Pathology of the palatal aponeurosis in cleft palate

OBJECTIVE: The palatal aponeurosis is a controversial structure, both in terms of its anatomy and its function. This article points out a pathologic finding in the cleft palate condition that has not been previously described. DESIGN AND METHOD: By means of surgical dissections, this study demonstrates in detail that the palatal aponeurosis exists even in cleft palates, but it is disrupted, malpositioned, and folded in two layers. PATIENTS: This dissection method has been performed on more than 150 patients with cleft of the hard and soft palate, with or without cleft of the lip and alveolus. At the time of operation, the children were between 6 and 8 months of age. RESULTS: It is possible to dissect the two layers of the palatal aponeurosis, to unfold the aponeurosis, and to form a tough tendinous plane. CONCLUSION: For a functional physiologic reconstruction of the cleft palate, it is necessary not only to reconstruct the levator veli palatini and palatopharyngeus muscle slings, but also to approximate and suture the fibers of the palatal aponeurosis to the corresponding fibers of the opposite side after unfolding them in a medio-dorso-cranial direction. In this manner, a continuous palatal aponeurosis can be created, which subsequently can serve as a transmitter of the muscle forces.     

A new method for strengthening palatal closure defects of the hard palate

Closure of minor defects in the hard palate can be done with local flaps. There is often a risk of perforation of the reconstructed area. In the case reported this complication was obvious due to a large, thin, flap-covered area. In strengthening the reconstruction fascia lata and Surgicel was used. The postoperative result was excellent and the rehabilitation of the patient was without complications.     

Cleft palate repair with a combined method of mucosal flap pushback of the hard palate

We report the significance of expression of interleukin-2 (IL-2) in human bladder tumor cell T24-transfected with IL-2cDNA and its effects an biological behavior of the cell. The positive clone of T24/IL-2 and T24/neo were selected by G418 after transfection using calcium phosphate precipitation method. By hybridization in situ, immunocytochemistry, and biological activity assays, we found that IL-2cDNA was successfuly delivered into T24 cell. The activity of IL-2 in T24/IL-2 cell culture medium was about 8-32IU/1 x 10(5) cell/24 h during the observation period of about 40 days. There were no marked differences in growing curve and clonegenicity in soft agar medium among T24, T24/neo and T24/IL-2. But the cell volume of T24/IL-2 was smaller in soft agar, and the tumorigenicity of T24/IL-2 was decreased in nude mouse.     

Free flap closure of recurrent palatal fistula in the cleft lip and palate patient

Recurrent palatal fistulas present a particularly vexing problem for the cleft surgeon. In this setting, the cycle of repair followed by breakdown results in increasing scar formation with associated soft tissue contracture and a resultant increase in fistula size. This pernicious cycle of events renders random local tissue transfers obsolete. As such, the cleft surgeon must look to tongue flaps or local axial pattern flaps as a means of bringing well-vascularized, pliable tissue into the defect. Although this approach has been the standard of care for the last few decades, we believe that the modern-day success rates of free tissue transfers (95%) make them a viable, one-stage means of closing these defects. In this report we present our clinical experience with recurrent palatal fistulas and highlight the effective use of the dorsalis pedis-first dorsal metatarsal artery free flap as a means of repair.     

Massive swelling of the tongue in two patients following the repair of cleft palate]

A laser Doppler perfusion imager (LDPI) for evaluation of skin blood flow is presented and its use illustrated in two cases with a presumptive diagnosis of reflex sympathetic dystrophy (RSD) treated with local anesthetic sympathetic blocks. Among the advantages are the good spatial resolution over the area measured (12 x 12 cm) and that measurements can be done without contact with the skin. Generating a complete image takes 4.5 min but if higher temporal resolution is needed continuous measurements at one point are possible by use of another software routine.     

Distraction osteogenesis for lengthening of the hard palate: Part II. Histological study of the hard and soft palate after distraction

To correct velopharyngeal incompetence, a new treatment concept was proposed in Distraction Osteogenesis for Lengthening of the Hard Palate: Part I (using lengthening of the hard and soft palate by distraction osteogenesis). Cephalometry and computed tomography showed successful elongation of the posterior hard palate with gradual calcification. Here the sequential use of fluorochrome markers (oxytetracycline, xylenol orange, DCAF [2,4-bis-N-N'-dicarboxymethyl aminomethyl fluorescein], and alizarin complexone) during the distraction and retention period is reported together with the histologic investigations using light and laser scan microscopy without prior demineralization. The experimental gap showed de novo osteogenesis in all dogs. The new bone was always in continuity with the original anterior and posterior palatal bone margins. It either bridged the experimental gap fully or left a small central zone of fibrous tissue, in which eventual ossification occurred. Several distinct zones could be distinguished: A small central zone was found with parallel strains of collagen fibers, oriented longitudinally in the direction of the distraction. Next to this zone a layer of undifferentiated mesenchymal precursor cells was seen in direct contact to newly formed bone. The next zone was coarse woven bone, showing a transition to mature lamellar bone through remodeling. No evidence of endochondral bone formation was found, i.e., all dogs showed exclusively intramembranous bone formation. The soft tissues showed no signs of alteration: in particular, there was no necrosis or scar formation. The soft tissues were not thinned but appeared to have followed the longitudinal displacement. In conclusion, gradual distraction osteogenesis of the hard palate could be a possible method for lengthening the palate to treat velopharyngeal incompetence.     

