The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems

Objective

Otitis media with effusion is common in infants with an unrepaired cleft palate. Although its prevalence is reduced after cleft surgery, many children continue to suffer from middle ear problems during childhood. While the tensor veli palatini muscle is thought to be involved in middle ear ventilation, evidence about its exact anatomy, function, and role in cleft palate surgery is limited.This study aimed to perform a thorough review of the literature on (1) the role of the tensor veli palatini muscle in the Eustachian tube opening and middle ear ventilation, (2) anatomical anomalies in cleft palate infants related to middle ear disease, and (3) their implications for surgical techniques used in cleft palate repair.

Materials and methods

A literature search on the MEDLINE database was performed using a combination of the keywords “tensor veli palatini muscle,” “Eustachian tube,” “otitis media with effusion,” and “cleft palate.”

Results

Several studies confirm the important role of the tensor veli palatini muscle in the Eustachian tube opening mechanism. Maintaining the integrity of the tensor veli palatini muscle during cleft palate surgery seems to improve long-term otological outcome. However, anatomical variations in cleft palate children may alter the effect of the tensor veli palatini muscle on the Eustachian tube’s dilatation mechanism.

Conclusion

More research is warranted to clarify the role of the tensor veli palatini muscle in cleft palate-associated Eustachian tube dysfunction and development of middle ear problems.

Clinical relevance

Optimized surgical management of cleft palate could potentially reduce associated middle ear problems.

     

软腭内肌肉排列的显微解剖学和组织学研究

目的 :旨在了解软腭内肌肉排列。方法 :应用正常和唇腭裂胚头标本 13例 ,做冠、矢和水平切片、染色、光镜观察 ;另用 3例正常儿童标本作腭肌显微解剖。结果 :悬雍垂肌沿软腭中线纵行 ;腭帆提肌和舌腭肌横行 ;咽腭肌在软腭内斜行 ,与悬雍垂肌和腭帆提肌纤维相混杂 ,腭裂胎儿更是如此。     

Craniofacial cephalometric morphologies in different cleft types: a retrospective cross-sectional study of 212 patients

Objective

The aim of this study was to evaluate and compare the craniofacial cephalometric morphologies among different cleft types in a Spanish population.

Methods

A retrospective cross-sectional study was carried out on 212 patients. The patients were subdivided into four groups according to their cleft types: unilateral cleft lip and palate; bilateral cleft lip and palate; cleft lip; and cleft palate. Angular and linear cephalometric measurements were taken on lateral radiographs.

Results

Unilateral cleft lip and palate was associated with a dolichofacial growth pattern, skeletal Class III with correct maxillary position, and lingual incisor inclination. Bilateral cleft lip and palate was associated with a mesofacial growth pattern, skeletal Class I with protruded maxillary position, and lingual incisor inclination. Cleft palate was associated with a mesofacial growth pattern, skeletal Class III with correct maxillary position, and lingual incisor inclination. Cleft lip was associated with a brachyfacial growth pattern, skeletal Class I with protruded maxillary position, lingual upper incisor inclination, and corrects lower incisor inclination. Significant correlations were observed between cleft types and their craniofacial cephalometric measurements.

Conclusions

The present information can be used for the determination of orthodontic treatment and even future orthognathic surgery planning, a requirement in most cleft patients.

     

Pierre-Robin-Sequenz — postoperative Komplikationen nach Gaumenspaltverschluss

Background

In a 25-year retrospective review of 1976–2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied.

Patients and methods

The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life.

Results

A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.

     

Predictors of speech outcomes in children with Pierre Robin sequence

Backgound

Pierre Robin sequence (PRS) has worse speech outcomes than isolated cleft palate. We aimed to search for possible associations of phonological outcomes with PRS status (isolated vs syndromic), clinical severity, soft palate muscles deficiency, or surgical procedure.

