Assessment of Two Years of Free Surgical Treatment of Cleft Lip, Palate and Alveolar (CLPA) in the Maxillofacial Surgery and Stomatology Department of the Hospital University of Treichville-Abidjan

Introduction: Cleft lip, palate and alveolar (CLPA) are congenital malformations of the face due to a defect in the fusion of embryonic buds during the first weeks of embryogenesis. These malformations affect the upper lip, the alveolar bone and the palate. The incidence in Africa ranges from 1/2000 to 1/500 births. Their multidisciplinary management is long and costly. Thus, the help provided by humanitarian organisations during free care campaigns is welcome. Materials and Methods: This is a retrospective descriptive study conducted from August 2014 to July 2016 in the Maxillofacial Surgery and Stomatology Department of the Treichville University Hospital in Abidjan, Côte d’Ivoire. The objective was to describe the epidemiological, clinical and therapeutic aspects of CLPA during a humanitarian campaign for free care. Results: 51 cases of CLPA were operated on. Males were involved in 54.9% of the cases, i.e. a sex ratio of 1.2. The average age of the patients at the time of the operation was 3.44 years with extremes of 3 months and 52 years. Patients with low socioeconomic status represented 84.3% of the cases. Cleft lips (31.4%) and cleft palates (33.33%) predominated. For cleft lips, unilateral forms were the most frequent (73.5%) and the left side was most often affected (59.2%). The most common surgical techniques used were MILLARD cheiloplasty for cleft lips (79.36%) and Dorrance pushback for cleft palates (78.05%). The postoperative course was simple in the majority of cases (80.47%). Patients and/or parents were satisfied with the postoperative results in over 90% of cases. Discussion: Cleft lip and palate are common. Their management by humanitarian missions through mass campaigns allows us to receive a large number of patients affected by this pathology who are treated with a high satisfaction rate. Conclusion: The characteristics of cleft lip and palate in this study are in many respects identical to those described in the literature, but with some differences specific to Africa, notably the absence of antenatal diagnosis and the advanced age at the time of treatment.

Rhinoplasty in Cleft Lip and Palate

Various surgical techniques and approaches have been described to repair cleft nose deformities. It is necessary to consider that since it is a congenital deformity, surgical management must consider the patient’s growth process, as well as the healing itself from the surgery. The present study aims to evaluate an alternative solution to secondary rhinology, aesthetic, and functional alterations to unilateral or bilateral cleft lift palate to minimize deformities and ensure good results. 11 patients were studied between 1995 to 2002, ten male and one female. In 8 cases, the patients had a history of cleft lip and palate on the left side, 2 patients with cleft lift palate on the right, and 1 patient with bilateral cleft lip and palate. 100% of the patients increased their naso-labial angle. This improved their appearance and structure, starting from a preoperative arithmetic mean of 39 degrees to a postoperative arithmetic mean of 96 degrees. Such intervention increased the naso-labial angle by 57 degrees. At the base of the nose, it was possible to improve the inclination of the alar line (line B) in 10 of the cases with a variation of 2 to 3 mm in relation to the perpendicular line A and only one case remained with the same inclination.

BHMT Gene Polymorphisms as Risk Factors for Cleft Lip and Cleft Palate in a Chinese Population

Objective Convincing evidence suggests a link between increased risk of nonsyndromic cleft lip with or without cleft palate （NSCL/P） and low intake of folic acid by the mother during pregnancy. The present study was designed to explore if genetic variation in the betaine‐homocysteine methyltransferase （BHMT） gene contributes to NSCL/P. Methods DNA was obtained from 166 individuals with NSCL/P and 285 healthy subjects. Three known single nucleotide polymorphisms （SNPs） present in the BHMT gene （rs651852, rs3797546, and rs3733890） were investigated by real‐time PCR‐based TaqMan genotyping. Results Neither allelic nor genotypic association was found between NSCL/P and SNPs rs651852 and rs3733890. SNP rs3797546 did not show allelic association with NSCL/P; however, a higher proportion of NSCL/P patients carry the CC genotype compared with the TT＋CT genotype （P=0.020, OR=2.10, 95% CI=1.11‐3.95）. Conclusion Our study suggests that polymorphism rs3797546 in the BHMT gene may confer genetic risk of NSCL/P in a recessive manner.