Facial growth and the need for orthognathic surgery after cleft palate repair: literature review and report of 28 cases

PURPOSE: Controversy still exists regarding the optimal timing and surgical technique for primary cleft lip and palate (CLP) repair, and treatment protocols vary considerably. This study reviews the literature on timing and technique for primary repair and reports on the outcome for a consecutive group of patients treated by a single surgical protocol at the Sunnyview Cleft Palate Clinic. PATIENTS AND METHODS: Twenty-eight patients treated by a standardized clinical protocol from infancy through adolescence were evaluated with respect to the need for orthognathic surgery to correct jaw size discrepancy. For each patient, data was collected regarding type of cleft deformity, total number of surgical procedures from infancy, surgeon performing the primary repair, and the need or indication for orthognathic surgery. RESULTS: Twenty-five percent of patients treated by this protocol required orthognathic surgery because of anteroposterior jaw size discrepancy. The number of prior operations was not a significant factor. The need for orthognathic surgery was seen in all types of CLP deformity. Different primary surgeons varied considerably in the percentage of their patients who ultimately required orthognathic surgery. CONCLUSION: The results of this study parallel other larger cohort studies with respect to the percentage of patients requiring orthognathic surgery. The number of prior operations does not significantly affect the later need for orthognathic surgery.     

Pharyngoplasty in patients with cleft lip and palate after maxillary advancement

The development of velopharyngeal incompetence and increased hypernasality after maxillary advancement has been described previously by several authors. If speech and velopharyngeal function deteriorate after maxillary advancement, pharyngoplasty is frequently the treatment procedure of choice because of the natural cause of the deficit. Of 91 cleft lip and palate patients who have undergone maxillary advancement at the Australian Cranio-Facial Unit, 23 patients received a pharyngoplasty after surgery. Thirteen of these patients who had pre- and postoperative speech evaluations were included in this study. Of the 13 patients, six patients received a superiorly based pharyngeal flap, two patients underwent an orticocheal pharyngoplasty, and five patients received either a revision or augmentation of the previous flap based on results of preoperative examinations. Serial nasendoscopic evaluations were available for 11 of these 13 patients, and they demonstrated that velopharyngeal function improved after pharyngoplasty in six patients and was unchanged in five patients. Of the 13 patients, 10 improved and three patients were unchanged on an intelligibility rating. Nine of the 13 patients demonstrated decreased hypernasality and four patients were unchanged. Hyponasality decreased in two patients increased in one patient, and was unchanged in one patient. Because the results obtained are considered acceptable, the authors conclude that pharyngoplasty can be used effectively to treat velopharyngeal dysfunction subsequent to Le Fort I maxillary advancement.     

Mouse palatal width growth rates as an "at risk" factor in the development of cleft palate induced by hypervitaminosis A

In this study, we examined the therapeutic antitumor effect of cytotoxic T lymphocytes (CTL) generated against CD86-transfected mouse neuroblastoma C1300. We first generated the transfectant, CD86 + C1300, expressing a high level of mouse CD86 on the cell surface. While CD86 + C1300 cells were rejected in syngeneic A/J mice when inoculated subcutaneously, neither vaccination nor any therapeutic antitumor effect was obtained, implying that C1300 may be a poorly immunogenic tumor. However, in vitro stimulation of splenocytes from either C1300-bearing or CD86 + C1300-rejecting mice with CD86 + C1300 cells resulted in remarkable CTL activity against C1300 cells. The CTL activity induced by CD86 + C1300 was mediated by T cell receptor/CD3 and CD8 and was further enhanced by the addition of interleukin-2. Intravenous inoculation of C1300 cells led to multiple organ metastases including the liver, lung, kidney, ovary, lymph node and bone marrow. To examine the therapeutic effect of CTL in this metastasis model, CTL induced by parental or CD86 + C1300 cells were administrated into C1300-bearing mice. Adoptive transfer of CD86 + C1300-induced CTL resulted in marked elimination of multi-organ metastases and prolonged survival in almost all mice, 70% of which survived indefinitely. These results indicate that adoptive transfer of CTL induced by CD86-transfected tumor cells in vitro would be effective and useful for tumor immunotherapy against poorly immunogenic tumors.     

