Michael O. Adeyemi

Prevalence of Orofacial Clefts in Nigeria

Orofacial clefts are the most common malformations of the head and neck. In Africa, orofacial clefts are underascertained, with little or no surveillance system in most parts for clefts and other birth defects. A Nigerian craniofacial anomalies study, NigeriaCRAN, was established in 2006 to support cleft research specifically for epidemiological studies, treatment outcomes, and studies into etiology and prevention. We pooled data from seven of the largest Smile Train treatment centers in the six geopolitical zones in Nigeria. Data from September 2006 to June 2011 were analyzed and clefts compared between sides and genders using the Fisher exact test. A total of 2197 cases were identified during the study period, with an estimated prevalence rate of 0.5 per 1000. Of the total number of orofacial clefts, 54.4% occur in males and 45.6% in females. There was a significant difference (P=.0001) between unilateral left clefts and unilateral right clefts, and there was a significant difference (P=.0001) between bilateral clefts and clefts on either the left or right side. A significant gender difference (P=.03) was also observed for cleft palate, with more females than males. A total of 103 (4.7%) associated anomalies were identified. There were nine syndromic cleft cases, and 10.4% of the total number of individuals with clefts have an affected relative. The significant difference between unilateral clefts and the gender differences in the proportion of cleft palate only are consistent with the literature. The present study emphasizes the need for birth defects registries in developing countries in order to estimate the exact prevalence of birth defects including orofacial clefts.

Cleft deformities in adults and children aged over six years in Nigeria: Reasons for late presentation and management challenges

In developing countries, untreated cleft lips and palates are found with increasing frequency and patients often present to the surgeon far past the optimal time for closure of the cleft deformities. A prospective study was conducted between March 2007 and September 2009, to identify the reasons and treatment challenges of delayed presentation of cleft lip and palate deformities at the Lagos University Teaching Hospital, Nigeria. Out of a total of 150 patients with cleft defects during the period, 43 (28.7%) were adults and children aged over six years. The mean age of these patients at the time of presentation was 17.3 years. The most common reasons for late presentation were lack of money (56.7%), lack of health care services nearby (18.4%), and lack of awareness of treatment availability (13.3%). Common challenges in these patients included surgical, orthodontic, speech, anesthetic, and psychological. Although adult clefts were significantly enlarged in three dimensions the anatomic landmarks were easier to discern than in an infant. However, extensive soft tissue dissection in adult cleft lip repair resulted in significant postoperative edema. Closure of wide palatal cleft often required the use of adjunct intraoral flaps. Despite late presentation, surgical outcome of these patients was satisfactory and comparable to cleft repair in infants.

Prevalence and bacteriology of bacteremia associated with cleft lip and palate surgery.

AbstractThe aim of the study was to determine the prevalence and bacteriology of bacteremia associated with cleft lip and palate (CLP) surgery. Three venous blood samples were obtained from 90 eligible subjects who presented for CLP surgery: before surgical incision, 1 minute after placement of the last suture, and 15 minutes thereafter. The samples were injected into an Oxoid Signal blood culture and transported to the laboratory for gram-positive/negative and aerobic/anaerobic bacteria analysis. Prevalence of bacteremia associated with cleft surgery was 38.1%. Prevalence rates of bacteremia in cleft lip surgery, cleft palate surgery, and alveoloplasty were 40.9%, 33.3%, and 50%, respectively. There was no significant difference in prevalence rate of positive blood culture in cleft lip surgery, cleft palate surgery, and alveoloplasty (P = 0.69). Positive blood culture was detected most frequently (47%) 1 minute after placement of the last suture. Of the 23 subjects who had positive blood culture at 1 minute, bacteremia persisted in 8 (35%) of them after 15 minutes. The most common bacteria isolated were coagulase-negative staphylococcus, Acinetobacter lwoffii, and coagulase-positive Staphylococcus aureus. Sex and age of the subjects, duration of surgery, blood loss, and type of cleft surgery were not significantly associated with positive blood culture. Bacteremia associated with CLP surgery is polymicrobial and persisted for at least 15 minutes after surgery in 35% of cases. This may reinforce the need for prophylactic antibiotics to protect at-risk patients from developing focal infection of the heart by oral flora.

