Binderoid complete cleft lip/palate

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.

Cleft Palate Repair without Lateral Relaxing Incision

Background:

The goals of successful palate repair include optimization of speech and feeding, avoidance of fistula formation, and mitigation of adverse maxillary growth. However, the effects of scar formation on maxillary growth have not been discussed in detail.

Methods:

Between November 2010 and December 2011, the palateplasty was performed for 24 patients with cleft palate (median age, 12 months; range, 11–18 months). In the velum, a symmetrical intravelar veloplasty with mucosal Z-plasty was performed on both the nasal and oral sides. In the hard palate, instead of lateral relaxing incisions, a 1-line mucoperiosteal incision along the cleft margins was designed with subperiosteal undermining in the entire palatine bone. The palatal mucoperiosteum was sutured together in the middle of the cleft, and the cleft was directly closed without lateral relaxing incisions. The patients were monitored for 6 months to 1.6 years.

Results:

None of the cases had issues concerning flap viability, and all palate repairs healed well. Postoperative results were satisfactory, without any complications such as dehiscence, perforation, or palatal fistula.

Conclusions:

The method presented in this article was effective, with successful palatal closure and without scar formation or mucosal defects along the alveolus. We conclude that minimum contracture of the hard palate was useful for not only mitigating adverse maxillary growth but also for orthodontics.

Rare Disease: Lobar Holoprosencephaly With a Median Cleft Lip-Case Report

Holoprosencephaly is a complex malformation of the brain associated with the median facial defects. Variability of the clinical picture is the characteristic of this anomaly. In most cases, the degree of severity of the facial anomaly correlates with the degree of damage to the brain. This article aims to present a rare case of child with a milder form of brain anomaly combined with a severe form of facial anomaly. The article also presents the application of a feeding stimulator to improve the child's quality of life. The anomaly was diagnosed by postnatal sonography of the brain, magnetic resonance imaging of the endocranium, and three-dimensional computed tomography of the craniofacial skeleton.

Repair of bilateral cleft lip and its variants

The surgeon who lifts a scalpel to repair a bilateral cleft lip and nasal deformity is accountable for: 1) precise craftsmanship based on three-dimensional features and four-dimensional changes; 2) periodic assessment throughout the child's growth; and 3) technical modifications during primary closure based on knowledge gained from long-term follow-up evaluation. These children should not have to endure the stares prompted by nasolabial stigmata that result from outdated concepts and technical misadventures. The principles for repair of bilateral complete cleft lip have evolved to such a level that the child's appearance should be equivalent to, or surpass, that of a unilateral complete cleft lip. These same principles also apply to the repair of the variants of bilateral cleft lip, although strategies and execution differ slightly.

Craniofacial and dental dysmorphology in patients with median facial dysplasia: long-term follow-up

Median facial dysplasia affects a subset of patients with cleft lip and palate exhibiting certain characteristics of median facial structure deficiencies without definable gross abnormalities of the brain. The aim of this study was to describe the craniofacial and dental morphology of almost skeletally mature patients with median facial dysplasia. Patients were selected for this retrospective study if they were diagnosed with median facial dysplasia and ≥15 years old. The craniofacial and dental morphology was evaluated by analysing cephalometric and panoramic radiographs. This sample of median facial dysplasia patients (9 males and 11 females; 6 unilateral and 14 bilateral clefts) had a mean age of 16.7 ± 1.9 years. Controls were age-, sex-, cleft type-matched, and nonsyndromic patients. The results showed that in patients with median facial dysplasia, the anterior cranial base and midface were shorter than in controls. The median facial dysplasia inter-orbital distance was shorter and the nasal bone was more retrusive than in controls. All patients with median facial dysplasia had several missing permanent teeth. These features require extensive surgical, orthodontic, and dental rehabilitation procedures.

Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate

BACKGROUND

Bilateral cleft lip-cleft palate is associated with nasal deformities typified by a short columella. The authors compared nasal outcomes of cleft patients treated with banked fork flaps to those of patients who underwent nasoalveolar molding and primary retrograde nasal reconstruction.

METHODS

A retrospective review of 26 consecutive patients with bilateral cleft lip-cleft palate was performed. Group 1 patients (n = 13) had a cleft lip repair and nasal correction with banked fork flaps. Group 2 patients (n = 13) had nonsurgical columellar elongation with nasoalveolar molding followed by cleft lip closure and primary retrograde nasal correction. Group 3 patients (n = 13) were age-matched controls. Columellar length was measured at presentation and at 3 years of age. The number of nasal operations was recorded to 9 years. The Kruskal-Wallis and Tukey-Kramer tests were used for statistical analysis.

