Background: Intra-oral surgeries such as cleft palate repair essentially require holding of the jaws in the open position to facilitate access to the oral cavity, which is mostly achieved with the use of mouth gags. Materials and Methods: The objective of this article is to present an account of various types and modifications of gags as surgeons, anesthetists, and innovators attempt to make that ideal mouth gag. The authors present this compendium of development of mouth gags using articles sourced from Medline, surgical catalogs, museums, ancient manuscripts, original quotes, techniques, and illustrations. Results: This article describes notable types and variants of mouth gags with an attempt to classify them. Conclusions: The huge number of modifications done and reports of newer variants appearing at regular intervals goes to prove that we are still far from developing the ideal mouth gag.

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Background: The prevalence of congenital heart defects (CHD) in children with cleft lips (CLs) and palate (CP) is reportedly higher than the general population. Several studies have described diverse rate of CHD in different localities. Aims and Objectives: To the authors' knowledge, the frequency and pattern of CHD among children with CLs and CP has not described in this geopolitical zone. Materials and Methods: This is a retrospective study of the echocardiographic records of all cases of CL and CP seen over a 4 years period, between November, 2010 and October, 2013. Data were analyzed and expressed using frequency tables and percentages. Results: A total 30 children were referred for echocardiographic screening (ECGS) during the period. There were 17 males and 13 females, giving a male:female of about 1:1. The age range was between 15 days and 12 years with a median age of 4 months. There were 6 (20%) cases of CHDs. Conclusions: The relatively high rate of CHD among children with oral clefts in this study justifies the need for ECGS for these categories of children.

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Objective: Aim of this study was to assess satisfaction with facial appearance and function following cleft lip and palate (CLP) surgeries. Materials and Methods: The surgical outcome of 70 consecutive patients who had CLP surgeries between October 2008 and December 2009 were prospectively evaluated at least 4 weeks postoperatively. Data collected included age, sex, type of cleft defects and type of surgery done, and postoperative complications. For cleft lip repair, the Pennsylvania lip and nose score was used to assess surgical outcome whereas the integrity of the closure was used for cleft palate repair. Results: A total of 70 subjects were enrolled in this study with 40 females (57.1%) and 30 males (42.9%) (female:male = 1.3:1). The age of the subjects at presentation ranged from 1 day to 26 years. Majority of the study group were infants 74.3% (52) and 25.7% (18) presented after age one. 19 (39.6%) of subjects were operated within the ages of 3 months for lip repair and 10 (45.5%) subjects after 18 months for palate repair. There was a good surgical outcome of 71.4% with an overwhelming parents/subjects satisfaction of 94.8% with the treatment outcome. Twelve cases (15.6%) in which surgical outcome was rated fair, the subjects or their parents were still very satisfied with the surgical outcome. Conclusions: There was a high patient satisfaction irrespective of treatment outcome. This satisfaction reflects not only the technical competence of the cleft surgeons, but also the dedicated performance of other supporting staffs of the hospital.

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Objective: The objective of this study was to investigate the association of cleft lip (CL) and/or cleft palate (CP) in people born to consanguineous parents. Methodology: This retrospective study was conducted at GSR Institute of Craniofacial Surgery, Hyderabad, a very high-volume cleft center. Medical records of 18,242 cleft patients who came for treatment in the past 13 years were physically searched for the presence of consanguinity of their parents. About 3653 patients' case records were identified. Then, the data related to gender, type of cleft, degree of consanguinity, presence of positive family history were collected from these 3653 patients' records and entered in Microsoft Excel which was later sent for statistical analysis. Results: Distribution of study participants according to various study variables such as gender, type of cleft, and degree of consanguinity showed interesting findings. Almost 20.02% of the total 18,242 cleft patients' records showed consanguinity of their parents. Nearly 96.7% of patients had CL. CP was seen in 73.7% of patients. About 57.8% of parents had the first degree of consanguinity. Only 3.5% had a positive family history. Chi-square test showed that there was a significant difference in the distribution of patients according to degree of consanguinity and CL, variations in CL and gender, cleft alveolus and gender, degree of consanguinity and CL. Conclusion: Consanguinity is a major etiological factor in CL and/or CP.