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目的探讨先天性腭裂患者的腭帆提肌肌纤维型组成和分布,借以了解先天性腭裂患者肌纤维特点。方法对2008年1月至2008年7月于青岛大学医学院附属医院口腔颌面外科就诊的先天性腭裂患者20名,取其腭帆提肌组织进行冰冻切片,采用肌球蛋白ATP酶组织化学染色法,对其进行肌纤维分型研究。结果先天性腭裂患者腭帆提肌经肌球蛋白ATP酶组织化学染色后可分出两种肌纤维型,其中Ⅰ型纤维占(26.4±3.1)%,Ⅱ型纤维占(73.6±6.3)%,两者比较差异具有统计学意义。结论先天性腭裂患者的腭帆提肌肌纤维以Ⅱ型纤维为主。     

腭裂整复术后腭帆提肌运动能力的观察

目的 观察腭裂及单纯唇裂患者在不同语音状态下腭帆提肌伸缩能力和倾斜角度的差异.方法 使用MRI拍摄3组研究对象:①单纯唇裂组(对照组)8例;②腭裂术后腭咽闭合功能不全组(velopharyngeal incompetence,VPI组)7例;③腭裂术后腭咽闭合功能完全组(velopharyngeal competence,VPC组)l0例,在静止位以及发"a"、"i"、"m"音时腭帆提肌的影像,并分析各图像中腭帆提肌垂直段的长度以及相对于面中份矢状面角度变化.结果 3组儿童随发"a"、"i"、"m"音,腭帆提肌垂直段的长度收缩率依次为[(13.5±11.7)%、(11.1±10.8)%、(8. 2±14.3)%];随发"a"、"i"、"m"音,相对于面中份矢状面角度依次变小[(43.18±4.984)°、(43.08±4.879)°、(39.48±5.046)°];3组研究对象发音时腭帆提肌长度和角度的变化差异无统计学意义(P＞0.05).结论 腭裂患者术后腭帆提肌的运动能力与单纯唇裂患者基本相同.     

Psychosocial acceptance of cleft patients: has something changed?

Objective

The main purpose of this study was to analyse the reactions of a panel (non-cleft adults) when observing cleft lip morphology. Although rehabilitation of cleft lip and palate is improving, there are still indications of social rejection of cleft patients by the people around them. Polarity profiles have been used since 1973 to measure social distance with regard to cleft patients. Because rehabilitation results and education of the society have improved in recent decades, we investigated whether social distance has been affected.

Setting

The setting of this study is the Department of Oral, Craniomaxillofacial, and Facial Plastic Surgery, University Hospital of Leipzig, Germany

Patients and participants

Using a cross-sectional study design, we enrolled a sample of adult laypersons (n = 273). For the survey, we followed the concept of photograph presentation and questionnaire investigation reported by Sergl and Schmid (1973). We presented anonymised frontal and profile pictures of the faces of 50 cleft patients and asked the laypersons to specify social distance. Three predictor variables (layperson gender, profession and year of evaluation) were grouped.

Results

Although social distance has reduced during the last 40 years, life situations which require emotional proximity still cause some concern. Professional background and gender affect laypersons’ attitudes.

Conclusion

Although rehabilitation of cleft lip and palate is much better than 40 years ago, social distance remains a problem in society. It is necessary to improve both results of rehabilitation of cleft patients and social acceptance by the people around them.

     

Magnetic resonance imaging of the levator veli palatini muscle in speakers with repaired cleft palate.

OBJECTIVE: To obtain detailed anatomic and physiologic information on the levator veli palatini muscle from MRI in individuals with repaired cleft palate and to compare the results with those from normal subjects reported by Ettema et al. (2002). DESIGN: Prospective study. SETTING: University-based hospital. PARTICIPANTS: Four men (ages 22 to 43 years) with repaired cleft lip and palate. MAIN OUTCOME MEASURES: Four quantitative measurements of the levator veli palatini muscle from rest position and dynamic speech magnetic resonance images were obtained: the distance between the origins of the muscle, angle of origin of the muscle, muscle length, and muscle thickness. RESULTS: The length and thickness of the levator veli palatini muscle varied among the subjects and were different from measurements obtained from normal subjects in a previous study. The distance between origin points, length, and thickness of the levator veli palatini muscle were smaller than those of the normal subjects. There were systematic changes of the levator veli palatini muscle, depending upon vowel and consonant types. Levator veli palatini muscle angle of origin and length became progressively smaller from rest, nasal consonants, low vowels, high vowels, and fricative consonants. These changes are consistent with those of the normal subjects. CONCLUSIONS: This study contributes to a better understanding of cleft palate anatomy in comparison with normal anatomy of the levator veli palatini muscle. The use of MRI shows promise as an important tool in the diagnosis and eventual aid to treatment decisions for individuals born with cleft palate.     