RESULTS

Initial columellar length was 0.49 +/- 0.37 mm in group 1 and 0.42 +/- 0.62 mm in group 2. Post-nasoalveolar molding columellar length was 4.5 +/- 0.76 mm in group 2. By 3 years of age, columellar length was 3.03 +/- 1.47 mm in group 1, 5.98 +/- 1.09 mm in group 2, and 6.35 +/- 0.99 mm in group 3. Group 2 columellar length was significantly greater (p < 0.001) than that of group 1 and not statistically different from that of group 3 (p > 0.05). All group 1 patients (13 of 13) needed secondary nasal surgery. No nasoalveolar molding patients (zero of 13, group 2) required secondary nasal surgery.

CONCLUSION

Nonsurgical columellar elongation with nasoalveolar molding followed by primary retrograde nasal reconstruction restored columellar length to normal by 3 years and significantly reduced the need for secondary nasal surgery.

Increasing accuracy of antenatal ultrasound diagnosis of cleft lip with or without cleft palate, in cases referred to the North Thames London Region

OBJECTIVES

To determine the accuracy of antenatal ultrasound diagnosis of cleft lip with or without cleft palate (CL +/- P) and isolated cleft palate (CP).

METHODS

This was a retrospective review of 256 surviving cases referred in 2002-2003 for treatment of CL +/- P.

RESULTS

We had referrals from 36 maternity units, 27 of which were in our local catchment area. There were 154 cases of CL +/- P, of which five had microform CL. Of the remaining 149, 88 (59%) were diagnosed on antenatal ultrasound examination. Among these 88 cases there were minor reporting errors in 22 (25%). These errors were in describing the side and type of the lip cleft in 10 cases, predicting if there was a CP in 10 cases, and recognizing the anomaly in two cases. There were 102 cases referred with isolated CP, of which 92 had overt CP and 10 submucous CP. None of these was diagnosed by antenatal ultrasound imaging. There was no significant difference in the accuracy of ultrasound diagnosis between district hospitals and teaching/tertiary units.

CONCLUSIONS

There is a good awareness and ability to detect CL +/- P by obstetric units from which referrals are received. Inaccuracies in antenatal ultrasound reports occur frequently when attempting to determine the type of CL and when predicting if there is a CP. We recommend that families should continue to be referred to specialist centers for counseling immediately after antenatal diagnosis, and comprehensive advice should always be given about clefts of the lip and palate.

The Spectrum of Orofacial Clefting

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the differing types of congenital clefting defects that extend outward from the perioral region. 2. Define the sites of anatomical disruption and deformities that these types of facial clefts cause. 3. Describe the cause and incidence, if known, of orofacial clefts and their inheritance/transmission risks.

BACKGROUND

Clefts of the orofacial region are among the most common congenital facial defects. The clinical presentation is usually that of a lateral cleft of the lip through the philtrum with or without extension through the palatal shelves. However, atypical forms of clefts with lip involvement also occur in a variety of patterns, some of which are embryologically predictable; others are not.

METHODS

An overview of the embryology, cause, and incidence of this diverse and interesting group of congenital orofacial clefts is presented.

RESULTS

Clefts involving the lateral upper lip; median upper lip; and oblique facial, lateral facial, and median mandibular regions are reviewed.

CONCLUSIONS

This review of orofacial malformations describes clefting anomalies that emanate from the mouth and lips. As the causes of orofacial clefts are better understood, it is becoming clear that a complex interplay between genetic and environmental variables causes these clefts. Future study of orofacial clefts will require increasingly sophisticated methods of elucidating these subtle interactions.

Bilateral cleft lip

The surgeon's objectives are normal nasolabial appearance and normal speech. The principles for synchronous repair of bilateral cleft lip have been established, and the techniques continue to evolve. Primary repair impairs maxillary growth, but little can be done at this time except to practice gentle craftsmanship and to minimize tension on the lower labial closure. The cutaneous lip should never be reopened for revision, and the number of secondary procedures involving the nasal cartilages should be kept to a minimum. Many adolescents with repaired bilateral cleft lip need maxillary advancement to improve projection of the nasal tip, to protrude the upper lip, and to attain normal sagittal skeletal harmony. With expected improvements in the technology of distraction osteogenesis, maxillary advancement may someday become as acceptable as orthodontic treatment.