A Systematic Review: Early Simultaneous Vomer Flap with Primary Cleft Lip Repair, Does it Bring More Benefits?

INTRODUCTION

Vomer flap is a technique to close cleft lip and palate. This technique is a simple procedure that has many benefits. However, the vomer flap's application together with primary lip closure is still questionable.

OBJECTIVE

To find out whether the vomer flap's application in primary cleft lip repair can provide significant benefits.

DESIGN

A systematic review was conducted using the PRISMA methodology has been licensed in PROSPERO databases (CRD42023399487).

SETTING

A comprehensive search was set out, utilizing eight data sources up to March 2023.

PARTICIPANTS

Both cohort studies and randomized control trials regarding the use of vomer flaps performed concurrently with cleft lip repair in children up to six months old.

RESULTS

This article involved 8 studies involving 542 patients who met the inclusion criteria, consisting of 6 retrospective cohort studies, 1 RCT study, and 1 prospective cohort study. Vomer flaps provide a reduction in palatal cleft distance of 3-5 mm, a relatively small number of fistulas (0-4%), improvement of velopharyngeal function (nasal tone and nasal emission), maximal development of the maxilla although it is still controversial.

CONCLUSION

The vomer flap's application in primary cleft lip repair provides many advantages, such as reduced palatal and alveolar clefts, decreased risk of oronasal fistula, increased velopharyngeal function, and increased maxillary growth. It is reliable for the management of cleft lip and palate.

Oral Microbiome as a Tool of Systemic Disease on Cleft Patients: A New Landscape

The oral cavity microbiome comprises benign and pathogenic bacteria, with more than 700 species identified. However, the current literature regarding resident bacterial flora in the oropharyngeal cavities in cleft lip/palate (CLP) patients still needs to be completed. This review aims to evaluate the role of the oral microbiome of cleft patients as an indicator in systemic diseases for which cleft patients might be at higher risk in the short or long term. A literature review was performed in July 2020 using Biomedical Reference Collection Comprehensive, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Dentistry & Oral Sciences Source via Elton B. Stephens Company/Online Database (EBSCO), Turning Research into Practice (TRIP), and PubMed. The keywords used were "oral, bacteria, microbiome, biota, flora, cleft, palate." The resulting 466 articles were deduplicated using Endnote. The total amount of articles' abstracts without duplicates was filtered using a set criterion. The title and abstract filter criteria included 1) cleft lip (CL) and/or cleft palate (CP) patients, 2) changes in the oral microbiome in CL and/or CP patients, 3) male and female patients 0-21 years old, and 4) English language. The full-text filter criteria included 1) CL and/or CP patients vs. non-cleft control patients, 2) oral bacteria, 3) nonprocedural measurements of microorganisms, and 4) case-control studies. A Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow chart was created using the EndNote data results. The final five articles of the systematic search indicated that the oral cavity of cleft lip and/or palate patients resulted in 1) contradicting levels of Streptococcus mitis and Streptococcus salivarius; 2) lower levels of Streptococcus gordonii, Bordetella dentium, Fusobacterium nucleatum, Veillonella parvula, Bacillus and Lautropia when compared to the control group; 3) higher levels of Staphylococcus epidermidis and Methicillin-sensitive Staphylococcus aureus compared to the control group; 4) presence of Enterobacter cloacae 36.6%, Klebsiella pneumoni 53.3%, and Klebsiella oxytoca 76.6% vs. absence in the control non-cleft group. Patients with CL and/or CP are at higher risk for caries, periodontal diseases, and upper and lower respiratory infections. The results from this review indicate that relative levels of certain bacteria may be associated with these issues. The lower levels of S. mitis, S. salivarius, S. gordini, and F. nucleatum in the oral cavity of cleft patients could be linked as a possible cause of the higher incidence of tooth decay, gingivitis and periodontal disease as high levels of these bacteria are associated with oral disease. Further, the higher incidence of sinusitis in cleft patients might be linked to low levels of S. salivarius in the oral profile of these patients. Likewise, E. cloacae, K. oxycota, and K. pneumoni have been linked with pneumonia and bronchiolitis, both of which are increased in cleft patients. The oral bacterial dysbiosis of cleft patients observed in this review may play a vital function in the oral microbiome's diversity, which could play a role in disease progression and disease markers. The pattern seen in cleft patients potentially demonstrates how structural abnormalities can lead to the onset of severe infection.

Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua

BACKGROUND

Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country.

DESIGN

Prospective outcomes study.

SETTING

Comprehensive Cleft Care Center.

PATIENTS

Candidate patients presenting for cleft lip or palate repair or revision.

INTERVENTIONS

Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals.

MAIN OUTCOME MEASURES

Complication was defined as fistula, dehiscence and/or infection.

RESULTS

Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery.

CONCLUSIONS

Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.

The Role of the Pediatric Dentist in the Multidisciplinary Management of the Cleft Lip Palate Patient

The focus of this paper is the pediatric dental care of Cleft Lip and Palate (CLP) children and the role of the pediatric dentist in the CLP team. The management of children with cleft lip and palate presents many challenges and a multidisciplinary and prepared team is always required. Affected individuals present a multiplicity of problems: effective management involves a wide range of specialities. The value of a multidisciplinary team is widely known and mentioned in the literature, but very few papers focus on the role and the importance of the pediatric dentist. Therefore, the purpose of this article is to underline the role of the pediatric dentist as a member of the cleft lip and palate team which ranges from prenatal counseling, presurgical prevention and orthopedics, to post-treatment rehabilitation and restoration.

Continuous Multidisciplinary Care for Patients With Orofacial Clefts-Should the Follow-up Interval Depend on the Cleft Entity?

Objective

The multidisciplinary follow-up of patients with cleft lip with or without palate (CL/P) is organized differently in specialized centers worldwide. The aim of this study was to evaluate the different treatment needs of patients with different manifestations of CL/P and to potentially adapt the frequency and timing of checkup examinations accordingly.

Design

We retrospectively analyzed the data of all patients attending the CL/P consultation hour at a tertiary care center between June 2005 and August 2020 (n = 1126). We defined 3 groups of cleft entities: (1) isolated clefts of lip or lip and alveolus (CL/A), (2) isolated clefts of the hard and/or soft palate, and (3) complete clefts of lip, alveolus and palate (CLP). Timing and type of therapy recommendations given by the specialists of different disciplines were analyzed for statistical differences.

Results

Patients with CLP made up the largest group (n = 537), followed by patients with cleft of the soft palate (n = 371) and CL ± A (n = 218). There were significant differences between the groups with regard to type and frequency of treatment recommendations. A therapy was recommended in a high proportion of examinations in all groups at all ages.

Conclusion

Although there are differences between cleft entities, the treatment need of patients with orofacial clefts is generally high during the growth period. Patients with CL/A showed a similarly high treatment demand and should be monitored closely. A close follow-up for patients with diagnosis of CL/P is crucial and measures should be taken to increase participation in follow-up appointments.

Family based and case-control designs reveal an association of TFAP2A in nonsyndromic cleft lip only among Vietnamese population

Aims

Dozens of causative genes and their mechanisms of nonsyndromic cleft lip with or without cleft palate (NSCL/P) were revealed through genome‐wide association and linkage studies. Results were, however, not always replicated in different populations or methodologies. This study used case–control and family based approaches to investigate the etiology of NSCL/P and its two subtypes: nonsyndromic cleft lip only (NSCLO) and nonsyndromic cleft lip and palate (NSCLP) among the Vietnamese population.

Methods

Two hundred and seventeen NSCL/P case‐parent trios (one affected child and two parents), including 105 NSCLO and 112 NSCLP were involved for a family based design; and 273 ethnic and region‐matched healthy controls with no cleft history in their families were recruited for a case–control design. Three SNPs consisting of TFAP2A (rs1675414 and rs303048) and 8q24 (rs987525) were genotyped using the TaqMan SNP genotyping assay.

Results

TFAP2A rs1675414 was associated with NSCLO, replicated by both case‐control and family based tests. Other SNPs yielded no evidence of susceptibility to NSCL/P or two subtypes.

Conclusion

The current investigation suggests an intriguing role of TFAP2A in the etiology of NSCLO among the Vietnamese population.

This study used case‐control and family‐based approaches to investigate the etiology of NSCL/P and its two subtypes: nonsyndromic cleft lip only (NSCLO), nonsyndromic cleft lip and palate (NSCLP) among Vietnamese population. TFAP2A rs1675414 was associated with NSCLO, replicated by both case‐control and family‐based tests.