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Background: Patients with cleft lip and palate (CLP) present with thin alveolar bone around the defect. Thin alveolar bone compromises orthodontic treatment. The aim of this study was to carry out three-dimensional (3D) assessment of the thickness of alveolar bone around the teeth adjacent to cleft and to compare the thickness of alveolar bone between cleft and noncleft side. Materials and Methods: Retrospective database of 16 cone-beam computed tomography (CBCT) scans of individuals with nonsyndromic unilateral complete CLP reported to two cleft centers in the year 2015 and 2016. Alveolar bone thickness of the teeth anterior and posterior to the cleft side in the buccal, lingual, mesial, and distal at three levels (3 mm, 6 mm, and 1 mm below the apex) from the cementoenamel junction (CEJ) using Dolphin 3D imaging software were measured. CBCT images of each cleft patient are divided into two groups, cleft and noncleft site. Each cleft side is subdivided into 1. Tooth anterior to the cleft 2. Tooth posterior to the cleft. Alveolar bone thickness of teeth at labial/buccal, palatal, and mesial/distal surfaces was measured. These subdivided groups were compared to contralateral teeth on the noncleft sites for individual surface. Statistical Analysis Used: Wilcoxon signed-ranks test and descriptive statistics were used. Results: The average alveolar bone thickness on the labial surface for teeth anterior to the cleft at 3 mm from CEJ is 0.15 (0, 0.80) mm and noncleft site is 0.85 (0.58, 1.28) mm (P < 0.05). The average alveolar bone thickness on the distal surface for teeth anterior to the cleft at 3 mm from CEJ is 0.90 (0.00, 1.65) mm and noncleft site is 1.11 (1.23, 3.60) mm (P < 0.05). The average alveolar bone thickness on the mesial surface for teeth posterior to the cleft at 3 mm from CEJ is 1.10 (0108, 1.38) mm and noncleft site is 1.45 (1.23, 1.98) mm (P < 0.05). Conclusions: The alveolar bone around the cleft sites is thin when compared with noncleft sites.

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Aims: The primary aim of this study was to correlate the incidence of cleft lip and palate (CLP) with possible etiological factors such as consanguinity, history of abortions or miscarriages, type of delivery, oral destructive habits, and family history. Materials and Methods: This retrospective study was completed using a standardized questionnaire which was prepared to investigate the information of 166 patients referred to/undergoing orthodontic rehabilitation treatment of CLP at the hospital. The variables assessed were consanguinity, affected members in family and relatives, gestational history, past abortions and/or miscarriages, medications taken by mother during pregnancy, and parental habits of tobacco chewing and/or smoking. Statistical Analysis Used: Correlation of the above-mentioned variables as well as any mutual effects of gender and cleft type was assessed statistically by Pearson's Chi-square test and Fisher's exact test. Results: The results of the present study provide demographic details of cleft patients in Gujarat, which show that cleft deformity is seen more in male patients (n = 98; 59%). Unilateral CL and palate of left side (CL + PUL) occurs most frequently (n = 62; 37.3%) both in male (n = 40; 40.8%) and female (n = 22; 32.4%) patients. Occurrence of CL + PUL is followed by bilateral CL and palate (CL + PB) (n = 45; 27.1%) and unilateral CL and palate of right side (n = 27; 16.3%). The oral destructive habits of parents (n = 82; 49.4%), past abortions and miscarriage (n = 47; 28.3%), family history (n = 26; 15.7%), and consanguinity (n = 24; 14.5%) could be correlated with the occurrence of CLP. Conclusion: This can serve as a guide for future reference to health workers so that they can take measures to create awareness among the people to avoid consanguineous marriages, use of tobacco, abortions, and create awareness about a family history. The outcome could also help government/public health sector workers to develop strategies for awareness, identification, and treatment of cleft deformities.

