Research guides the parameters for assessment and treatment of individuals with cleft lip and/or palate (CL/P). Most developing countries cannot provide an adequate standard of cleft care, due to limited resources. Speech-language therapists and audiologists in developing countries can contribute to improving cleft care through early communication intervention to minimise/prevent the negative impact of a cleft on a young child’s communication ability and to support the families. However, they require linguistically and contextually relevant assessment instruments for early identification of communication disorders in these children. The aim of the research was to develop and evaluate a communication assessment protocol for young children with CL/P, for use in Mauritius, a developing country in the Indian Ocean with a multilingual and multicultural population. A further aim was to develop an electronic database of children with CL/P in the public health sector of Mauritius. Eighty-eight children, with CL/P, 0-6 years, were selected by consecutive sampling and their parents acted as participants. Four speech-language therapists and audiologists from the public health sector of Mauritius participated in the data collection and appraisal of the newly developed assessment protocol. A mixed methods research design was selected. Based on exploratory research of cleft care in Mauritius and international recommendations for assessment of young children with CL/P, a comprehensive Communication Assessment Protocol was compiled and speech elicitation materials in Creole and French were prepared. Speech-language therapists and audiologists conducted assessments, using non-invasive procedures to assess feeding, hearing, communication skills development, emergent literacy skills, speech production and voice of the participants. Digital video and audio recordings of the elicited speech samples were made and auditory-perceptual procedures for speech analysis and inter-rater comparisons for reliability were employed. The communication assessment protocol was useful in describing the characteristics of the children with CL/P treated in the National Health System in Mauritius. The speech-language therapists and audiologists together with the parents of the children as partners in assessment were successful in early identification of communication delays/disorders in children with CL/P (73%) and also referrals to other health care professionals. The protocol was evaluated and accepted for application in clinical practice. The newly developed Communication Assessment Protocol was applied by local speech-language therapists and audiologists with the possibility of implementing this assessment instrument nationally. This was an important contribution to improve cleft care in Mauritius where interdisciplinary team-based cleft care has not occurred to date. / Thesis (DPhil)--University of Pretoria, 2009. / Speech-Language Pathology and Audiology / Unrestricted

In der vorliegenden Dissertation wurde anhand von 1042 extraoralen Fotos im Profil und en face untersucht, wie sich das Wachstum longitudinal bei 166 gesunden Kindern, je zehn Kindern mit isolierter Gaumenspalte, einseitiger Lippen-Kiefer-Gaumenspalte sowie doppelseitiger Lippen-Kiefer-Gaumenspalte operiert nach dem Leipziger Konzept entwickelt, sowie inwiefern sich die einzelnen Gruppen in verschiedenen Altersstufen voneinander unterscheiden. Dazu wurden pro Gruppe jeweils fünf Jungen und fünf Mädchen kaukasischer Herkunft, geboren in den Jahren 1994 bis 2001, mit einer nichtsyndromalen Spalte ausgewählt, die ab der Geburt über mehrere Jahre hinweg fotografiert wurden. Diese Fotos wurden digitalisiert und denen von Kontrollpatienten gegenüber gestellt. Anhand von Winkeln der klassischen Morphometrie und Grafiken und Statistiken der geometrischen Morphometrie wurden die Veränderungen im Wachstum analysiert und die Kontrollpatienten mit dem Leipziger OP-Konzept verglichen. Es konnte gezeigt werden, dass die geometrische Morphometrie durchaus geeignet ist, das Gesichtswachstum anhand von extraoralen Fotos zu beurteilen. Weiterhin konnte bestätigt werden, dass mit dem Leipziger Konzept zur funktionellen Rehabilitation von Patienten mit Lippen-Kiefer-Gaumenspalten sehr gute Operationsergebnisse und vor allem Langzeitergebnisse erzielt werden können.

There has been a rise non-governmental organizations (NGOs) as part of a global health system that seeks to treat children with cleft lip and palate (CLP) in resource-poor countries. As a craniofacial abnormality, CLP affects a child’s ability to communicate and consume food, and the stigma associated with the condition leads to both social and physiological suffering. International NGOs use an apolitical humanitarian rhetoric to justify the need to provide this life-saving surgery. This thesis assesses CLP interventions by applying a critique of neoliberalism to explore the ways economic rationalities are extended to the domain of humanitarianism. By employing an ethnographic approach of “studying up,” this thesis critiques a North American NGO, referred to as Mission Smile. To reveal how neoliberal rationalities are embedded within the organization, this research draws on data from media analysis, participant observation, and interviews with medical volunteers and employees at Mission Smile. This thesis argues that neoliberal rationalities permeate throughout the organization. Economic calculus are not only embedded in the organization’s goal to provide surgery to “as many children as possible,” but also undergirds the distribution of humanitarian aid. Moreover, the surgery Mission Smile provides is described as an “investment in a child’s future” that enable children with CLP to become a contributing member of society. While this study reveals how neoliberal rationalities can converge with values of humanitarianism, it also shows that the extension of neoliberal rationalities into new domains is not a cohesive process. Volunteers describe an emergence of communitas, a feeling of bubbling joy and a shared humanity, and a development of a moral relationship with their recipients that lies partially outside the domain of market rationalities. / Graduate