Association of Single Nucleotide Polymorphisms on Locus 18q21.1 in the Etiology of Nonsyndromic Cleft Lip Palate (NSCLP) in Indian Multiplex Families

Background  Cleft lip palate (CLP) is a common congenital anomaly with multifactorial etiology. Many polymorphisms at different loci on multiple chromosomes were reported to be involved in its etiology. Genetic research on a single multigenerational American family reported 18q21.1 locus as a high-risk locus for nonsyndromic CLP (NSCLP). However, its association in multiple multiplex families and Indian population is not analyzed for its association in NSCLP.

Aim  This study was aimed to evaluate whether high-risk single nucleotide polymorphisms (SNPs) on chromosome 18q21.1 are involved in the etiology of NSCLP in multiplex Indian families.

Materials and Methods  Twenty multigenerational families affected by NSCLP were selected for the study after following inclusion and exclusion criteria. Genomic DNA was isolated from the affected and unaffected members of these 20 multiplex families and sent for genetic analysis. High-risk polymorphisms, such as rs6507872 and rs8091995 of CTIF , rs17715416, rs17713847 and rs183559995 of MYO5B , rs78950893 of SMAD7 , rs1450425 of LOXHD1 , and rs6507992 of SKA1 candidate genes on the 18q21.1 locus, were analyzed. SNP genotyping was done using the MassARRAY method. Statistical analysis of the genomic data was done by PLINK.

Results  Polymorphisms followed the Hardy–Weinberg equilibrium. In the allelic association, all the polymorphisms had a p -value more than 0.05. The odds ratio was not more than 1.6 for all the SNPs.

Conclusion  High-risk polymorphisms, such as rs6507872 and rs8091995 of CTIF , rs17715416, rs17713847 and rs183559995 of MYO5B , rs78950893 of SMAD7 , rs1450425 of LOXHD1 , and rs6507992 of SKA1 in the locus 18q21.1, are not associated with NSCLP in Indian multiplex families.

Clinical Follow-Up in Orofacial Clefts-Why Multidisciplinary Care Is the Key

(1) Background: Although most clinicians involved in the treatment of cleft patients agree upon the major importance of interdisciplinary cooperation and many protocols and concepts have been discussed in the literature, there is little evidence of the relevance of continuous interdisciplinary care. We aimed to objectify the type and number of therapeutic decisions resulting from an annual multidisciplinary follow-up. (2) Methods: We retrospectively analyzed the data of all 1126 patients followed up in the weekly consultation hours for cleft patients at university clinics in Leipzig for the years 2005-2020. We assessed the clinical data of every patient and specifically evaluated the treatment decisions taken at different points in time by the participating experts of different specialties. (3) Results: In total, 3470 consultations were included in the evaluation, and in 70% of those, a therapeutic recommendation was given. Each specialty showed certain time frames with intense treatment demand, which partially overlapped. Nearly all therapy recommendations were statistically attached to a certain age (p < 0.001). (4) Conclusions: There is an exceptionally high need for the interdisciplinary assessment of patients with cleft formation. Some developmental phases are of particular importance with regard to regular follow-up and initiation of different treatment protocols. The therapy and checkup of cleft patients should be concentrated in specialized centers.

CRISPLD2 Gene Polymorphisms with Nonsyndromic Cleft Lip Palate in Indian Population

Cleft lip palate (CLP) is one of the common congenital anomalies with multifactorial etiology. Many genes are associated with its etiology. In one of the studies CRISPLD2 gene polymorphisms rs1546124, rs4783099, and rs16974880 were reported in the Chinese population. However, its role in the Indian population is not yet studied. Hence, this research was conducted on the Indian population to know the role of these high-risk polymorphisms in patients with nonsyndromic CLP. Following an inclusion and exclusion criteria, 20 multiplex CLP families were selected from a high volume cleft center in India. Genomic DNA was isolated from these families. Single nucleotide polymorphism (SNP) rs1546124, rs4783099, and rs16974880 were analyzed for their association using MassARRAY method. A whole-genome association analysis toolset, PLINK was used for statistical analysis. The polymorphisms followed Hardy–Weinberg equilibrium. None of the polymorphisms showed any significance. Hence the high-risk polymorphisms rs1546124, rs4783099, and rs16974880 are not associated with nonsyndromic CLP in Indian population.

