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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Classification of the cleft has evolved over a century. Many descriptive, diagrammatic, and coding systems have been proposed to be used. However, there are only few which have stood the test of time. One of them is Indian classification. Indian classification of cleft lip (CL) and palate proposed in 1975 is a popular classification in India presently. There are numerous combinations of cleft deformities, and we found that some of them could not be classified appropriately with the original classification. The clefts are classified in three groups: CL as Group 1, cleft palate as Group 2 and Group 3 for combined CL, alveolus and palate in continuity. Originally right, left, midline, and alveolus were abbreviated. To make the classification wholesome, the original classification has been revisited and presented with additional features. The basic classification in three groups remains as original. Additional abbreviations have been added to classify the special situations. Partial, submucosal, Simonart's band, protruding premaxilla, and microform have been added to the list of abbreviations. This classification has been used for over 30 years by the author in over 4000 cleft patients. We find it simple to use, versatile enough to classify almost all possible cleft combinations, easy for communication during discussion and convenient to write as diagnosis in patients' files. Easy computer archiving and efficient retrieval of the data are the special features of this classification.

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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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The management of a patient with cleft palate is complex. Various prevalent surgical techniques are presented, but no universal agreement exists on the appropriate treatment strategy. There is a consensus of opinion that normal speech should be the most important consideration in the therapeutic plan. Growth disturbance should be minimized, but not at the expense of speech impairment because facial distortion can be satisfactorily managed by surgery, whereas speech impairment can often be irreversible. There is a need for well-controlled, prospective studies to establish the validity of the widely different claims of superior results from various techniques. Cleft patients should be managed in a center with a multidisciplinary team. Cleft palate remains a significant and interesting challenge for current and future plastic surgeons.

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Objective: To present various ways of transfer and result of buccinator myomucosal flap (BMMF) in primary and secondary repair of palatal cleft and palate fistula. Design: This study has been designed on the basis of a clinical experience and literature search. Route of single or two BMMF(s) transfer was either lateral or posterior to the greater palatine neurovascular bundle. The flap has been used to repair defect in nasal layer, oral layer, or in combined nasal as well as oral layer of the palate. Materials and Methods: More than 160 palatoplasties have undergone palate repair with the use of BMMFs between 1999 and 2011. The analysis includes 98 palate repair. Unilateral flap was used most commonly in primary repair of nasal side of wide unilateral cleft palate (CP); whereas, two flaps were used mostly in primary repair of wide bilateral CP and in secondary palate repair for large fistula. Results: The fistula rate; in primary palatoplasty patients was 4.8% and in secondary palatoplasty patients, it was 8.3%. Good speech has been achieved in primary palatoplasty patients. After secondary palatoplasty also patients had good speech following therapy. Conclusion: The presented technique has been effective in anatomical and functional repair of wide palatal defects primary as well as secondary. The literature has been reviewed along with.

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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 purpose of this communication is to explore in detail the developmental anatomy of the soft palate, its pathologies, and strategies for management. Despite the voluminous literature regarding complete cleft palate in its usual presentation, little attention has been paid to the biology of the isolated soft palate cleft. It exists as a spectrum, ranging in severity from the submucous variant, with nothing notable save a groove and a palpable defect of the posterior spine, all the way to a complete disruption of the soft tissue envelope and the horizontal palatine shelves. All these presentations are but variations of common pathology. Much can be gained from a disciplined examination of these. Our discussion includes two parts. The first part is on the embryologic events that generate the mesenchymal building blocks from which the posterior palate is constructed: palatine bone, oral and nasal mucosa, palatine aponeurosis, and muscle slings. Palate structures develop from neural crest and mesoderm; these tissues originate at specific sites along the axis of the embryo and they can be mapped according to the developmental units of the central nervous system (CNS) from which they are innervated. These units, called neuromeres, are specific zones within the neural tube, the boundaries of which are established by the expression pattern of homeotic genes. The forebrain (prosencephalon) has telencephalon and 3 prosomeres, the midbrain (mesencephalon) has 1-2 mesomeres, and the hindbrain (rhombencephalon) has 12 rhombomeres. Each neuromere has a specific neuroanatomic content and is hardwired to specific tissues outside the brain. We next consider a model of the palate which is analogous to a pinball machine that consists of a platform (bone) and mobile “flippers” or lever arms (the velum). In this study, the osseous platform is discussed in detail with neural crest bones being coded by the sensory innervation of their surrounding soft-tissue envelope. Maxilla, palatine bone, and vomers are all derivatives of hindbrain neural crest arising from rhombomere 2 but distributed according to various neurovascular pedicles of the V2 stapedial system, the anatomy of which will be explained in detail. Next, the evolution of palate will be presented as a series of innovations favoring increased metabolic capacity. A final appendix presents a functional classification of cranial nerves which I have endeavored to make straightforward. This will prove useful when reading the second part of this manuscript having to do with the neuromuscular apparatus of the soft palate.