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Introduction: There is a wide disparity in the access to treatment facilities between developed and developing countries in cleft lip and palate (CLP) management. Factors ranging from poverty and illiteracy to paucity of healthcare services affect the patient accessing these services. Objective: Information regarding the socioeconomic and educational status of the parents of CLP patients admitted in a tertiary centre in Northern India was collected and analyzed to find any correlation between the above and the age of child at the first presentation to the hospital. Methods: Data were collected from parents of 200 consecutive patients of CLP presenting for surgery. The data set included variables such as age and sex of the child, age and literary status of the parents, household income, distance to the hospital from home, and the source of information that made them visit the hospital. Results and Conclusion: There was significant association between the age of first presentation and the literary status of the mother and father (P = −0.005 and 0.02, respectively), socioeconomic status of the family (P = −0.02), and the distance from the hospital. Other observations, though impressive, were not statistically significant. This proves the impact of socioeconomic and literary status of parents on availing access to healthcare services for their children.

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Purpose: To discuss the advantages of pedicle buccal fat pad flaps used to cover areas of exposed bone of the lateral hard palate. Patients and Methods: Fifty patients had buccal fat pad flaps used in cleft palate repair. Fat pad is filled into the lateral defect and sutured to palatal flap and gingiva without any tension over the midline suture of palatal flap. Results: No patients had any perioperative complication related to buccal fat pad or donor-site. In all cleft palate patients, the recipient areas fully epithelialized within 2 weeks or less. No patients had developed infection, loss of graft, palatal fistulas, or cheek depression. Conclusion: This technique allows safe, simple, durable, autologous, and vascularized coverage of the denuded bony hard palate.

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Introduction: Three-dimensional (3D) printing (additive manufacturing, rapid prototyping) is a technology that has attracted the attention of craniofacial surgeons to gain perfection in analysis, planning and execution of complex surgical challenges. Rapid prototyping technology was introduced to surgery via computer-aided design/computer-aided manufacturing, which enabled two-dimensional planning. The purpose of this article is to demonstrate the application of 3D printing (3DP) technology in craniofacial surgery, with a specific intention of addressing the planning of complex 3D deformities. Materials and Methods: This was a retrospective analysis of our surgical cases where we have used 3DP technology in 10 cases from 2014 to 2016 at a tertiary care hospital in India. 3D models were used in planning the correction of hypertelorism, craniosynostosis - open and endoscopic techniques, hemifacial microsomia, skull bone defects, and secondary orbital floor defects. The process of preparing a 3DP implant from a locally based company to suit the economic constraints of the patient has also been addressed in this article. Results: Each of the 10 patients are discussed, where this technology was used for planning, execution and training in craniofacial surgery. With the experience gained through these cases, the authors discuss the advantages of using 3DP technology in assessment of the true defect, accurate planning of the procedure, performance of model surgery, patient education, resident training, preparation of custom made implants, and more importantly providing all of these in an economical price using a locally based company for production of 3D models. Conclusion: 3DP models will revolutionize the way plastic and craniofacial surgeons think and plan surgical simulation. The authors recommend a wider application of such a technology to orthognathic surgery and any surgery that requires bony osteotomies with movement.

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Introduction: Craniosynostosis is a pathologic condition resulting from the premature fusion of cranial vault sutures, resulting in craniofacial deformities. Anterior craniosynostosis can involve a combination of metopic/unicoronal or bicoronal sutures. Aims and Objectives: Fronto-orbital advancement (FOA) is the standard surgical treatment. This article attempts to highlight the importance of modifying the osteotomies and reshaping of the cranial vault based on individual requirements to achieve the best possible result. Method and Results: Three consecutive cases of anterior craniosynostosis (metopic with unicoronal, unicoronal with sphenoethmoidal, bicoronal) with individual modifications of the technique used in each case are presented. Conclusion : FOA has to be tailored for each variant of anterior craniosynostosis and its requirements. The Technical variations can be applied to any combination of anterior craniosynostosis.