Genome-wide and Interaction Linkage Scan for Nonsyndromic Cleft Lip with or without Cleft Palate in Two Multiplex Families in Shenyang,China

Objectives To identify the loci involved in nonsyndromic cleft lip with or without cleft palate （NSCL/P） in Northern Chinese people in Shenyang by using genomewide and interaction linkage scan.Methods Two multiplex families in Shenyang from North China were ascertained through probands with NSCL/P.Blood of every member was drawn for DNA extraction and analysis.Genotypes were available for 382 autosomal short tandem repeat （STR） markers from the ABI Prism Linkage Mapping Set version 2.5.Linkage between markers and NSCL/P was assessed by 2-point parametric LOD scores,multipoint heterogeneity parametric LOD scores （HLODs）,and multipoint nonparametric linkage score （NPL）.Results The initial scan suggested linkage on Chromosomes 1,2,and 15.In subsequent fine mapping,1q32-q42 showed a maximum multipoint LOD score of 1.9（empirical P=0.013） and an NPL score of 2.35 （empirical P=0.053）.For 2p24-p25,the multipoint NPL increased to 2.94 （empirical P=0.007）.2-locus interaction analysis obtained a maximum NPL score of 3.73 （P=0.00078） and a maximum LOD score of 3 for Chromosome 1 （at 221 cM） and Chromosome 2 （at 29 cM）.Conclusion Both parametric and nonparametric linkage scores greatly increased over the initial linkage scores on 1q32-q42,suggesting a susceptibility locus in this region.Nonparametric linkage gave a strong evidence for a candidate region on chromosome 2p24-p25.The superiority of 2-locus linkage scores compared to single-locus scores gave additional evidence for linkage on 1q32-q42 and 2p24-p25,and suggested that certain genes in the two regions may contribute to NCSL/P risks with interaction.

A Case-control Study of Environmental Risk Factors for Nonsyndromic Cleft of the Lip and/or Palate in Xuzhou,China

In this study, we sought to determine the association between environmental factors and nonsyndromic cleft of the lip and/or palate （NSCLP） to understand the etiology of the disease. A total of 200 NSCLP cases and 327 controls were recruited at the Maternal and Child Health Hospital of Xuzhou City. We conducted face-to-face interviews with the mothers of both cases and controls. The factors increasing the risk of NSCLP were a positive family history [odds ratio （OR）=56.74], pesticide exposure （OR=8.90）, and indoor decoration pollution （OR= 4.32）. On the other hand, the factors decreasing the risk of NSCLP were a high education level （OR=0.22） and supplementation of folic acid （OR=0.23） and multivitamins （OR=0.16）. Positive family history, pesticide exposure, and indoor decoration pollution are associated with the risk of NSCLP. In contrast, high education level and folic acid and multivitamin supplementation are protective factors against NSCLP.

Comparison of Congenital Tooth Deficiencies Seen in Permanent Teeth in Individuals with Unilateral Cleft Lip and Palate to Those without Cleft Lip and Palate

Objective: To compare the congenital tooth deficiencies seen in permanent dentition in individuals with unilateral cleft lip and palate (UCLP) to non-cleft individuals with Angle Class I malocclusion. Method: The study was performed on orthopantomograph films of 50 individuals with UCLP aged between 12 - 16 years and 50 individuals with Angle Class I malocclusion individuals aged between 13 - 15 years. Individuals with UCLP;32 clefts were on the left side and 18 clefts were on the right side. Permanent third molar teeth deficiency was excluded from the study. Results: In 50 individuals with UCLP;35 (70%) upper lateral incisors were congenitally deficient in the cleft area, while 15 (30%) missing lateral teeth were found in the non-cleft side. In control group, 12 (24%) of 50 patients had congenital lateral incisor deficiency. Congenital deficiency of upper lateral incisor in UCLP;the cleft area was higher than the non-cleft side (p < 0.01). The difference was statistically important when compared with the control group (p < 0.001). In 50 individuals with UCLP;while 27 (54%) of second premolar teeth were congenitally deficient in cleft side, 23 (46%) were missing in non-cleft side. In control group, 18 (36%) congenital second premolar deficiency was detected. However, second premolar congenital deficiency was higher in UCLP group when compared to control group (p < 0.01). Conclusion: The deficiency of the lateral incisors in the cleft side is more often congenitally deficient than upper second premolar teeth and this should be considered in the treatment planning from an early age.