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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: We strive to achieve a functional and aesthetic repair in cleft lip patients bestowing them with all natural landmarks and making the evidence of the repair undetectable for better quality of life and complete social acceptance. The last to offer is a moustache for an adolescent male cleft lip patient. Aim: The current study is a review of moustache restoration carried out for patients after cleft lip repair. It includes 18 cases with a follow-up of 6 months to 2 years. Materials and Methods: Follicular unit extraction using 0.9 mm motorized punches is the preferred technique. Alternative method is follicular unit transplant strip technique, where individual hair follicles are dissected for a 0.5-0.6 cm × 5-6 cm strip of scalp. Each follicle serves as a micro graft. Grafts are implanted in premade needle tracks flush to the skin. Spacing is 2-3 mm in the first sitting. Second sitting may be planned 6-8 months later to add density. Results: Hair growth along the scar is delayed, it begins 4-5 months after the transplant, and complete growth is seen by 6 months. There can be 7-10% loss of grafts. Conclusion: Follicular unit micro grafting can be used for restoration of moustache after a complete cleft lip repair. Moustache provides animation of the face, restoration of aesthetic landmark, taking away the typical cleft lip look and building up confidence of the patient.

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Good speech is the ultimate aim in palate repair. Muscle function has to be optimum for the palate to be able to move to provide this goal. The fact that there has been a multitude of techniques of palatal repair indicates that none has been able to attain the intended objective. The method of intravelar veloplasty as a funtional technique has been the one that has gained wide acceptance all over the world. Use of magnification loops and microscope and better understanding of the cleft anatomy has helped to further refine the technique. This review aims at evaluating the outcome of this technique and its various modifications and complications. Literature search was performed in PubMed, Embase and Lilacs Bireme using the terms 'intravelar veloplasty', 'cleft palate repair', and radical muscle dissection'. No restriction were placed with regards to date of publication or language. Abstracts of the articles were assessed and the selected articles were reviewed in full by the authors. There is a striking diversity in the extent of muscle dissection between cleft surgeons. The evidence from the studies available showed better speech outcomes and velopharyngeal competence with radical intravelar veloplasty with varying complication rates. Uniformity in defining the degree of dissection of muscle by using a classification and standardised methods of outcome measurements are to be used in future studies to provide high quality evidence to guide decisions.

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Congenital lateral oral synechia is a very rare anomaly which may be present in association with cleft palate and other facial abnormalities. Infants with lateral oral synechiae usually present very early in the neonatal period with restricted mouth opening and the resultant feeding difficulty, warranting early operative intervention. In the present article the authors report a 12-year-old child with lateral oral synechiae and cleft palate, presenting in late childhood and managed successfully by single-stage surgical correction.

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Background: Treacher Collin Syndrome is one of the most disfiguring congenital anomalies of the face, the visible part of the human body used for the identification of an individual. It is an inherited disorder in which there are bilateral symmetric anomalies of the structures within the first and second branchial arches. In general, there is complete penetrance and variable expressivity of the trait. Increased frontonasal angle and deep antegonial notch are syndrome specific characteristic distinguishing Treacher Collin Syndrome from other Syndromes. Main objectives of the presenting this case are to evaluate the validity of the aforementioned clinical signs for the diagnosis and to find out the significance of the surface area of antegonial notch in patient suffering from Treacher Collins syndrome. Methods: Persons of two generations of a family effected with Treacher Collins syndrome were examined for two cardinal signs traditionally associated with this disorder along with the normal siblings of the second generation for the above parameters. Conclusion: Significantly increased fronto nasal angle, frontal sinus area and deep antegonial notch was found in the father and son exhibiting characteristic signs of Treacher Collins-Franceschetti Syndrome in comparison to normal individuals of the family.