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Background: Area and volume of the pharyngeal airway in surgically treated unilateral cleft lip and palate (UCLP) patient: A cone beam computed tomography (CBCT) study. Context: Surgical repair of cleft causes restriction of maxillary growth and mid face but the effect of this reduced growth on volume of the pharyngeal airway has not been investigated thoroughly. Aims: The aim of the study was to assess the area, volume and smallest cross-sectional area of the pharyngeal airway in individuals with UCLP using CBCT and compare with age and sex matched noncleft controls. Settings and Design: Retrospective study. Materials and Methods: The study was carried out on 20 surgically treated UCLP patients and compared with 40 normal non cleft subjects with Class I skeletal relation within age group of 7-14 years. CBCT image processing and analysis were performed using Dolphin Imaging software (11.7 version premium; Dolphin Imaging and Management Solutions, Chatsworth, Calif) and volumetric rendering was done for airway analysis. Statistical Analysis Used: All statistical analyses were performed with SPSS software (version 15.0J for Windows; SPSS, Inc., Chicago, IL). An independent sample t-test was used to determine the significance of the difference between the means. Results: No significant difference was found in the area and volume of nasopharynx, oropharynx, hypopharynx, total pharyngeal volume (P = 0.86) and minimum axial area (P = 0.69) of the pharynx between the groups. Conclusions: Using CBCT, this study found that there was no significant difference in the pharyngeal area and volume between UCLP and noncleft groups. Further investigations are necessary to clarify the relationship between pharyngeal structure and airway function in patients with CLP.

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Velopharyngeal insufficiency (VPI) is a condition in which there is incomplete closure of the velopharyngeal valve during speech production. This results in hypernasality and/or audible nasal emission. Nasal emission can cause additional secondary characteristics, including weak or omitted consonants, compensatory articulation productions, short utterance length, and even dysphonia. Overall, this condition affects the quality and intelligibility of speech production, which can have a significant effect on the individual's communication and social interactions. This article provides a brief overview of how the management of VPI has evolved over the past 40 years (which is the extent of this author's career). In addition, the current state of the art in VPI management is discussed from this author's perspective. Finally, a pathway is suggested for the future evolution of care for patients affected by VPI.

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Enlarged persistent parietal foramen is rare congenital skull defect and associated anomalies like underlying encephalomalacia, and venous malformations are known. We here report a very rare association with persistent occipital foramina and occipital encephalocele. This patient presented later in life with complaints of headache and seizure. Basic clinical examination like palpation of scalp was helpful in diagnosing this rare condition. Radiological investigations later revealed an array of associated congenital abnormalities like hypoplastic inferior sagittal sinus, which is even rare finding in a single case.

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Introduction: The cleft palate repair is commonly performed procedure in plastic surgery practices. In addition, this is also procedure done by trainees to the senior most surgeons. One of common procedure for trainee who are introduced to cleft lip and palate surgeries. Literature is flooded with articles on complication of cleft palate repair and probable factors influencing it till the latest one, which suggest that we are far from getting desirable results in cleft palate repair. Review: The common complications of cleft palate repair are fistulae, velopharyngeal insufficiency and detrimental effect on maxillary growth. Palatal fistula is commonly stated in literature with variable incidence ranging from 3-40% ¹ , with an average of 7-10%. Other complications are poor speech outcome and poor growth potential of maxillary bone due to scars following palate repair. Every attempt needs to be made to avoid complications or reduce the rate of complications. This article reviews the factors and pitfalls that are likely to increase the chances of complication following palate repair. Conclusion: As surgeon we are duty bound to reduce the avoidable complication, specially related to judgment and techniques. However, the complication due to inherent deficiency of tissue like hypoplastic soft palate muscles and poor scarring tendencies leading to complications are not avoidable.