Rhinolith in a patient with cleft palate: a case report

Dental anomalies are well documented in patients with cleft palate, although reports of intranasal teeth in these patients are extremely rare. This paper discusses the case of a rhinolith associated with tooth-like structures in a patient with a treated cleft palate.     

Association between non-right-handedness and cleft lip with or without cleft palate in a Chinese population

The ori region of an Erwinia stewartii plasmid, pSW1200 (106 kb), has been cloned and sequenced. This region consists of a gene encoding a protein which has 91% similarity and 73% identity with the RepA protein of bacteriophage P1. The ori region also consists of eight copies of 19-bp iterons which are highly homologous to the iterons of P1. Similar to plasmid P1, pSW1200 replicon has a copy number of approximately 1. On the other hand, the copy number increases about ninefold if three of the iterons located downstream from repA gene are deleted. We also demonstrate that pGEM-5Z consisting of a copy of P1 iteron is incompatible with a pSW1200 derivative, pSW1201, suggesting that pSW1200 and P1 DNA are incompatible and both belong to the IncY group.     

The effect of muscle repair on postoperative facial skeletal growth in children with bilateral cleft lip and palate

Systems for testing genetic toxicology are components of carcinogenic and genetic risk assessment. Present routine genotoxicity-testing is based on at least 20 years of development during which many different test systems have been introduced and used. Today, it is clear that no single test is capable of detecting all genotoxic agents. Therefore, the usual approach is to perform a standard battery of in-vitro and in-vivo tests for genotoxicity. Work-groups of the European Union (EU), the Organization for Economic Co-operation and Development (OECD), and, very recently, the work-group of the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) have defined such standard battery tests. These and some currently used supplementary or confirmatory tests are briefly discussed here. Additional test systems for the assessment of genotoxic and carcinogenic hazard and risk are seriously needed. These tests must be more relevant to man than are current assays and less demanding in respect of cost, time and number of animals. Another aspect for reassessment derives from the actual situation in the pharmaceutical industry. Companies have to prepare for the world economy of the 21st century. Therefore, pharmaceutical research is speeding up tremendously by use of tools such as genomics, combinatorial chemistry, high throughput screening and proteomics. Toxicology and genotoxicology need to re-evaluate their changing environment and must find ways to respond to these needs. In conclusion, genetic toxicology needs to answer questions coming from two major directions: hazard and risk identification and high throughput testing.     

A fiberscopic analysis of velopharyngeal movement before and after primary palatoplasty in cleft palate infants

The usefulness of bioelectrical impedance (BI) with anthropometry to measure total body water (TBW) was evaluated in very-low-birth-weight (VLBW) infants. A specific regression equation to measure TBW in a VLBW population was developed by simultaneously using the H2[(18)O] dilution method and BI in 12 infants with a gestational age of 24-30 wk and weighing <1200 g at birth. After an oral dose of H2[(18)O], the tracer dilution was measured in expired carbon dioxide. BI measurements were made with a model BIA-101 apparatus (RJL Systems, Detroit). Electrodes were placed in the standard position as well as proximally on the leg and the forearm. The best correlation was observed between body weight and TBW (r = 0.989). For BI, the best correlation was obtained when gestational age was used as a covariable along with body weight and crown-heel length (r = 0.985). The correlation was comparable with proximal electrode placement (r = 0.985). The new correlation was evaluated in 6 infants weighing < 1008 g. A significant correlation between BI and H2[(18)O]-measured TBW was observed (r = 0.988). Published regression equations for infants consistently gave higher estimates of TBW in another group of 14 infants weighing <1200 g than did the new correlations. TBW represented 84-95% of body weight in these VLBW infants. TBW could be computed simply from body weight alone. Use of BI and length as covariables did not add significantly to the estimate of TBW in VLBW infants.     

Complex segregation analysis in a sample of consecutive newborns with cleft lip with or without cleft palate in Italy

The mode of inheritance of cleft lip with or without cleft palate (CL/P) has been extensively investigated, but the results are controversial. We report results of complex segregation analysis performed in the families of 636 consecutive newborns with CL/P registered in the northeast Italy and Emilia Romagna congenital malformation registries to test hypotheses regarding CL/P inheritance. The programs POINTER and COMDS have been used. POINTER could not distinguish between alternative genetic models, and only the hypothesis of no familial transmission could be rejected. COMDS results, after inclusion of the severity parameter, rejected the hypotheses of a single major locus and were consistent with the two-locus model with a major dominant locus and at least one modifier locus.