Intraosseous Leiomyoma of the Mandible: A Case Report of the Rare Entity and Review of Literature

Introduction

Leiomyoma is a rare tumor of smooth muscle origin with a very low incidence in the maxillofacial region. Intraosseous occurrence of oral leiomyoma is even rare with involvement of mandible followed by maxilla.

Aim

The purpose of this paper is to present a case of intraosseous leiomyoma of the left mandibular angle region with the review of literature describing this rare entity. The paper also highlights the need to include this entity in differential diagnoses of jaw lesions.

Material and Method

An extensive search of literature was carried out on the Medline-Pubmed and Google Scholar database using the keywords leiomyoma, maxilla, mandible, oral and palate to thoroughly search and collect all the reported cases of intraosseous leiomyoma.

Result

To the best of our knowledge till date only 22 cases of intraosseous leiomyoma have been reported in the maxillomandibular region we represent the 23rd case of the intraosseous leiomyoma in a 36 year old male patient.

Conclusion

Though uncommon but it is known to occur in the jaws therefore intraosseous leiomyoma should be included in the list of differential diagnoses of radiolucent lesion of mandible and maxilla.

     

The San Venero Roselli pharyngoplasty: an electromyographic study of the palatopharyngeus muscle

Electromyography of the palatopharyngeus and salpingopharyngeus muscles was performed in three groups: normal subjects, subjects with cleft palate before surgical treatment, and subjects with repaired palatal clefts incorporating the San Venero Roselli pharyngoplasty. Results suggested that the salpingopharyngeus muscle is inconsistently present in man. The palatopharyngeus is primarily concerned with swallowing and is not active during velopharyngeal closure. Its activity is not affected by the San Venero Roselli procedure. The surgical approximation of this muscle may be advantageous because of its antagonistic action to the levator veli palatini.     

Rating dental arch relationships and palatal morphology with the EUROCRAN index on three different formats of dental casts in children with unilateral cleft lip and palate

Background

The EUROCRAN index has been used in inter-center studies to assess dental arch relationship (DAR) and palatal morphology (PM) in children with unilateral cleft lip and palate (UCLP). For this type of inter-center research, a scoring method that could be performed over the internet would be the most effective. Therefore, the aim of this study was to investigate the reliability of application of the EUROCRAN index on 3D digital models or photographs of plaster models instead of using plaster models.

Methods

The EUROCRAN reference models were presented in three formats: plaster models, 2D photographs of plaster models, and 3D digital models. Plaster models of children with UCLP (n?=?45) were rated. Of each case, all three formats were rated by six calibrated observers in random order. The strength of agreement of the ratings was assessed with kappa statistics. Concordance among observers was evaluated with the intra-class correlation coefficient (ICC).

Results

The ICC showed a good inter-observer agreement for the DAR and poor inter-observer agreement for the PM. Intra-observer agreement for the DAR was moderate to very good, yet for the PM poor to moderate. Comparison between the three formats per observer for the DAR was good or very good and for the PM moderate to poor.

Conclusions

The overall results show that the EUROCRAN index is an acceptable and reliable scoring method for the DAR on plaster models, 2D photographs of plaster models, and 3D digital models. However, due to the small range of deviations in palatal morphology between the cases in our study, the PM component of the index was difficult to assess.

Clinical relevance

In clinical audits and inter-center studies, plaster models can be substituted by 2D photographs of plaster casts or 3D digital models when grading treatment outcome with the EUROCRAN index.

