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PubMed2005

Comparison of the rate of palatal fistulation after two-flap and four-flap palatoplasty.

We studied 73 repairs of cleft palate (48 cleft lip and palate and 25 isolated cleft palate) done during a 7-year period (January 1996-October 2002) by the same plastic reconstructive surgeon. Two-flap or four-flap palatoplasty techniques were used to provide tension-free, three-layer repairs for patients with cleft palate. Their ages ranged from 10-244 months (mean 27). The postoperative follow-up period ranged from 6 to 60 months (mean 21). There was a palatal fistulation rate of 7% (5/73). There were two fistulas after two-flap palatoplasty (5%, 2/39), and three fistulas after four-flap palatoplasty (9%, 3/34). The mean diameter was 7.8 mm (range 5.1 to 13). There was no significant difference between the two techniques.

Adolescent↗
PubMed1986

Genetic differences among the A/J X C57BL/6J recombinant inbred mouse lines and their degree of association with glucocorticoid-induced cleft palate.

Hydrocortisone sodium phosphate was injected intramuscularly into A/J, C57BL/6J and recombinant inbred lines from these two parental lines to study the genetics of steroid-induced cleft palate in a situation of identical maternal and fetal genotypes. The strains were typed for H-2 (the major histocompatibility locus), beta-glucuronidase and beta 2-microglobulin, which served as markers on chromosomes 17, 5 and 2, respectively. Hepatic glucocorticoid binding capacity had been previously measured in Hepes buffer and Hepes buffer plus dithiothreitol (DTT). The level of glucocorticoid binding in Hepes buffer and in Hepes plus DTT, as well as their ratio, was compared to the incidence of steroid-induced cleft palate in the recombinant inbred lines. A correlation was found between the response of glucocorticoid binding to DTT (expressed as a ratio of binding in the presence of DTT to binding without DTT) and hydrocortisone-induced cleft palate. When analyzing the effect of the three chromosomal markers on hydrocortisone-induced cleft palate, the b alleles of beta 2-microglobulin and of beta-glucuronidase were associated with a higher incidence. Genetic analyses of the differences between these two inbred strains of mice in the incidence of steroid-induced cleft palate show it not to be monogenic.

Alleles↗
PubMed1976

Genetics of cortisone-induced cleft palate in the mouse-embryonic and maternal effects.

Differences between mouse strains in frequency of embryonic, cortisone-induced cleft palate were examined. Probit analysis demonstrated a family of linear and parallel dose-response curves for different inbred and hybrid embryos. Since the differences between genotypes were not in the slopes of the response curves but rather in their location, it is proposed that the median effective dose (ED50) of cortisone required to induce cleft palate (or the tolerance) provides a more appropriate definition of the response trait and its difference that a frequency statement. The tolerance of C57BL/6J is dominant to that of A/J. A maternal effect of A/J relative to C57BL/6J dams caused a two-fold reduction in the embryonic tolerance of cortisone. Cortisone-induced cleft palate and mortality were separate response traits. In these and previous studies on cortisone- and other glucocorticoid-induced cleft palate in the mouse, the nature of the cleft-palate-response curve appeared to be the same for all glucocorticoids, and within-strain differences in tolerance could be used as measures of potency or bioassays for a particular effect of the glucocorticoids.

Animals↗
PubMed2001

Mandibular and palatal tori, bone mineral density, and salivary cortisol in community-dwelling elderly men and women.