TYMS gene 5'-and 3'-untranslated region polymorphisms and risk of non-syndromic cleft lip and palate in an Indian population

Dear Editor： Increased homocysteine levels due to vitamin B6 or B12 deficiency or genetic defects in folate pathway genes are associated with an increased incidence of non-syndromic cleft lip with or without cleft palate （NSCLP）tlj. Thymidylate synthase （TS） is a folate-dependent enzyme that catalyzes methylation of 2＇-deoxyuridine-5＇-monophosphate （dUMP） to 2＇-deox- ythymidine-5＇-monophosphate （dTMP）, a rate-limiting step in DNA synthesis,

Upper Airway Changes after Maxillary Distraction Osteogenesis in Cleft Lip and Palate Patients

Purpose: To measure the upper airway changes associated with maxillary distraction osteogenesis in cleft lip and palate patients in the immediate post operative period and 12 months later. Materials and Methods: Seven patients with repaired cleft lip and palate (CLP) presented with severe maxillary hypoplasia. They were examined initially at T1 predistraction phase. Records taken included radiographs (orthopantograms OPG, lateral cephalometric, posteroanterior). Cephalometric analysis was done to evaluate the upper airway. Mean age is 17 years and the reverse overjet > 6 mm. They underwent maxillary Le Fort I distraction using external rigid distracters (RED). Cephalometric analysis to evaluate the upper airway was repeated at the end of the consolidation phase T2 and twelve months after distractor removal T3. Results: The range of maxillary advancement was between 8 - 15 mm (mean 9 mm). The anteroposterior distance of the superior velopharynx (PPS) and middle velopharynx (SPPS) increased at T2. A small amount of reduction in these values was recorded at T3. The inferior velopharynx (MPS) and the oropharynx (IPS, EPS) showed minimum increase in anteroposterior distance in only two patients at T2 and no change at T3. Conclusion: All seven patients showed clinical improvement in the upper airway and an increase in the upper airway values on lateral cephalometric radiographs.

Association of Single Nucleotide Polymorphisms in IRF6 and TGFA Genes With Nonsyndromic Cleft Lip With Or Without Cleft Palate in Chinese Patients

Objective： Nonsyndromic cleft lip with or without cleft palate（NSCL/P） is a common birth defect with unclear etiology. Both genetic and environmental factors may contribute to NSCL/P. Many genes have been identified as candidate genes associated with this disease. Interferon regulatory factor 6（IRF6） gene and transforming growth factor-a（TGFA） gene seem to be crucial in the predisposition of NSCL/ P. Here we evaluated some single nucleotide polymorphisms（SNPs） loci of TGFA and IRF6 genes in Chinese nuclear families consisting of fathers, mothers and affected offspring with NSCL/P. Methods：Fifty patients of NSCL/P were confirmed by the plastic surgeons. They and their parents were included in the study, all with the informed consents. SNPs loci of TGFA and IRF6 genes were analyzed by microarray technology. Some PCR products were randomly chosen and sequenced to check microarray results. The distribution of gene type and allele frequency between patient group and parents group were compared. Then a Haplotype Relative Risk（HRR） and Transmission Disequilibrium Test（TDT） were performed. Results：The sequences of randomly selected PCR products were all consistent with the microarray results. All loci were in Hardy-Weinberg equilibrium. There were no significant differences in the distribution of genotypes and alleles between patients and their parents. Using HRR and TDT analyses the V274I of IRF6 was associated with NSCL/P, while another SNP locus oflRF6 was not. Strong evidence of linkage disequilibrium was found between the 2 SNP loci of TGFA and disease with the HRR analysis, but not with the TDT analysis. Conclusion：Our study confirms the contribution of IRF6 in the etiology of NSCL/P in populations of Asian ancestry. The association of TGFA with NSCL/P requires further research.