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Objective: Various risk factors (RFs) have been associated with cleft lip and/or cleft palate (CL/P) in many populations, but none has been identified in a South-Western Nigerian population. We sought to identify the prevailing RFs for nonsyndromic CL/P in the South-Western Nigerian population. Study Design: We conducted a case-control study at Obafemi Awolowo University Teaching Hospital (OAUTH) Ile-Ife. Patients with nonsyndromic CL/P presenting at the OAUTH and randomly selected infants conceived and delivered in the same zone as the patients were studied. We elicited information on RFs for CL/P around subjects' conceptions. Results: 157 patients aged 1 day to 4 months and 157 controls were reviewed. A female preponderance was observed (F:M= 1.24:1). Chi-square tests reveal that mother's age, gravidity at the birth of index child, pregnancy illnesses, child's birth rank, maternal medication use in the first trimester (FT), the absence of antenatal care (ANC), positive family history; and parent's occupational exposure differed significantly between these groups. A logistic regression revealed increased odds of having a child with CL/P with paternal age ≥40 years, maternal age ≤20 years, pregnancy illness, febrile illness in FT, attempted abortion, and birth rank ≥4 ^th . Furthermore, primigravid status at birth of index child, the absence of ANC, history of neonatal death, medication use in the FT, as well as parent's occupation demonstrated varying increased odds that attained statistical significance. Conclusion: Multiple interrelated factors may be implicated in the etiology of CL/P in the studied population. We advocate prompt health education and public enlightenment directed at addressing and eliminating these RFs.

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Objective: The purpose of this study was to report the epidemiological profile and surgeries done on patients with cleft lip and palate from August 2007 to December 2014. Materials and Methods: A retrospective study was done to evaluate the patients operated for either cleft lip (with or without alveolus), cleft palate or secondary correction. The age of operative intervention, sex distribution, type of cleft, laterality, type of surgery, and duration of stay were reported. Results: A total of 411 cleft patients were seen during this period (August 2007-December 2014). Among this 36 (8.7%) patients had an incomplete cleft lip, 57 (13.9%) had a complete cleft lip, and 29 (7%) had cleft lip with alveolus. Isolated cleft palate was seen in 104 (25%) patients and cleft lip and palate were seen in 185 (45%) patients. Eighty percentage patients were aware of the surgeries for cleft lip and palate by various hospital communications. The mean age of patients operated for cleft lip was 5.3 months and Randall Tennison modified repair was done in 88% of these patients. The mean age of patients undergoing palatoplasty was 1.6 years and the most common surgery done was pushback palatoplasty with intervelar veloplasty (73.6%). Seventy-six patients underwent a secondary correction, out of which 30 patients got lip revision and 26 got fistula repair. A total of 15 patients had other associated anomalies. The average duration of stay in hospital for a cheiloplasty patient was 7 days, of palatoplasty was 8 days and of secondary surgery was 5 days. Conclusion: This study indicates that cleft lip and palate are most common types of cleft predominantly on the left side and males being more. Newspapers, various medical institutions, and media are useful measures to spread public awareness about early surgery, follow-up, secondary corrective surgeries, speech and dental therapy. Early diagnosis and appropriate timings of these surgeries produce satisfactory results with minimal morbidity.

