECTIVE

To describe the population of patients with cleft lip and/or palate (CL/P) in terms of cleft phenotypes, gender, age, ethnic group, family history, clinical presentation (syndromic vs nonsyndromic), some environmental and behavioral factors, and some clinical features.

DESIGN

Descriptive retrospective study.

SETTING

Patients attending the genetics counseling practice in Operation Smile Foundation, Bogotá, Colombia, for over 8 years.

PARTICIPANTS

No screening was conducted. All patients requiring clinical genetics assessment in Operation Smile Foundation were included in the study.

RESULTS

Left cleft lip and palate (CLP) and nonsyndromic forms were the most frequent types of malformations in this population. Psychomotor retardation and heart disease were the most frequent comorbidities in these patients. A low proportion of mothers exposed to passive smoking during pregnancy was observed and low birth weight accounted for an important number of cases. Aarskog, velocardiofacial, and orofaciodigital syndromes were the most frequent syndromic forms of CLP in this population.

CONCLUSIONS

In this study, the most frequent type of CL/P was the nonsyndromic complete left CLP. Aarskog, velocardiofacial, and orofaciodigital syndromes were the most frequent syndromic forms of CL/P in this population.

Presurgical Orthopedic Treatment of a 3-Year-Old Child with Unoperated Complete Bilateral Cleft Lip and Palate and Protruding Premaxilla

Unoperated patients with bilateral complete cleft lip and palate (BCCLP), who do not receive orthopedic treatment in infancy and present with significant sagittal excess of the premaxilla, are among the most difficult patients to treat. Delay in primary reconstruction reduces the elastic characteristics of the tissues. The resulting rigidity of bony structures accompanied by the wide alveolar and palatal clefts associated with sagittal excess of the premaxilla pose a great challenge for both surgeon and orthodontist. There is no unique protocol for treatment of these conditions. This paper describes the use of orthopedic treatment in an unoperated 3-year-old male child with BCCLP and a protrusive premaxilla whose appearance and function were both severely affected. A modified Meazzini technique, as described in operated BCCLP patients with a downward-displaced premaxilla, was used. The device itself consists of the 2 independent components mutually connected by a 17 × 25 steel arch. The first is an active fan-type expander. The second consists of an acrylic cap covering the premaxilla and 3 brackets used for the steel arch application. They are connected by a rectangular steel 17 × 25 archwire. Reduction of the premaxillary sagittal excess of is carried out with an elastic chain. The use of this orthopedic appliance is a reliable and valuable presurgical treatment in the therapy of children with BCCLP and protrusive premaxilla whose orthopedic and surgical treatment have been delayed.

Long-Term Follow-up of Unilateral Cleft lip and Palate: Incidence of Speech-Correcting Surgeries and Fistula Formation

OBJECTIVE

The ideal surgical protocol and technique for primary closure of unilateral cleft lip and palate (UCLP) are unclear, and the development of velopharyngeal insufficiency and fistulae following primary repair is common. This study aimed to determine the long-term surgical burden of care in terms of secondary surgeries, defined as speech-correcting surgeries (SCSs) and fistula repair, in a UCLP population, and to compare outcomes of various surgical protocols.

DESIGN

Retrospective, single-center review.

PARTICIPANTS

The study comprised 290 nonsyndromic children with complete UCLP. Different surgical protocols entailing both single-stage and 2-stage approaches were compared, and the surgical outcome was analyzed at the time of alveolar bone grafting (ABG) and post ABG.

RESULTS

Altogether 110 children (37.9%) underwent secondary surgery by the time of ABG. Of the total population 25.9% (n  =  75) had undergone SCS and 17.2% (n  =  50) had undergone fistula repair. The respective incidences at follow-up (post ABG) were 30.3% (n  =  88) and 18.9% (n  =  55). Median age at ABG was 9.8 years and at follow-up was 16.3 years. No significant difference emerged in terms of secondary surgeries between the techniques and protocols applied at primary repair. However, some differences occurred regarding the location of fistulae; the single-stage procedure had more anterior fistula repairs, particularly connected to a perialveolar fistula.

CONCLUSIONS

Although the outcome differences between the surgical protocols were small, indicating that none of the treatment protocols was clearly superior to another, attention was drawn to the favorable outcomes of the single-stage protocol.

Evaluating Psychosocial Problems in School-Age Children with Cleft Lip and Palate in Bandung, Indonesia Using CBCL/6-18

BACKGROUND

Cleft lip with or without palate (CL  ±  P) may impact children's eating, drinking, speaking, breathing, and hearing. We aim to evaluate psychosocial problems in Indonesian cleft center school-age patients identified after one or more surgical interventions.

METHODS

This is a cross-sectional study of parent report of patients with unilateral CL  ±  P who had cleft surgery from 2011 to 2016 in the Bandung Cleft Center using the Bahasa Indonesia version of CBCL/6-18 questionnaire. Descriptive statistics were completed based on measure norms and score ranges.