Dental implant placement in alveolar cleft patients: a retrospective comparative study on clinical and aesthetic outcomes

The aim of this retrospective study was to assess the clinical and aesthetic outcomes, and patient satisfaction, following dental implant therapy in cleft patients. Implant survival, changes in marginal bone level, pocket probing depths, plaque and bleeding indices, aesthetics, and patient satisfaction were assessed in 17 alveolar cleft patients and 17 matched controls. At follow-up (mean 72.4±46.4 months), one implant had been lost in the cleft group. Mean marginal bone loss at follow-up was -0.4±0.4mm in cleft patients and -0.2±0.4mm in controls. Aesthetics of the peri-implant soft tissues (pink aesthetic score) were less favourable (P=0.025) in cleft patients (5.0±1.9) than in controls (6.5±1.7), while peri-implant parameters were comparable in the two groups. Overall patient satisfaction was 8.6±0.9 in cleft patients and 8.9±1.1 in controls (P=0.331). In cleft patients, no difference in aesthetics was observed between patients who received additional bone augmentation at 3 months prior to implant placement and those who did not (P=0.092). Dental implant therapy in cleft patients is associated with high implant survival, minor marginal bone loss, healthy peri-implant soft tissues, and high patient satisfaction. Only the aesthetics of the soft tissues was worse in cleft patients compared to augmented non-cleft patients.

Rotational Advancement in Cleft Nose Rhinoplasty - Buccal Mucosal Grafts Serve as a Powerful Tool

OBJECTIVE

Our aim was to analyze our technique of a modified rotational advancement in conjunction with buccal mucosal grafts (BMGs) in a subgroup of severe cleft cases.

DESIGN

A retrospective clinical and photographic evaluation was conducted. Columella angle (CA) and tip projection (TPR) served as instruments in a photometric analysis.

SETTING

Academic university hospital and specialized craniofacial cleft center.

PATIENTS

At the time of the secondary rhinoplasty, 61 cleft patients were included, all 17 years or older.

INTERVENTIONS

Rotational advancement with usage of BMGs was performed in selected cases by a single surgeon.

MAIN OUTCOME MEASURES

Nasal symmetry and aesthetic appearance.

RESULTS

From 2003 to 2011, 29 unilateral severe cleft cases (group I) underwent a modified alar rotational advancement with BMGs. Group II, with 32 cases, represented patients without BMGs. Technique and management of BMGs were described in detail. The complication rate of donor and recipient site presented as very low. The CA was improved significantly in both groups. Also, TPR improved (not significantly) in group I. Using our technique, we considerably enhanced the aesthetic results and symmetry in secondary cleft rhinoplast.

CONCLUSIONS

Rotating the vestibular skin makes it possible to eliminate the traction of this skin on the repositioned alar cartilage, therefore achieving a more pleasing and stable nasal symmetry in secondary cleft rhinoplasty. Versatile BMGs close this gap, thus making them a powerful tool in the arsenal of the reconstructive cleft surgeon.

Common dental anomalies in cleft lip and palate patients

BACKGROUND

Cleft lip and palate (CLP) is the most common orofacial congenital malformation in live births. CLP can occur individually or in combination with other congenital deformities. Affected patients experience a number of dental, aesthetic, speech, hearing, and psychological complications and have a higher incidence of severe dental conditions. The purpose of this study is to characterise the different types of dental anomalies that are frequently associated with CLP patients based on a literature survey.

METHODS

By literature survey, this study characterises the different types of dental anomalies that are frequently associated with cleft lip and palate patients.

RESULTS

Common dental anomalies associated with CLP are supernumerary tooth, congenitally missing tooth, delayed tooth development, morphological anomalies in both deciduous and permanent dentition, delayed eruption of permanent maxillary incisors, microdontia, and abnormal tooth number.

CONCLUSION

The incidence of certain dental anomalies is strongly correlated with Cleft lip and palate, a finding that is consistent with previous studies.

Evaluating aesthetics of the nasolabial region in children with cleft lip and palate: professional analysis and patient satisfaction

Cleft lip and palate is one of the most common deformities of the craniofacial region, and treatment of this deformity is essential for social reintegration. One of the major goals of surgery and treatment of craniofacial deformities is to improve the aesthetic appearance of the face, and thereby improve the patient's social acceptability. Here, we present a critical review of the criteria for aesthetic evaluation of the nasolabial region in cleft patients by assessing publications with the highest level of evidence, including professional evaluation, and patient satisfaction. The findings indicate treatment of this condition represents a major challenge for multidisciplinary team care.