BACKGROUND: This investigation evaluated the relationship between the presence of tori and bone mineral density (BMD) and salivary cortisol levels. METHODS: A total of 230 healthy, community-dwelling elderly men (n = 129) and women (n = 101) aged 60 and older participated in this study. Forty-three women were on hormone replacement therapy (HRT). This was a component of a 5-year longitudinal study measuring subjects' body composition, hormone levels, physical activity, and diet every 6 months. Subjects were examined for the presence of tori by visual inspection and digital palpation. BMD at six sites was measured by dual-energy X-ray absorptiometry. Salivary cortisol levels were measured by radioimmunoassay. RESULTS: Twenty-three percent of all subjects had mandibular tori, 13% had palatal tori, and 12% had both mandibular and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. The presence of mandibular tori was significantly correlated with BMD of the lumbar spine, femoral neck, trochanter, and Ward's triangle for all subjects, and with the femoral neck and trochanter of women not on HRT. Men with palatal tori had lower levels of salivary cortisol in the evening. CONCLUSIONS: This study documented the high prevalence of mandibular and palatal tori in a group of 230 elderly, community-dwelling subjects. Women not on HRT and all subjects taken as a group with mandibular tori had higher BMD. The presence of tori at young adulthood may be a marker of higher BMD in the future and of a lower risk for developing osteoporosis.

Aged↗
PubMed2002

Mechanism of secalonic acid D-induced inhibition of transcription factor binding to cyclic AMP response element in the developing murine palate.

Regulation of gene expression via the protein kinase A (PKA) pathway is mediated through Ser133 phosphorylation of the transcription factor (TF), cAMP response element (CRE) binding protein (CREB). Secalonic acid D (SAD), a mycotoxin causing cleft palate (CP), induces phosphorylation of palatal CREB in vivo. SAD-induced increase in phosphoCREB (pCREB), however, is associated with decreased binding of TF to CRE in vivo. Mechanism(s) involved in these two effects of SAD were studied using palatal nuclear extracts (PNE). Stimulation of CREB phosphorylation by SAD was confirmed in vitro in both cell culture and cell-free systems, and this phosphorylation was not altered by currently known CREB kinase (PKA, CaMK, MEK, p38MAPK, PKC) or phosphatase inhibitors. SAD-induced increase in pCREB, however, was associated with decreased TF binding to CRE in vitro. Two-dimensional gel analysis ruled out additional inhibitory phosphorylations. Addition of SAD to PNE following an increase in PKA-phosphorylated CREB resulted in reduced TF binding to CRE. Further, SAD was shown to bind directly to phosphorylated nuclear proteins (pCREB) with greater affinity. In addition, the inhibitory effect of SAD occurred with CRE of proliferating cell nuclear antigen (PCNA) gene. These studies confirm that stimulation of CREB phosphorylation by SAD does not involve sites other than Ser133 and is mediated by a novel kinase. They also indicate that SAD directly binds to CREB to inhibit its binding to CRE of genes such as PCNA. This effect could lead to reduced palatal mesenchymal cell number, smaller palatal shelf, and thus CP.

Animals↗
PubMed1979

Tomographic diagnosis of palatal defects.

We present the results of a pilot study conducted to evaluate the effectiveness of palatal tomography in patients suspected of having palatal defects not detectable by other methods. Twelve patients were involved in the projects, ranging in age from 3 to 11 years. There were 8 boys and 4 girls. Each patient was evaluated with voice recordings, lateral cineradiographic x-rays, and palatal tomograms. Nine of the 12 patients were found by tomography to have palatal defects that had not been detected either by cineradiography or by clinical investigation, including physical examination of the palate. The results of this study are presented with clinical findings.

Child↗
PubMed1979

Influence of cleft palate closure by osteotomy technique on growth of the dentomaxillary complex in human beings.

Properly done, osteotomy cleft palate closure in human beings reproduces a normal dentomaxillary complex in patients with an incomplete cleft palate and in those with a narrow unilateral complete lip and palate cleft. In wider complete clefts, the dentomaxillary complex is influenced by the constrictive action of the lip muscle during closure rather than by the osteotomy procedure. Plaster casts of osteotomy surgical cases late postoperatively demonstrate the normal growth pattern achieved. Variations in cleft palate osteotomy have been worked out for every type of cleft palate.

Child, Preschool↗
PubMed1990

Klippel-Feil anomaly, cleft palate, and bifid tongue.