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Context: Treatment of patients with cleft lip and palate (CLP) anomaly requires a multidisciplinary approach from birth until adulthood. Many children with cleft anomaly are born in rural areas where resources for treatment and awareness on cleft care are limited. Consequently, many patients may receive limited or suboptimal care due to multitudes of reasons. Aims: The current study was aimed to record the baseline data on the spectrum of clinical profile of cleft patients, treatment protocols, quality of treatment and the residual treatment needs of patients with CLP anomaly visiting three major hospitals across Delhi and National Capital Region (NCR). The experience gained from the three-center study would be used to lay a framework to conduct a nationwide multicenter study in terms of logistics, feasibility and difficulties. Materials and Methods: The study titled "CLP anomaly in India: Clinical profile Risk factors and current status of treatment: A hospital based study" was started in 2010 as a Task Force project of Indian Council of Medical Research. The Pilot phase, which started in 2012, encompassed three cleft centers across Delhi and NCR, namely, All India Institute of Medical Sciences, Safdarjang Hospital and Medanta - The Medicity. Data for 126 non-syndromic CLP subjects was recorded on a specially designed performa. Each case was evaluated by a team of specialists comprising of a Plastic Surgeon, an Orthodontist, ENT Surgeon, Dental Surgeon, Speech therapist and an Audiologist. Clinical records included profile and intraoral photos, dental study models, audiometric and speech evaluation data. The current paper attempts to highlights a few of relevant observations of the pooled data from three centers. Results and Conclusions: The results indicate a lack of uniform protocol followed in providing care to cleft patients. A great variation was found in the quality of treatment received by many of the patients.

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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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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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Purpose: The study's objectives were to assess the effect of articulation therapy for bilabials on SODA errors, cleft type errors (CTEs), and percentage of correct consonants-revised (PCC-R) in children with repaired cleft lip and palate. Methods: Single-subject with multiple baselines research design was used to investigate the changes in bilabials across four-time points. Four participants with repaired cleft lip and palate (RCLP) between 4 and 7.11 years were considered. For the assessment, pictures of six words were visually presented, and the participants were asked to name them. Three speech-language pathologists identified SODA errors and cleft type errors (CTE), based on which PCC-R was calculated. Participants underwent ten intensive articulation therapy sessions: phase I focused on auditory discrimination training and phase II on production training. The production training mainly focused on the phonetic placement approach, shaping the target sound, and improving the oral airflow. Results: Overall, SODA error analysis revealed substitution and distortion errors during the baseline assessment. CTE analysis indicated weak oral pressure consonant followed by a glottal stop, nasalization of voiced pressure, nasal consonants for oral pressure consonants, and voicing errors. PCC-R scores ranged from 0% to 83.33%. Assessment 4 indicated only distortion errors during SODA error analysis, weak oral pressure consonants during CTE analysis PCC-R was 100%. The obtained results indicate an improvement in the articulation placement and oral airflow; thus, the participants benefited from the intervention program.

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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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Introduction: Compensatory Articulation Disorder (CAD) is frequently seen in individuals with Cleft of lip and Palate (CLP). Speech intervention with metacognitive strategies in these individuals requires a long period of time. Objective: To study the use of metacognitive strategies in therapeutic intervention of individuals with Cleft of Lip and Palate. Methodology: 14 Marathi speaking Children with CLP between 4 to 6 years of age were evaluated for language and articulation. 7 Speech Language Pathologists devised Percentage Correct Consonants on the Photo Articulation Test for Articulation pre and post intervention. Language measures were compared pre and post therapy on the Receptive Expressive Emergent Language Scale. Results: There was a significant difference between articulation and language measures pre and post intervention respectively which is attributed to the use of metacognition strategies. Conclusion: Severity of CAD and effectiveness of strategies used for correcting articulation errors are linked to one another. Assessment of CAD and therapy scaffolding metacognition strategies can be used in Speech treatment of individuals with CLP.