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Objective: The objective of this study was to evaluate the effects of presurgical nasoalveolar molding (PNAM) therapy by standard Grayson technique (G1) and Yen Modification single step NAM technique (G2) on alveolar tissues in patients with unilateral cleft lip and palate (UCLP) using three-dimensional digital models. Materials and Methods: Totally, 10 patients with a mean age of 20 ± 16.07 days, having complete UCLP, were included in this prospective study. The maxillary plaster models were scanned. The study sample was divided into two group of 5 UCLP patients (G1 treated by standard Grayson technique and G2 treated by Yen Modification) for linear, angular, and area measurements before and after PNAM therapy. The distances between the identified landmarks were measured on the maxillary casts, and the distance and area measurements were performed using software Poly works (IIT Delhi). All subjects had undergone PNAM therapy for 3 months, the alveolar segments should have been approximated (≤5 mm), and the cleft width after PNAM should be reduced. Results: The decrease of the cleft width and arch length on the cleft side were significantly altered on the affected side (P < 0.005). No significant changes were observed when comparing both the groups using standard Grayson technique and Yen Modification single step NAM technique (G1 and G2). Conclusion: PNAM therapy effects mainly in the anterior alveolar segment and reduction of palatal and alveolar cleft width in patients with unilateral clefts of lip, alveolus, and palate in both Grayson and Yen Modification single step NAM technique. Both the Groups G1 and G2 suggested same treatment outcome in term of alveolar molding, but single step technique reduces patient's visits.

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Context: Orofacial cleft (OFC) is one of the common craniofacial malformations. The etiology of these OFCs is multifactorial. One of the etiological factors is consanguinity (marriage between blood relatives). There is a lack of literature reporting the number of people affected with OFCs due to consanguinity. Aims: The aim of this study is to report the occurrence of OFC and associated factors in relation to consanguinity from a craniofacial hospital specializing in OFCs, head and neck cancer, and trauma management in South India. Setting and Design: This was a hospital-based study, retrospective case record analysis. Methodology: One thousand two hundred and forty-seven consecutive patients' secondary data records with cleft lip (CL), cleft palate (CP) and cleft lip and palate (CL/P) were collected from January 2007 to July 2009. Statistics: Frequency of consanguinity in relation to OFC was analyzed using Chi-square test according to the nature of clefts and selected demographic features such as sex, region, and religion. Results: A total of 47.2% patients' parents had consanguineous marriage. Consanguinity was seen in 60.2% of male and 39.7% of female patients. CL/P was noticed in 40.9%, followed by CL (36.7%) and CP (22.2%). Males predominated in all types of clefts proportionally with the study population as compared to females. Statistically, significant association (P = 0.04) was seen with consanguinity and CP. Conclusion: Nearly half of the study population had a positive history of consanguinity. Statistically, a significant association was seen between CP and consanguinity. CL/P cases were the most common type identified, followed by CL and CP. Males predominated in all types of clefts. The prevalence of OFC is high, and there is a potential of congenital disabilities from consanguinity. These findings indicate a clear and urgent need for setting up a National Registry of Congenital Anomalies along with craniofacial defects, to monitor these trends and the corresponding need for supportive services.

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Background: The long-term care of patients with a visible appearance difference may involve many years of multidisciplinary treatment. In addition to providing the physical treatment component, support for the emotional and psychosocial implications must also be considered. The primary objective of this project was to survey healthcare professionals (HCPs) from each of the participating countries to ascertain their level of awareness and understanding of the issues facing those with visible differences, their level of confidence in supporting those patients, and their current and required level of training. Secondary objectives were to gauge the perceived importance of appearance and the psychosocial impact for individuals with visible differences. Methods: Questionnaires were completed by multidisciplinary HCPs in four European countries and Australia. Results: The results for all countries (110 participants) indicate that the majority of HCPs do not feel confident in dealing with the psychosocial needs of people with an appearance disfigurement. Conclusion: All countries identified and supported the need for training of multidisciplinary HCPs to be able to identify and support the psychosocial problems experienced by individuals and families. A collaborative future training program aimed at providing effective psychosocial support and was identified to be the most efficient mode to meet the training requirement. Provision of training will offer the knowledge base for effective psychosocial support and address the unintentional marginalization and social exclusion that may occur by untrained HCPs.