Distal cervical caries in second molars associated with impacted mandibular third molars: a case-control study

OBJECTIVE: This study compares the incidence of cervical caries in the mandibular second molar associated with impacted third molar with that of fully erupted third molar. STUDY DESIGN: The participants consisted of subjects with second molar adjacent to an impacted third molar (study group), and subject with second molar adjacent to a fully erupted third molar (control group). Incidence of cervical caries on the second molar and other variables were recorded and analyzed for both groups. RESULTS: The incidence of distal cervical caries in the study group was 15.7% and no case of distal cervical caries was seen in the control (P = .000). DMF score in study group was significantly lower than in control (P = .000). The incidence of distal cervical caries increased with age of subjects and DMF scores (P ≤ .05). CONCLUSIONS: Distal cervical caries in second molars is a phenomenon limited only to impacted mandibular third molars.

An evaluation of surgical outcome of bilateral cleft lip surgery using a modified Millard's (Fork Flap) technique

Background: The central third of the face is distorted by the bilateral cleft of the lip and palate and restoring the normal facial form is one of the primary goals for the reconstructive surgeons. The history of bilateral cleft lip repair has evolved from discarding the premaxilla and prolabium and approximating the lateral lip elements to a definitive lip and primary cleft nasal repair utilising the underlying musculature. The aim of this study was to review surgical outcome of bilateral cleft lip surgery (BCLS) done at the Lagos University Teaching Hospital. Materials and Methods: A review of all cases of BCLS done between January 2007 and December 2012 at the Lagos University Teaching Hospital was done. Data analysis included age and sex of patients, type of cleft deformity and type of surgery (primary or secondary) and whether the cleft deformity was syndromic and non-syndromic. Techniques of repair, surgical outcome and complications were also recorded. Results: A total of 39 cases of BCLS involving 21 males and 18 females were done during the period. This constituted 10% (39/390) of all cases of cleft surgery done during the period. There were 5 syndromic and 34 non-syndromic cases. Age of patients at time of surgery ranged between 3 months and 32 years. There were 24 bilateral cleft lip and palate deformities and 15 bilateral cleft lip deformities. Thirty-one of the cases were primary surgery, while 8 were secondary (revision) surgery. The most common surgical technique employed was modified Fork flap (Millard) technique, which was employed in 37 (95%) cases. Conclusion: Bilateral cleft lip deformity is a common cleft deformity seen in clinical practice, surgical repair of which can be a challenge to an experienced surgeon. A modified Fork flap technique for repair of bilateral cleft lip is a reliable and versatile technique associated with excellent surgical outcome.

Pattern of presentation and management of lip injuries in a Nigerian hospital.

AIMnHuman lip injuries, although uncommon, present major challenges in terms of reconstructive options and the outcome of surgical management. The reconstructive techniques are usually varied but the ultimate objectives of treatment are to achieve healing, function, and aesthetics. The aim of this study was to report the etiology, pattern of presentation, and surgical management of lip injuries in Lagos University Teaching Hospital (LUTH).nnnMATERIALS AND METHODSnA prospective study of consecutive cases of lip injury was conducted at the Oral and Maxillofacial Surgery Clinic of the Lagos University Teaching Hospital. Data collected included age and sex of patients, etiology, pattern of presentation, and surgical techniques of repair.nnnRESULTSnA total of 13 patients with lip injury to the lip were included in the study (M = 6, F = 7). Human bite (11 cases) was the most common cause of injury followed by electric burns (2 cases). The most (81.8%) frequently affected site was the lower lip. Most patients presented within 72 hours after injury with infected wound. Treatment offered included thorough debridement and primary repair using various surgical techniques. A one-stage surgical technique was employed in all cases. Healing was uneventful in all cases and satisfactory.nnnCONCLUSIONnMost of the lip injuries in the present study were due to human bites with almost equal sex distribution. Lower lip was most commonly affected. All cases were successfully treated by debridement, broad spectrum antibiotic coverage, and one-stage surgical repair with a favorable outcome.