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Osteopetrosis also known as "marble bone disease" is a group of rare genetic disorders caused by osteoclast failure, which ranges widely in severity. Osteopetrosis presents with a spectrum of craniofacial abnormalities such as frontal bossing, macrocephaly, hydrocephaly, and cranial hyperostosis. Osteopetrosis is caused by failure of osteoclast development or function and mutations in at least 10 genes have been identified as causative in humans, accounting for 70% of all cases. These conditions can be inherited as autosomal recessive, dominant or X-linked traits with the most severe forms being autosomal recessive. We present a rare case of osteopetrosis in a 10-year-old boy who reported with an unhealed socket after tooth extraction. The characteristic clinical and radiographic findings were suggestive of intermediate osteopetrosis.

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Craniofacial microsomia (CFM) is the second most common craniofacial anomaly treated surgically in craniofacial centers worldwide. This craniofacial condition is variably associated with anomalies of the ears, jaws, orbits, soft tissue of face and function of the facial nerve. It can also be associated with extra-cranial deformities like cervical and rib anomalies. Largely, the etiology of CFM is unknown, but prenatal exposures of some drugs and genetic abnormalities may be associated with the condition. Diagnosis and treatment of CFM is challenging due to a wide spectrum of deformities (both osseous and soft tissue). Depending upon the severity of the deformity a wide variety of surgical treatment plans exist. After treating forty cases of CFM, we experienced that, though the treatment of severe form of CFM is difficult, but a coordinated multi-specialty team approach, especially of Reconstructive plastic surgery, orthognathic surgery, ear, nose and throat specialists leads to a successful and rewarding outcome.

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Objective: The aim of this study was to evaluate functional and speech outcomes of superiorly based pharyngeal flap (SBF) pharyngoplasty combined with radical intravelar veloplasty (RIVVP) for the management of velopharyngeal insufficiency (VPI) following surgically repaired cleft palate. Design: A case series with chart review. The study was conducted in academic tertiary care medical centre. Patients and Methods: Fifteen patients with VPIs following surgically repaired cleft palate were managed between May 2011 and August 2014, with SBF pharyngoplasty combined with RIVVP. Results: We found that the speech defects improved by a success rate of 93.4%; the VP function became normal (circular pattern of closure) in 80% of patients and the postoperative overall success rate of VP competence grades was 93.4%. Moreover, we found that the overall incidence of complications were 33.3%. Conclusion: By doing SBF pharyngoplasty combined with RIVVP the surgical procedure was satisfactory in both functional and speech outcomes.

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Introduction: Automatic speech processing (ASP) software is a nasality assessment tool. ASP studies focusing on investigating sentences to find nasality and correlating ASP scores with other objective assessment scores measuring nasality are scarce. Hence, the present study aimed at comparing the nasalance values of the ASP software with the nasometer in typically developing children (TDC) and children with repaired cleft palate (RCP) across different stimuli. Methods: Participants included 30 Kannada speaking TDC and 10 children with RCP (9–12 years). Speech stimuli (oral, nasal, and oronasal sentences) were recorded and the values were obtained from the ASP software as well as the nasometer. The following statistical tests were applied: mixed ANOVA, repeated measures ANOVA, paired samples t-test, independent samples t-test and Pearson's correlation. Results: Like nasometer, the nasalance values of ASP software were high for the nasal sentences followed by the oronasal sentences and the oral sentences, for both the populations. Higher nasalance values were found for children with RCP than for TDC across all the stimuli. Significant differences were found in nasalance values between the instruments in oral and oronasal sentences in TDC and nasal sentences and oronasal sentences in RCP. The nasalance values across the stimuli between nasometer and ASP software in both the groups showed no significant correlations. Conclusions: ASP software was successful in identifying nasalance in TDC and children with RCP. However, a major issue needs to be addressed concerning the dynamic range of the software and it has to be validated on a large number of populations.

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