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Background: Children with cleft palate (CCP) frequently shows language and/or speech disorders. However, a significant number of children cannot receive speech pathology treatment on a regular basis. For these children, new modalities of intervention have to be developed for stimulating speech and language. Objective: The purpose of this paper is to study and compare the two modalities of speech intervention in CCP: a conventional approach providing speech therapy in 1 h sessions, once a week, and a total immersion speech camp in which CCP received therapy within a naturalistic environment 10 h/day for a period of 5 days. Materials and Methods: Twenty-three children were studied. A matched control group was assembled. Children included in the experimental group attended a total immersion speech camp for 5 days. Matched control children received speech therapy once per week in 1 h sessions. Results: When comparing the advances of the CCP participating in total immersion speech camps to CCP assisting to speech therapy 1 day a week, significant similar advances (P > 0.05) in articulation were demonstrated. Moreover, significant improvements (P < 0.05) were found when articulation deficits were compared before and after the speech treatment periods. Conclusion: Total immersion speech camps seem to be a valid and reliable option for speech intervention in CCP.

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Introduction: The aim of the present study was to evaluate the developmental relationship in the vertebral column in the cervical region and to relate its association in patient's with cleft lip and palate. Materials and Methods: The sample consisted of 228 cleft patients in the experimental group and 225 non cleft samples in control group. Cleft patients are subdivided into cleft palate only (CPO), Unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP). Cervical vertebrae were traced on lateral cephalogram in children with cleft lip and palate to determine the prevalence of vertebral anomalies and their categorization. The cervical vertebral anomalies were classified into two types: posterior arch deficiency (PAD) and fusion anomalies (FUS). Results and Conclusion: The study showed 19 percent of cleft patients with cervical vertebral anomalies and 4 percent of control group with cervical vertebral anomalies. Posterior arch deficiency occurred more frequently in unilateral cleft lip and palate(UCLP) and cleft palate only (CPO), Fusion occurred significantly more often in bilateral cleft lip and palate (BCLP).

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Background: Cleft lip and palate repair seeks to restore normal form, improve feeding and achieve normal speech, which requires velopharyngeal competence. The absence of this ability, termed velopharyngeal insufficiency (VPI), is seen in a wide range of patients following primary cleft palate repair. This review article focuses on patient assessment and the surgical management of VPI. Recent trends and future directions in management are also presented. After reading, one should be able to describe the various treatment approaches for a patient with suspected VPI. Materials and Methods: A PubMed search was conducted using the following search terms: VPI, velopharygneal incompetence, VPI, velopharynx, velopharyngeal port, velopharyngeal mechanism, veloplasty, intravelar veloplasty and hypernasal speech. Relevant manuscripts were identified by abstract review and additional articles selected based on bibliography review. Articles were restricted to those in the English language. A total of 88 articles were selected for further review. Conclusions: VPI is a common complication following primary palatoplasty. The decision to operate, as well as the selection of operative procedure, depends on a multimodal patient assessment, including speech evaluation and imaging studies of the pharyngeal mechanism. A thorough understanding of velopharyngeal anatomy and physiology is crucial to understanding the deficits in patients with VPI as well as the myriad methods of surgical correction. While many techniques are available, there are no conclusive data to guide procedure choice and newer techniques of imaging and treating patients with VPI continue to evolve.

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The cleft lip nasal deformity has been well described. However, for a long time, cleft surgeons feared that repair of the cleft lip nose at the time of primary repair would cause a growth disturbance especially of the nose. Hence the nasal deformity was not repaired until later. However, from the time of Blair and Barrett Brown, it has been shown that there are no deleterious growth effect from primary nasal interventions. At our centre the senior surgeon has performed primary nasal correction including septal respositioning from the late 1960s. There has been no deleterious growth effect and the overall appearance of the nose has actually improved. This is now well established through many objective studies. Hence it is now imperative that the deformity of the nose including the septum be addressed at the time of primary unilateral cleft lip repair.

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