RESULTS

There were 104 participants (56.7% male) with a median age of 8 years old and 73.0% had unilateral cleft of lip, gum, and palate. We found that speech and appearance problems were not perceived by parents for 34.6% of participants after undergoing surgery. The majority of parents reported normal range scores for the Social scale (93.3%) and the School scale (92.3%). In contrast, largely due to the restrictions in the covid-19 pandemic, 78.8% of the patients had below normal range scores for the Activities scale. Borderline or Clinical range scores were reported for 6.7% of children on the Problem Items section and 15.4% of parents endorsed one or more Critical Items about their children, which indicate significant behavioral concerns.

CONCLUSION

In this study, we found 6.7% of the school-age children population with CL/P had psychosocial problems. The result of this study hopefully can shed some light in the long-term psychosocial conditions of the CL/P children post-operatively.

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty

PURPOSE

Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty.

METHODS AND MATERIALS

A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models.

RESULTS

The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone.

CONCLUSIONS

Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

Does Early Secondary Alveolar Bone Grafting Influence Need for Additional Maxillary Advancement Procedures in Cleft Lip and Palate?

OBJECTIVE

To determine if secondary alveolar bone grafting (SABG) timing in patients with cleft lip and palate (CLP) influences the future need for additional maxillary advancement procedures, particularly Le Fort I osteotomy with rigid external distraction (RED).

DESIGN

Retrospective cohort study. Groups were separated by SABG timing: early mixed dentition (ages 68 years) or late mixed dentition (ages 9-11 years). The criterion for RED was negative overjet ≥8 mm, and sufficient dental development for RED.

SETTING

Single tertiary care institution.

PATIENTS

Patients with CLP that underwent SABG from 2010 to 2015. Exclusion criteria included syndromic conditions, SABG surgery at age >12 years, current age <12 years, and <2 years follow-up. 104 patients were included.

MAIN OUTCOME MEASURES

The number of RED candidates and treated patients.

RESULTS

There was no statistical difference in the number of RED candidates (P  =  .0718) nor treated patients (P  =  .2716) based on SABG timing; stratification by laterality was also insignificant. Early SABG is associated with higher odds of being a RED candidate (pooled, unilateral, bilateral) and treated patient (pooled and unilateral); however, there were no statistically significant associations between SABG timing and the number of RED candidates and treated patients as determined by logistic regression models.

CONCLUSION

There is no statistically significant association between SABG timing and the odds of being a RED candidate or treated patient. Future prospective studies are recommended to assess the relationship between SABG timing and maxillary growth in patients with CLP.

The Current State of Cleft Care in Sub-Saharan Africa: A Narrative Review

OBJECTIVE

To identify practices and limitations of cleft care in sub-Saharan Africa (SSA).

DESIGN

A retrospective narrative nonsystematic literature review was performed.

SETTING

Literature exploring the management practices of cleft lip and/or palate across regions in SSA was included.

PARTICIPANTS

Full text case reports, retrospective studies, prospective studies, clinical trials, and review articles written and published in English between 1966 and February 1, 2021, were included in this analysis utilizing PubMed, MEDLINE, EMBASE, and Google scholar databases.

MAIN OUTCOME MEASURES

Qualitative themes identified in analysis were clinical practice patterns, current infrastructure and limitations of cleft repair, training and interdisciplinary teams, economic analyses, and international partnerships.

RESULTS

Significant barriers to care identified in SSA include lack of hospital resources, craniofacial training, access to multidisciplinary specialists, and public awareness. These problems make the entire care journey difficult for patients. Increasing public education has the power to diminish late presentations to hospitals. Providing adequate hospital resources and craniofacial training through international and organizational partnerships can ensure that more patients will receive care. Increasing the availability and number of multidisciplinary specialists is crucial to follow up care which aims at improving functional outcomes.

CONCLUSION

This narrative review highlights current practices and limitations in cleft care, emphasizing the importance of effective and timely repair of clefts in SSA. Targeted efforts aimed at establishing sustainable infrastructure for cleft care in SSA can have significant individual and community health and economic benefits.

Histologic Aspect of the Curved Vomerine Mucosa in Cleft Lip and Palate

Background:

Common surgical techniques aim to turn the entire vomerine mucosa with vomer flaps either to the oral side or to the nasal side. The latter approach is widely performed due to the similarity in color to the nasal mucosa. However, we lack a histologic description of the curved vomerine mucosa in cleft lip and palate malformations.

Methods:

We histologically examined an excess of curved vomerine mucosa in 8 patients using hematoxylin–eosin, periodic acid–Schiff, Elastin van Gieson, and Alcian blue stains. Tissue samples were obtained during surgery at 8 months of age.

Results:

Our histological analysis of the mucoperiosteum overlying the curved vomer revealed characteristics consistent with those of an oral mucosa or a squamous metaplasia of the nasal mucosa, as exhibited by a stratified squamous epithelium containing numerous seromucous glands. Some areas showed a palisaded arrangement of the basal cells compatible with metaplasia of respiratory epithelium, but no goblet cells or respiratory cilia were identified. Abundant fibrosis and rich vascularity were present.

Conclusion:

The vomer mucosa showed no specific signs of nasal mucosa. These findings should be considered in presurgical cleft orthopedics and palatal surgery for further refinement. Shifting the vomer mucosa according to a fixed physiologic belief should not overrule other important aspects of cleft repair such as primary healing and establishing optimal form and function of palatal roof and nasal floor.