Orofacial clefts (OFCs) are among the most common structural birth defects and a public health problem. Several studies suggest that maternal obesity pre-existing diabetes mellitus (DM), and the underlying metabolic abnormalities, may be involved in the pathogenesis of cleft lip (CL) and cleft palate (CP) birth defects. Although hypertension and gestational diabetes mellitus (GDM) have been associated in a few studies with congenital birth defects, studies examining the risk associated with OFCs are limited. The overall objective of this dissertation was to examine the association between maternal obesity, DM, GDM, and hypertension and the risk of OFCs in case-control studies. Analyses of data from an international consortium revealed that maternal obesity (pre-pregnancy BMI >30), compared to normal weight (18.525), was associated with an increased risk of cleft palate with or without cleft lip (CP/L) (adjusted odds ratio (aOR) =1.13 [95% confidence intervals (CI) 1.01-1.25]). We also found a marginal association between maternal underweight and CP/L (1.0 [reference]; aOR=1.14 [0.97-1.34]. CL only was not associated with maternal bodyweight. Interestingly, among college-graduates, there was no increased risk of CP, but mothers with less than a completed college education had an increased risk of CP for underweight and obesity. Investigation of the Utah OFC data provided evidence that maternal GDM is significantly associated with isolated (aOR=2.63 [1.30-5.34]) and non-isolated clefts (aOR=2.66 [1.02-6.97]). Maternal hypertension is significantly associated with non-isolated clefts (aOR=6.56 [2.18-19.77]). We found a further elevated risk of OFCs among GDM mothers and those with hypertension who were also obese. The analyses of data from an international consortium revealed significant associations between maternal diabetes and the risk of OFCs. The estimated relative risk of DM for isolated OFCs was 1.33 [1.14-1.54] and was slightly higher for multiple OFCs (aOR=1.86 [1.44-2.40]). Diabetic mothers with abnormal body-mass-index had an increased risk for having inborn with OFCs. Throughout the dissertation, we demonstrated the extent in which maternal obesity, pre-existing DM, GDM, and maternal hypertension may increase the risk of OFC birth defects. The results highlight the need for pre-conceptional program planning for the prevention of OFCs with screening for abnormal glucose tolerance and hypertension.

December 2011. A thesis submitted to the College of Dental Medicine of Nova Southeastern University of the degree of Master of Science in Dentistry. Introduction: The nasoalveolar molding appliance is used pre-surgically in cleft lip and palate patients as a method of bringing together the lip and alveolus by applying force to direct desired growth.1 It is used in the infant to reduce the pre-surgical severity of the initial cleft and to improve alignment of the base of the nose and lip segments.1 The purpose of this study was to examine the long-term effect of nasoalveolar molding on facial growth and nasolabial esthetics in complete unilateral cleft lip and palate patients. Methods: Sixteen (N=16) post-surgical cleft lip and palate patients who had undergone nasoalveolar molding as infants and twelve (N=12) control patients, treated surgically without nasoalveolar molding, were recalled for a clinical examination including impressions, photographs, and a lateral cephalogram. Dental models were analyzed using the Goslon Yardstick, developed by Mars et al. in 1987.2¬ Photographs were analyzed using the Asher-McDade method for rating the nasolabial appearance in patients with cleft lip and palate.3 Finally, lateral cephalograms were digitized and analyzed using Dolphin Imaging software. Results: Separate ordinal logistic regression models indicated no significant difference between the molding and non-molding groups in Goslon score, nasal form, nose symmetry, vermilion border or nasolabial profile assessments. Generalized linear models revealed one cephalometric variable to be statistically significant between the two groups. The ANB angle was decreased by 2.34 degrees on average in the group who underwent nasoalveolar molding prior to cheiloplasty. Intra-rater and inter-rater weighted kappa statistics were calculated for each variable. Conclusion: Short-term benefits of nasoalveolar molding have been documented in the literature. However, more long-term studies are needed in order to demonstrate the longitudinal effects of the appliance on esthetics and midfacial growth. Due to the limitations of cleft lip and palate studies, it is often difficult to accurately assess treatment effects. Through inter-center studies such as the Eurocleft and Americleft projects, some limitations and biases can be overcome in order to compare various protocols and outcomes.4 In the future, it is the desire of the investigators to include the current sample of nasoalveolar molding patients in the future efforts and expansion of the Americleft study.