Expectations of Caregivers of Patients with Cleft Lip and Palate Attending the Cleft Clinic of KATH for the First Time

Background: Cleft lip and palate (CLP) is one of the most prevalent congenital malformations affecting the face worldwide, with high prevalence in Asians, Americans, and Caucasians and low in Africans. Orofacial Clefts (OFCs) are among the causes of perinatal death in Ghana. The children often experience difficulties in swallowing, feeding, and speaking. These children often face problems in cognition, education, and communication. Caregivers’ ignorance of treatment, poverty, and noncompliance with follow-up schedules are obstacles to optimal cleft care. Most studies focus on the incidence of cleft, but not much is known about caregivers’ expectations. Methodology: An exploratory qualitative study design was used for this research between October and November 2020. The study site was the Komfo Anokye Teaching Hospital, (KATH), Kumasi, Ghana. The respondents were recruited from the oral health clinic. Included in the study were all CLP caregivers attending the cleft clinic for the first time. Purposive sampling was used to select fifteen caregivers who met the inclusion criteria. Face-to-face interviews with a semi-structured interview guide were used to collect data. The data were analyzed using NVivo software. Three major themes and six sub-themes emerged from the data analysis using thematic analysis. Ethical clearance was obtained for data collection. Results: Most caregivers were expecting their babies to be operated on, and they were certain that the cleft would be repaired at the end of the treatment, but they were unfamiliar with the process and cost of treatment. Less than half of the caregivers reported that they were oblivious to what to expect the first time visiting but had hopes that the healthcare professionals would be able to close the cleft for their babies. Conclusion: The majority of the caregivers expressed fear and disappointment at the diagnosis of their child. Some caregivers were very scared to the level where they had to hide the babies from the public. Others reported being already in financial difficulties, so their children’s conditions would compound them.

Three-dimensional finite element analysls for external midface distraction after different osteotomy in patients with cleft lip and palate

Objective To study three - dimensional finite element analysis for external midface distraction after different osteotomy in patients with cleft lip and palate ( Clp) . Methods Three - dimensional Fem models of Le Fort Ⅰ,Ⅱand Ⅲ,osteotomy in Clp patients were estabolished. External midface distraction were simulated. An anteriorly and inferiorly directed 900 g force was

Orthognathic Surgery for Achieving Facial Balance and Harmony in Cleft Patients

Cleft surgery requires an expert team performing ongoing treatment in order to achieve optimal outcomes. The senior author's(KES) experiences of more than 2000 patients with cleft lip and palate treated by a surgical-orthodontic protocol were introduced. The paper here will concentrate on not only correcting the occlusion as others have described,but also on what one surgeon can do to achieve optimal aesthetic balance, harmony and beauty. The results of orthognathic surgery in respect to function, stability, cosmesis, and complications are also audited.

Immunisation Status of Children Born with Orofacial Clefts Who Visited the Komfo Anokye Teaching Hospital (KATH) Multidisciplinary Cleft Clinic