The Klippel-Feil anomaly is a condition characterized by congenital vertebral fusion, which may be associated with a short neck and a low posterior hairline. In the patient presented here, there was congenital cervical fusion, cleft palate, and bifid tongue. The occurrence of cervical fusion and cleft palate has been reported previously, but this is the first report, to the author's knowledge, of these malformations being accompanied by a bifid tongue. The embryological association between Klippel-Feil anomaly and cleft palate has been alluded to on few occasions. Investigators have suggested that the short, fused neck limits movement of the head and thus of the tongue from between the palatal shelves. This report postulates that the mechanism is more complex and that it is based on a change in structural relations between certain key areas involved in the background of palatal shelf elevation.

Cleft Palate↗
PubMed1998

Epidemiology of cleft lip and palate in Thailand.

During the years 1989 to 1991, a survey for the epidemiology of cleft lip and palate was carried out in Thailand using detailed forms. One thousand ninety-six patients were recorded and 593 patients were operated during that period. All records were analyzed. Six hundred forty-seven patients (59%) lived in northeastern Thailand. Of the 593 operated patients, 26% had cleft lip only, 48% had cleft lip and palate, and 25% had cleft palate only. Men predominated all groups except for the cleft palate-only group. Twenty-six of 593 patients had associated congenital anomalies. Two hundred thirty-seven of 1,096 patients had a history of cleft lip and palate in their first- and second-degree relatives (21.62%). Five hundred seventy-eight of 1,096 mothers (52.74%) had a history of taking drugs. Analgesics were among the drugs taken most often.

Abnormalities, Drug-Induced↗
PubMed2002

Articulation disorders associated with maxillary growth after attainment of normal articulation after primary palatoplasty for cleft palate.

Little attention has been given to the connection between maxillary growth and the emergence of articulation disorders among cleft palate patients who previously successfully attained normal articulation after undergoing primary palatoplasty. Follow-up assessment of 22 surgically treated unilateral cleft lip and palate patients who attained normal articulation before school entry revealed that, during mixed dentition, half the patients exhibited palatalized articulation and half retained normal articulation. To determine the possible effect on articulation of growth changes in dental arch dimensions, a comparison was made of deciduous dentition and mixed dentition oral cavity measurements. Indications are that palatalized articulation occurs in patients with a smaller anterior palatal volume, the presence of linguoversion teeth, and poorer growth ability. Results reveal the importance of early management of dental arch dimensions, and the need for periodic assessment and management of articulation even for patients who attain normal articulation subsequent to primary palatoplasty.

Articulation Disorders↗
PubMed2003

Influence of periosteum on donor healing after harvesting hard palate mucosa.

The authors report the influence of periosteum on healing of palatal defect based on more than 10 years of experience of harvesting hard palate mucosa. Between June of 1991 and May of 2001, the authors harvested 80 hard palate mucosae as graft material for skin and mucosa defects. All grafts were harvested from the center of the hard palate. Patients ranged in age from 10 to 82 years old. Of 80 mucosae, 54 were harvested with periosteum, and periosteum was not retained in the defect bed. The other 26 mucosae were harvested without periosteum, which was therefore retained in the defect bed. The healing time increased depending on the defect size in both groups of patients retaining and not retaining periosteum. There was a significant relationship between the defect size and healing time in both groups (Spearman's rank correlation test, p < 0.0001 in both groups). In the two groups, there was no significant relationship between patient age and healing time in the patients with defect smaller than 1.99 cm or larger than 2.00 cm2. There were no significant differences in the rate of patients with pain and bleeding between the groups retaining and not retaining periosteum. In the group not retaining the periosteum, all 54 patients showed a flat or atrophic smooth surface at more than 6 months after epithelization and had no discomfort. However, 17 patients showed flat or atrophic smooth surface in the group retaining the periosteum and the remaining 9 patients showed hypertrophy at more than 6 months after epithelization, with accompanying discomfort. The rate of the patients with hypertrophy in the group of patients retaining periosteum was significantly high as compared with that in the group of patients not retaining periosteum (p = 0.000013, Fisher's exact test). In 26 patients retaining periosteum, the age of the patients with hypertrophic surface was significantly younger than that of the patients with flat or atrophic surface (p = 0.0010, Welch's -test), and the defect size in the patient with hypertrophic surface was significantly smaller than that of the patients with flat or atrophic surface (p = 0.0028, Welch's t-test). In conclusion, our study demonstrated that the existence of periosteum in the palate donor bed does not contribute to reduced healing time or reduced pain. Rather, retaining the periosteum caused hypertrophy of the donor site, leading to discomfort, especially in young patients with a comparatively small defect.