     

Patterns and surgical significance of facial nerve branching within the parotid gland in 43 cases

Purpose

Different patterns of facial nerve branching within the parotid gland were detected, and these anatomical variations may affect the treatment approaches and outcomes of surgery. The aim of this study was to identify the patterns of facial nerve branching with the parotid gland and their importance in surgical procedures.

Materials and methods

A total of 43 patients undergoing surgical treatments of parotid lesions were included in this study. Each patient’s demographic data and type of operation were recorded. In addition, the courses of the facial nerve within the gland were classified into six types according to their branching patterns and communication.

Results

In all of the patients, the facial nerve consisted of one trunk separated into two divisions. Branching type III was the most common variety found (30.2 %) followed by type II (23.2 %), while type V represented the least frequent pattern (4.6 %).

Conclusion

It is essential for surgeons to become familiar with the different types of nerve morphologies in order to avoid morbidity and preserve the facial nerve during surgery. Variations and anastomosis can explain the different consequences of facial nerve injury that may occur after parotid surgery.

     

Comparison of Outcome of Modified Millard’s Incision and Delaire’s Functional Method in Primary Repair of Unilateral Cleft Lip: A Prospective Study

Background

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another. No one technique of cleft lip repair consistently produces ideal aesthetic and functional results.

Objectives

This study was conducted to compare the outcomes attained using two different designs of skin incision used for surgical correction of unilateral cleft lip.

Materials and Methods

Modified Millard’s incision and Delaire’s functional method techniques were performed and evaluated on 18 patients who received primary unilateral cleft lip repair. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid’s bow, lip length, and nostril symmetry and appearance of the alar dome and base. Chi-square and Fisher exact test, Student t test (two tailed, independent) and Student t test (two tailed, dependent) were used for statistical analysis of study parameters at 5 % level of significance.

Results

Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. The outcome of our surgical methods was good and suggested quantitative changes with progressive diminution of asymmetry of the cleft and non cleft sides.

Conclusion

Lip length improvement was better in case of modified Millard’s incision. The Delaire’s functional method of cleft lip repair results in improved nasal symmetry due to correction of the abnormal insertions of the underlying musculature.

     

A Self-Retaining Lingual Flap Guarding Device During Surgical Removal of Impacted Mandibular Third Molar

Introduction

Lingual nerve damage is one of the common complications following mandibular third molar surgery. On considering the impact of lingual nerve damage on the patient’s quality of life, it is necessary to exercise caution to minimize its occurrence.

Material and methods

Although many lingual retractors are available, in this article we describe an indigenously designed lingual retractor for use in mandibular third molar surgery.

Conclusion

The indigenous lingual retractor described in this article provides advantages like clear access and excellent retention unlike conventional retractors.

     

Long-Term Effect of Maxillary Distraction Osteogenesis (DO) on Nasal Index in Adult Patients with Cleft Lip and Palate Deformities

Purpose

To test the hypothesis that there is no immediate and long-term effects of maxillary distraction osteogenesis (DO) on nasal index among adult subjects with cleft lip and palate deformities.

Materials and Methods

Twelve adult subjects in the age range of 17–20 years with complete unilateral cleft lip and palate underwent advancement of maxilla by DO. The immediate and long-term effects of maxillary DO on nasal index were evaluated from extra-oral full face frontal photographs recorded prior to DO (T₀), at the end of active DO (T₁) and at least 2-years after the DO (T₂). The ANOVA, Post Hoc test (Bonferroni) and Pearson correlation coefficients were used. The probability value (P value) 0.05 was considered as statistically significant.

Results

SNM angle and Ptm-M distance increased significantly by DO (P < 0.001). The nasal index increased significantly (P < 0.01) by 13.85 % from T₀ value of 85.15 ± 4.49 to 99.02 ± 11.16 % at the end of active distraction (T₁) and by 12.69 to 97.84 ± 9.14 % at the end of long-term follow-up (T₂). The correlation between sagittal maxillary advancement and nasal index was statistically significant (P < 0.001). For each millimeter of maxillary advancement, the nasal index increased by 1.38 % and 1.8 % at the end of active distraction and long-term follow-up respectively.