Background: The Ghana Expanded Programme on Immunisation recommends that children receive Bacillus Calmette-Guerin (BCG) and Oral Polio Vaccine (OPV) at birth;three doses of Penta vaccine and OPV at 6, 10 and 14 weeks of age;and measles vaccine at 9 months of age. Aim/Objective: To evaluate the immunisation status of children born with orofacial clefts who visited the KATH multidisciplinary Cleft clinic. Methodology/Statistics: The study was a descriptive study with a cross-sectional design. The methodology consisted of in-person interviews of mothers of children born with cleft lip and palate reporting at KATH Cleft clinic. Interview guides were used for mothers who could not read. Mothers who were literate and as such could answer the questions directly were given questionnaires to fill. Result: It was reported that of the 83 children included, 47 (57%) had been fully vaccinated and on time, 24 (29%) had been fully vaccinated but delayed and 12 (14%) had not been vaccinated at all. Children with isolated cleft palate and macrostomia were fully vaccinated on time (77.3% and 100%, respectively) as compared to those with combined cleft lip and palate (43.3%) and isolated cleft lip (50.0%). The majority (77%) of the mothers who either had not vaccinated their children or had delayed in vaccinating them attributed stigmatisation as the main cause. Most of the mothers (95%) had knowledge of immunisation. About two-thirds of the mothers (65%) agreed that establishing an immunisation centre at the cleft clinic is the best way to improve immunisation rate among children with orofacial clefts. Conclusion: The study showed that the percentage of children with orofacial cleft who visited the KATH Cleft Clinic and were vaccinated on time was above the national average. Cleft palates were more vaccinated and on time than cleft lips. According to the children’s mothers, lack of timely vaccination was mainly due to the stigma associated with clefts in their societies.

Advancement of maxillary anterior segment by distraction osteogenesis for severe maxillary retrusion in cleft lip and palate

Background Maxillary anterior segmental distraction osteogenesis （MASDO） is a recently used method for correction of severe maxillary retrusion in cleft lip and palate （CLP） patients.In this article,we evaluated the feasibility of MASDO using rigid external distraction （RED） and rapid orthodontic tooth movement to correct severe maxillary retrusion in CLP patients.Methods Fourteen male and five female complete CLP patients between the ages of 18 and 22 years （mean age 19.7 years） at the time of distraction,with severe maxillary retrusion,were treated with the rigid external distraction （RED） device after maxillary anterior osteotomy.Rapid orthodontic tooth movement was started one week after the MASDO.Standard profile photographic,cephalometric films were obtained preoperatively and after therapy.Sella-nasion-point A （SNA） and Sella-nasion-point B （SNB） angles were measured to reflect changes in maxillary and mandibular position,and the distance between anterior nasal spine and posterior nasal spine （ANS-PNS） was measured to represent the maxillary dental arch length.Results The SNA angle increased from an average of 74.6° （range 73.0°-78.0°）,preoperatively,to 83.4° （range 78.6°-88.0°） after the RED was removed （P ＜0.01）.All cases of severe maxillary retrusion were improved.Nine patients＇ profiles became harmonious after therapy.One patient had a bimaxillary protrusion deformity and needed further surgery.The regenerate alveolar crest and edentulous space on both segments was almost completely eliminated after rapid orthodontic tooth movement.Conclusion MASDO with the RED system and rapid orthodontic tooth movement is a successful way of correcting severe maxillary retrusion in CLP patients.

Reading-related Brain Function Restored to Normal After Articulation Training in Patients with Cleft Lip and Palate:An fMRI Study

Cleft lip and/or palate(CLP)are the most common craniofacial malformations in humans.Speech problems often persist even after cleft repair,such that follow-up articulation training is usually required.However,the neural mechanism behind effective articulation training remains largely unknown.We used fMRI to investigate the differences in brain activation,functional connectivity,and effective connectivity across CLP patients with and without articulation training and matched normal participants.We found that training promoted task-related brain activation among the articulation-related brain networks,as well as the global attributes and nodal efficiency in the functional-connectivity-based graph of the network.Our results reveal the neural correlates of effective articulation training in CLP patients,and this could contribute to the future improvement of the post-repair articulation training program.