Adolescent↗
PubMed1999

Histologic and physiologic effects of electrocautery, CO2 laser, and radiofrequency injury in the porcine soft palate.

OBJECTIVES: This study was undertaken to compare the effects of electrosurgery, CO2 laser, and radiofrequency on the histological structure and physiological properties of the soft palate. These surgical techniques are used for stiffening and reducing the soft palate in the treatment of snoring and mild sleep apnea. STUDY DESIGN: Fifteen pigs were divided into five groups. METHODS: group 1 underwent electrosurgery incision of the lateral soft palate and excision of the uvula. Group 2 underwent the same procedure with the CO2 laser. Group 3 underwent CO2 laser ablation of the midline soft palate mucosa. Group 4 underwent radiofrequency volumetric reduction. Group 5 served as control. After 5 weeks the animals were sacrificed. Soft palate mucosa and muscle were subjected to tensiometric and histological analysis. Statistical analysis of tensiometric measurements was done with an ANOVA using a Bonferroni-Dunn correction. RESULTS: Tensiometric measurements of the mucosa were increased over normal controls when the surgical technique resulted in mucosal disruption. When the surgical technique resulted in primarily muscle disruption (radiofrequency) tensiometric measurements of the muscle were increased over controls. Histological analysis demonstrated normal remucosalization in all specimens, with fibrosis increased at the site of the primary injury. CONCLUSIONS: The type of injury produced resulted in identifiable patterns of physiological and histological change. Understanding of the effects of available surgical techniques is important in guiding our choice of surgical approach and allows us to better counsel our patients on their surgical options.

Animals↗
PubMed2001

The use of palatal island flaps as an adjunct to microvascular free tissue transfer for reconstruction of complex oromandibular defects.

OBJECTIVE: To determine the efficacy of using palatal island flaps in combination with free tissue transfer for reconstruction of large, complex oral cavity defects. STUDY DESIGN: Prospective evaluation of patients with large, combined defects of the oral cavity reconstructed with palatal flaps in conjunction with microvascular free tissue transfer. METHODS: Elevation of a palatal flap was performed after completion of tumor resection. The flap was rotated and secured into place. A free flap was then harvested and inset to reconstruct the remaining oromandibular defect. Free flaps included the rectus abdominis (6), fibula (16), and radial forearm (6). RESULTS: Large complex oral cavity defects were repaired with a palatal island flap in conjunction with microvascular free tissue transfer in 28 consecutive patients. There were no complications associated with this flap. CONCLUSION: Maximal functional rehabilitation of large, complex oral defects requires independent reconstruction of the various regions of the oral cavity rather than single flap reconstruction. When used as an adjunct to free tissue transfer, the palatal island flap offers a reliable method for reconstructing large combination defects.

Fibula↗
PubMed1980

Anatomy and physiology related to cleft palate: current research and clinical implications.

The most important areas for future research related to the anatomy and physiology of cleft palate are thus: (1) the role of the tensor tympani muscle in auditory tube clearance; (2) the specific etiology of auditory tube dysfunction associated with cleft palate; (3) the nature and extent of variability in the muscular deformities associated with various types of cleft palate; (4) the nature and extent of vascular abnormalities associated with clefts of the palate; and (5) the investigation of cleft palate as one aspect of a craniofacial syndrome.

Cleft Palate↗
PubMed1988

Development of the orbicularis oris muscle in normal and cleft lip and palate human fetuses using three-dimensional computer reconstruction.