Indiana University-Purdue University Indianapolis (IUPUI) / The Riley Children's Hospital Craniofacial Anomalies Team rigorously follows a treatment protocol developed by Dr. Sheldon Rosenstein for the treatment of cleft lip and palate patients. Rosenstein's protocol incorporates primary bone grafting and alveolar molding appliances for cleft lip and palate patients. While other cleft lip and palate treatment centers utilize alveolar molding appliances, there remains debate concerning the efficacy of primary bone grafting. The principal detraction of primary bone grafting is the concern that such early surgical treatment affects maxillary and craniofacial growth and development. The purpose of this retrospective study was to analyze post-treatment lateral head plates and dental casts of cleft lip and palate circumpubertal patients treated in infancy at Riley Hospital in Indianapolis by the Craniofacial Team following Rosenstein's protocol. The hypothesis was that primary alveolar bone grafting in conjunction with the use of alveolar molding appliances contributes to the early stabilization of the alveolar segments, and produces no statistically significant difference in craniofacial development among primary bone grafted patients and nongrafted patients. The dental arch dimensions of the nongrafted patients (control group) consisted of the same data utilized by Moorrees in his study of the dentition of the growing child. The dental arch dimensions of nongrafted cleft patients consisted of the same data utilized by Athanasiou in his study of the dentition of cleft patients treated surgically without bone grafting. Of the eight measurements made by the three examiners, six demonstrated excellent interexaminer agreement, one demonstrated moderate interexaminer agreement, and one demonstrated poor interexaminer agreement. The arch width and length for the grafted group was significantly smaller (p < .05, Student's t-test) than the normal group in all measures except for the mandibular canine width. The arch width and length for the grafted group was not significantly different (p < .05, Student's t-test) than the nongrafted group, except for the maxillary molar width where the grafted group was smaller than the nongrafted group. The cephalometric values of the Riley group were compared against a nongrafted group, an early primary grafted group, and the Bolton standard values cited in Rosenstein's study. The Bolton standard values were used as the control group. This study found the cephalometric values of the Riley experimental group (treated following Rosenstein's protocol) to be of no statistically significant difference (p < .05, Students t-test) when compared with cephalometric values of the nongrafted and primary alveolar grafted groups cited in Rosenstein's 1982 study. The cephalometric values of the Riley experimental group were less than the cephalometric values of the nonclefted patients (Bolton standard control group) cited in Rosenstein's 1982 study. Interexaminer agreement ranged from poor to good with the poorest agreement among the linear values of ANS/PNS and GO/ME. The intraclass correlation coefficient values for SNA,m ANB, and SNB ranged from fair to moderate. The Riley cephalometric values were equal or slightly better than Rosenstein's grafted and nongrafted groups. Though smaller than the control group, the Riley cephalometric values were of no statistical significance (p < .05, Students t-test) when compared with the same parameters cited in Rosenstein's study. Although these findings infer that the patients treated following Rosenstein's protocol demonstrate some degree of craniofacial growth attenuation when compared with nonclefted patients (Bolton standard control group), the Riley patients showed no worse growth attenuation than similar patients treated without Rosenstein's protocol for primary alveolar grafting. The hypothesis of this thesis was that Rosenstein's protocol was viable and non-detrimental when compared with other treatment regimens. The results of this study support the hypothesis that Rosenstein's surgical protocol is not a contributing factor in craniofacial growth attenuation among cleft lip and palate patients.

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A brief overview of adolescents and young adults with CLP and their multidisciplinary needs will be presented and a service delivery model for transition of care described (Vallino & Louw, 2017). The key components of the clinical toolbox to be discussed are: 1) communication strategies and styles with adolescents and young adults, 2) practical strategies for preparing and supporting the adolescent, young adult, and their families for the transition of care, 3) tips for developing self-management of health through health education and health promotion, 4) assessments and protocols as outcome indicators incorporating the domains of the ICF with an emphasis on self-report to gain a holistic perspective of function and QOL, and 5) outcome indicators of transition of care for individuals with CLP.