The Tessier number 9 cleft

[Paramedian frontal clefts or superior orbital clefts]

Superior orbital frontal clefts are one of the rare craniofacial clefts described by Tessier in 1976, and occur most often sporadically. They are numbered 9, 10 and 11 in this classification, and are located respectively laterally, in the middle and medially to the upper part of the orbit. Their clinical expression is variable on soft tissue and bone, with possible dissociation of involvement. They range from a simple aesthetic defect to an eyes functional prognosis. CT scans are systematically required in this context. Their management must be adapted to the polymorphism of the damage, and is based on multidisciplinary approach. In case of ocular risk, the eyelid reconstruction is an emergency. In all other cases, treatment is deferred, but must be carried out at an early stage to ensure the child's healthy development.

A rare case of cleft number nine associated with atypical cleft number two

The incidence of the craniofacial cleft is rare ranging between 1.43 and 4.85/100,000 births. Tessier number nine cleft being the rarest, there are a few reports of detailed ophthalmologic examinations performed in them. In this study, 1-day-old female neonate delivered by normal vaginal delivery at term, weighing 1480 g presented with right eye dystopia, cleft extending through the lateral third of the upper eyelid, brow ending at the temporal region, conjunctival congestion, clear cornea 10 mm in diameter, normal anterior chamber, pupil 2 mm reactive to light, clear lens, and normal fundus. Cleft extended downward from the right medial canthus involving the nasal ala and left forearm had an oblique-crease with camptodactyly. We thus report a case of anterior segment abnormality with an oblique craniofacial cleft. The cause of which is unclear, amniotic band syndrome being a possible cause.

Ophthalmic considerations in the management of Tessier cleft 5/9

PURPOSE

To describe a patient with Tessier cleft number 5 and 9 and review the literature on the ocular impairment and management of this extremely rare anomaly.

METHODS

Interventional case report and literature review.

RESULTS

The literature review showed that the present patient is the second case with clefts 5/9. The ophthalmic consequences of this rare association are virtually unreported. Our case demonstrates that the presence of cleft number 9 adds a cicatricial component on the upper eyelid that severely impairs the dynamics of this lid. The corneal status of the patient was successfully managed with simultaneous upper eyelid lengthening and facial reconstruction.

CONCLUSION

In order to avoid corneal perforation, simultaneous upper and lower eyelid reconstruction is mandatory in cases of cleft 5/9. The affected patients should be continuously followed in order to prevent amblyopia.

The Tessier Number 5 Facial Cleft: Surgical Strategies and Outcomes in Six Patients

The Tessier no. 5 facial cleft is an extremely rare congenital malformation. Only 26 cases have been described in the English-language literature. The cleft begins in the upper lip just medial to the oral commissure, extending across the cheek as a groove ending at the junction of the middle and lateral thirds of the lower eyelid. The bone involvement usually includes an alveolar cleft in the premolar region, extends across the maxilla lateral to the infraorbital nerve, up to the infraorbital rim and orbital floor. The goals of the surgical procedure include reconstructing the lower eyelid, repositioning the lateral canthus, closure of the labiomaxillary cleft, and restoration of the skeletal continuity (including the orbital floor defect) with bone grafts. We present six patients with the Tessier no. 5 facial cleft who have been treated in our combined centers and discuss the surgical options and difficulties faced in the reconstruction of this rare and challenging craniofacial malformation. To date, we have treated six patients (two with bilateral and four with unilateral clefts). Three of the patients with unilateral clefting had an associated no. 4 cleft and one patient with a bilateral cleft had an associated no. 3 cleft. This paper represents the largest series to date documenting surgery for patients with the Tessier no. 5 facial cleft.

Our experiences managing a rare cranio-orbital cleft

A unilateral upper lateral orbital cleft, fitting the description of the extremely rare Tessier cleft number 9 is reported. The management and surgery of this patient are discussed, and the relevant literature is reviewed. The usefulness of three-dimensional computed tomography reconstructions and plastic models in planning the surgery is discussed.

A Paramedian Cleft of the Lower Lip

We report the unusual case of a baby with a paramedian cleft of the lower lip. In 1976, Tessier described a classification of craniofacial clefts based on personal observations, and he predicted the possibility of further clefts being discovered by labeling midline mandibular clefts "30." This case of a paramedian cleft of the lower lip would fit into what could be a new Tessier 28/29 cleft. In the future, clefts in new locations around the mouth may be seen, thus filling the gaps in Tessier's classification.

Amniotic band syndrome: the association between rare facial clefts and limb ring constrictions

The pathologic cause of both rare craniofacial clefts and congenital limb ring constrictions is the subject of some debate. Uncommon though these two conditions are, they have often been anecdotally reported in association. This study sought to determine the frequency of congenital limb anomalies in general and limb ring constrictions in particular amongst a population of patients with rare craniofacial clefts. Eighty-five cases of nonsyndromal, rare, craniofacial cleft were identified from a population of 280 patients assessed at the Women's and Children's Hospital, North Adelaide, with a diagnosis of rare craniofacial cleft classifiable by the Tessier system. Twenty-two patients (25.9 percent) displayed congenital limb anomalies. Eleven of these (12.9 percent) showed evidence of limb ring constrictions, a frequency much greater than in the general population. The group with limb ring constrictions demonstrated a significantly greater complexity of involvement with craniofacial clefting than the non-limb ring constriction group (4.27 clefts/patient versus 2.3 clefts/patient, p < 0.01). The distribution of craniofacial cleft locations in patients with evidence of limb ring constrictions was found to differ significantly from those with other or no limb anomalies (p < 0.01). The clefts in cases in which limb ring constrictions coexist are largely restricted to the paramedian 2-12, 3-11, 412 axes. This study confirms an association between rare craniofacial clefts and limb ring constrictions. The two conditions may therefore possess common etiology.

Oblique facial clefts: a report of Tessier numbers 3, 4, 5, and 9 clefts

The oblique facial cleft is an extremely rare and disfiguring congenital anomaly of the face. Tessier (1990) proposed an anatomic classification of the facial, craniofacial, and laterofacial clefts that was a great advance in the study of these clefts. The clefts were found to occur with an incidence of 1.43 to 4.85 in 100,000 births (Kawamoto, 1976). The exact incidence of these unusual facial clefts is unknown, and estimates vary widely because of the rarity of their occurrence and the lack of standard methods of data collection. To adequately examine the occurrence of oblique clefts, the medical community must be aware of the problem, and new cases should be presented. On the basis of clinical, radiologic, and surgical examinations, soft tissue and skeletal disruptions of three patients with the most rare craniofacial clefts (Tessier 3, 4, 5, and 9) are presented.