As part of an ongoing study of cleft lip and palate fetal morphology, normal and dysmorphic development of the human fetal orbicularis oris muscle was studied in a cross-sectional sample of 29 human fetuses (20 "normal" and 9 cleft lip and palate) ranging in age from 8 to 21 postmenstrual weeks. The specimens were embedded in celloidin and sectioned at 20 microns, and every tenth section was stained with hematoxylin and eosin. A computer reconstruction technique was applied to produce three-dimensional representations of the orbicularis oris muscle. The orbicularis oris muscle in the normal fetal sample with discernible lip fibers (N = 15) increased symmetrically in both fiber density and complexity from 12 to 21 weeks. Metrically, muscle volume and thickness growth curves were consistent with qualitative observations. In contrast, the unilateral cleft lip and palate fetal specimens with discernible lip fibers (N = 3) exhibited a 3.5-week delay in overall muscle development, asymmetrical fiber distribution, and abnormal fiber insertions. However, quantitatively, no significant (p greater than 0.05) differences were noted in orbicularis oris muscle thickness or volume between the normal and cleft lip and palate fetal specimens through 21 weeks. Findings suggest that orbicularis muscle deficiency, noted clinically in cleft lip and palate neonates, may be a result of perinatal functional dysmorphogenesis rather than congenital mesenchymal reduction or deficiency.

Cleft Lip↗
PubMed1992

The effect of palate repair on otitis media with effusion.

Cleft palate in children is very frequently associated with otitis media with effusion. In this prospective study of 150 cleft palate children aged between 2 and 18 months, the prevalence of otitis media with effusion at myringotomy before palate repair was 92 percent. Otoscopic and tympanometric follow-up assessments for 140 children indicate that there is minimal improvement in middle ear status after palate repair. The condition is persistent in 70 percent of children up to 4 years of age. Furthermore, there is no evidence that age at repair or type of cleft is influential. These findings have implications for otologic management of cleft palate children. Early routine unilateral ventilation to ensure adequate hearing but minimize the morbidity of ventilation tubes is advocated.

Cleft Palate↗
PubMed1992

Free forearm flap for closure of difficult oronasal fistulas in cleft palate patients.

There were four patients with palatal clefts who had been operated on many times previously but who still had large oronasal defects due to wound disruption. Moreover, there was considerable scar in the residual palatal tissue, which was contracted in the anteroposterior dimension. These patients were treated with a radial forearm flap transfer. The technical aspects of this reconstruction are emphasized, especially methods to enhance primary healing and to facilitate in setting the flap. Three of the patients were successfully reconstructed with one operation. The fourth had a small area of dehiscence anteriorly that was later closed with advancement of the flap tissue. There were no other complications. With the replacement of healthy tissue, the palate could be pushed further back to achieve better repair of the muscle. This would contribute to better speech function. In every patient, nasal regurgitation was eliminated, and speech quality improved significantly. The radial forearm flap is ideal for intraoral use, providing thin, hairless skin with a long, large-caliber vascular pedicle. It can reconstruct defects in one stage with well-vascularized tissue and minimal dissection of the palate. In a select group of cleft palate patients, this free-tissue transfer should be considered to achieve closure of large oronasal fistulas in patients with dense scar.

Adult↗
PubMed1995

The palatal island flap on retrospection.

The place of the palatal island flap in present-day surgery is evaluated. Attention is drawn to the hitherto unrecognized fact that the first palatal island flap was executed decades before its general introduction in 1962. Its origins are discussed, and the subsequent process from its use as a panacea to the gradual evolution of its indications is described. Variations in anatomy, complications, success rates, and contraindications are reviewed. Attention is paid to the problems inherent in studies of palate surgery, both retrospective and prospective. A balance is made up of what has and has not been proven adequately. To date, no advantages over other palate-lengthening procedures have been established, while there is some evidence that it might in fact be deleterious to maxillary growth. As a result, at present, the palatal island flap is used mainly in closure techniques, as in fact was done by the first two surgeons using that it more than half a century ago.

History, 19th Century↗