Global and communicative development skills in preschool children with cleft lip and palate

Importance:Cleft lip and palate(CLP)is globally among the most common childhood malformations.This disorder impacts childhood development,including speech and language,and affects children worldwide.Objective:To analyze child development skills(adaptive fine motor,gross motor,personal-social,and language)in preschool children with isolated CLP compared with children without this malformation.Methods:The participants included an experimental group of 27 children with isolated CLP and a comparison group of 27 children without CLP aged between 48 and 59 months.The groups were evaluated using two instruments:the Denver Developmental Screening Test II(DDST-II)and the Avaliapao do Desenvolvimento da Linguagem(ADL-Language Development Assessment).Data were analyzed by descriptive and inductive analyses,using the Student’s Mest and the Mann-Whitney test,at a significance level of P<0.05.Results:All children in the comparison group performed within normal standards for their age range in the DDST-II and the ADL.The worst performance in the experimental group was observed in language skills,followed,in declining order,by adaptive fine motor,personal-social,and gross motor as measured by the DDST-II.Children with isolated CLP also performed poorly in receptive,expressive,and global language in the ADL.No statistically significant differences were observed in the experimental group’s scores for the ADL and the DDST-II.Interpretation:Developmental skill levels were below expectations for children of this age with isolated CLP.

Combination of congenital cleft lip and palate with congenital diaphragmatic hernia: a severe disease course

Congenital cleft lip and palate （CLP） is the most ＇common birth defect now in China. The incidence is 1.62%0 according to the data （1988-- 1992） provided by the National Center for Birth Defects Monitoring. It is also one of the congenital anomalies that have excellent prognosis. But severe complications may occur in the cases accompanied some other deformities. Here we report a case of death caused by left-sided posterolateral congenital diaphragmatic hernia （CDH）, type Bochdalek, after the cleft operation.

A novel FZD6 mutation revealed the cause of cleft lip and/or palate in a Chinese family

Cleft lip and/or palate(CL/P)is a most common craniofacial birth defect which has multifactorial etiology.In our study,we aimed to discover the underlying etiological gene variation in a Chinese family diagnosed as non-syndromic CL/P(NSCL/P).The blood sample of the proband and her parents were detected by whole exome sequencing.The Mendelian inheritance pattern,allele frequency,variation location,function analysis and literature search were applied to filtrate and screen the mutation.Besides,the candidates were confirmed by Sanger sequencing.We meanwhile explored the conservative analysis and protein homology simulation.As a result,a start-lost mutation c.1A>GAtg/Gtg in the Frizzled-6(FZD6)gene predicting p.Met1 was detected.The variation has not been reported before and was predicted to be harmful.The alteration caused missing of two starting amino acids that are evolutionarily conserved for FZD6 protein.Moreover,the specific structure of the mutant protein obviously changed according to the results of the homologous model.In conclusion,the results suggest c.1A>GAtg/Gtg in the FZD6(NM_001164616)might be the genetic etiology for non-syndromic CL/P in this pedigree.Furthermore,this finding provided new etiologic information,supplementing the evidence that FZD6 is a strong potential gene for CL/P.

Non-prosthetic treatment using segmental osteotomy and bone grafting in a patient with cleft lip and palate

This case report aimed to present the course of surgically combined comprehensive orthodontic treatment of a male adult with cleft lip and palate,showing a left alveolar cleft,lateral deviation of the major segment of the maxilla,and palatal transposition of the lateral incisor.Preoperatively,the midline of the upper central incisors was shifted by 7.0 mm to the right,the right lateral incisor showed palatal transposition,and the residual alveolar cleft was 6.5 mm.Segmental Le Fort I osteotomy of the major segment,and simultaneous bone grafting into the extended alveolar bone and former cleft region were performed at 18 years and 4 months of age.Thus,midline correction,alignment of the right lateral incisor,and cleft closure were achieved;no further prosthetic treatment was required.

Ectrodactyly-ectodermal dysplasia-cleft lip/palate syndrome:a rare entity

Ectrodactyly-ectodermic dysplasia-cleft lip/palate(EEC)syndrome is a rare congenital anomaly of inherited origin and varying clinical features.This syndrome has three main symptoms,which display variable expression and penetrance.The management of this syndrome is challenging,with few reports in the medical literature.We present a case of a 22-year-old boy with EEC syndrome and offer insight into current knowledge about this syndrome.