Conclusion

The advancement of maxilla by distraction osteogenesis among subjects with cleft lip and palate deformities increased nasal index significantly.

     

Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

Objective

In the treatment of bilateral cleft lip and palate (BCLP) patients, there is discussion about the management of the position of the premaxilla. This literature analysis summarises the literature on managing this condition.

Materials and methods

A PubMed, Embase and Cochrane Library search was conducted resulting in 4465 articles which were screened on title and abstract.

Results

Seventy-one articles were available in full text, 16 of which were included in this literature analysis. We searched on keywords timing and technique, complications, growth of the maxilla and results after bone grafting the alveolar process. This literature analysis has shown that there are various ways to correct the position of the premaxilla. These can be divided into primary, early, late secondary and tertiary intervention before the age of 8 years, between the ages of 8 and 12 years and older than 12 years. Correction is done with surgery, orthodontics or a combination, with or without bone grafting.

Conclusions

An osteotomy of the premaxilla in combination with secondary alveolar bone grafting appears to be the most successful technique. Combining early secondary alveolar bone grafting with osteotomy creates more room to ensure a watertight closure of the nasal mucosa resulting in fewer postoperative complications. Before surgery, the orthodontist should try to optimise the position of the premaxilla for its surgical correction prior to bone grafting.

Clinical relevance

The treatment of BCLP patients is still based on experience and expert opinions. This literature analysis tries to give a summery on how to handle the protruded and displaced premaxilla.

     

Techniques to Improve Reliability and Predictability of the Dorsal Pedicled Tongue Flap in Closure of Palatal Defects and Oronasal Fistulae

Introduction

Despite the improvement in surgical techniques in cleft palate surgery, oronasal fistulas continue to remain a challenge, usually the result of residual palatal and alveolar clefts and post-palatoplasty defects. The tongue flap is an extremely versatile, sturdy, reliable and efficient means of closure of anterior as well as posterior, unilateral and bilateral palatal defects, effectively functionally obliterating the oronasal communication, owing much of its success to its highly vascular structure, good mobility, texture match, central location and low donor site morbidity. However, it has a few drawbacks. Flap dehiscence and detachment during the early postoperative period is a troublesome complication owing to tongue movements during normal activities such as speaking, swallowing, yawning and coughing.

Aim

This article describes some of the methods which can be used to effectively alleviate these shortcomings.

Methods

A protocol of immobilizing the tongue by tethering it to the maxillary teeth for the 3-week postoperative period, and also maintaining the patient on nasogastric feeding, until the patient is taken up for surgical separation the pedicle, was employed in all patients in this case series.

Results

There was a successful and predictable take of the tongue flap at the donor site, namely the palatal/oronasal fistula with its successful closure, in all the patients.

Conclusion

Treatment of the oronasal fistula using a two-layer closure using the nasal mucoperiosteum together with an anteriorly based dorsal tongue flap is an easy and efficient method, whose reliability can be further increased by avoiding a common complication, namely tongue flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth and also maintaining the patient on nasogastric feeding for the 3-week postoperative period.

     

Extracranial Trigeminal Schwannomas: A Retrospective Analysis

Objective

To analyse the clinic-radiological features and treatment outcome of extracranial trigeminal schwannomas.

Method

Medical records and radiographs of patients treated, from January 2011 to December 2013, for neurogenic tumors were retrospectively reviewed. Extracranial schwannomas other than those of trigeminal nerve were also excluded. A number of parameters, including the patient’s age, gender, site, clinical features, radiographic features, histologic variants and treatment provided as well as any associated complications were recorded and analysed.

Result

A total of 5 patients met the inclusion criteria. The patients were males, aged 16–56 years. All the schwannomas appear to originate from the terminal branches of trigeminal nerve.

Conclusion

Long standing asymptomatic swelling of cheek should include trigeminal schwannomas as the differential diagnosis. The diagnosis though confirmed by the histologic examination but can also be made on the basis of MRI finding. Neural function can be preserved by meticulous surgery.