Orofacial injuries associated with eclampsia in patients presenting at a Nigerian Tertiary Hospital.

A prospective study was conducted to determine the incidence and pattern of orofacial injuries among eclamptic patients at the Lagos State University Teaching Hospital between December 2008 and November 2009. The incidence of orofacial injuries was 42%. Most injuries were due to bite and forceful insertion of hard objects into the patients mouth by relatives during convulsive episodes. The type of antenatal care received had an influence on the incidence of orofacial injuries and there was a correlation between the number of convulsions and orofacial injuries. The mortality rate from eclampsia was 20.6%, and presence of orofacial injuries was a risk factor for mortality. Obstetricians and other healthcare providers should be familiar with the ways of preventing these injuries and seek early maxillofacial consultation when they occur. There is need for community education on the dangers of forceful insertion of hard objects into the mouth of eclamptics during fits.

Orofacial and dental injuries associated with seizures in paediatric patients in Lagos University Teaching Hospital

OBJECTIVEnTo determine the prevalence and pattern of presentation of orofacial and dental injuries in children with seizures at the Childrens Emergency Unit of the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria.nnnMETHODSnThis was a prospective study of children with febrile or non-febrile convulsion who presented at the Childrens Emergency Unit of LUTH between July 2008 and August 2009. The age, gender, type of convulsion and the presence/absence of orofacial and other bodily injuries were recorded in a proforma. Mechanism, type and classification of injury were recorded for patients with orofacial injuries.nnnRESULTSnA total of 257 children (148 males and 109 females) with febrile/non-febrile convulsion were included in the analysis. The mean age (SD) of patients was 32.8 ± 40.5 months. There were 223 (86.8%) cases of febrile convulsion and 34 (13.3%) cases of non-febrile convulsion. Thirteen children sustained orofacial injuries giving a prevalence of 5.1%. There was no significant difference in the prevalence of orofacial injury between patients with febrile convulsion (4.5%) and those with non-febrile convulsion (8.8%) (P=0.282). The most common cause of orofacial injuries was forceful insertion of hard object into the mouth during convulsive episodes. Twelve (92.3%) patients sustained soft tissue injury, while one sustained both soft and hard tissue injuries. The most common site of injury was the lip.nnnCONCLUSIONSnOro-facial and dental injuries may occur in children with seizures. It is therefore important that these injuries be looked for by the paediatrician and the dentist/oral and maxillofacial surgeons should be involved in managing these children.

Blood transfusion requirements in cleft lip surgery.

OBJECTIVEnCleft lip surgery is a common procedure performed by surgeons worldwide. The aim of the study was to determine blood transfusion requirements and factors influencing blood transfusion in cleft lip surgery.nnnMETHODSnTransfusion rate in 100 consecutive patients who had cleft lip surgery was prospectively evaluated at the Lagos University Teaching Hospital, Nigeria. Data collected included age and sex of patients, type of cleft defects, type of surgery done, preoperative haematocrit, duration of surgery, amount of blood loss during surgery, the number of units of blood cross-matched and those used. Cardiovascular parameters at the point of transfusion were also recorded. Each patient was made to donate a unit of homologous blood prior to surgery.nnnRESULTSnMean estimated blood loss during surgery was 26.5 ± 47.1 ml. Most patients (92%) lost between 2 and 50 ml of blood. Mean estimated blood loss in unilateral cleft lip surgery was not significantly differently from that of bilateral cleft lip surgery (P=0.46). Only five patients (5%) required blood transfusion. The mean blood transfused was 50.0 ± 16.9 ml. All the patients transfused had a preoperative haematocrit of <30% (23-27%). The cross-match-to-transfusion ratio for cleft surgery was 20. The transfusion index was 0.05 and overall blood-ordering quotient was 20.nnnCONCLUSIONnCleft lip surgery is a low volume blood loss surgery. Homologous blood donation prior to cleft lip surgery in patients with preoperative haematocrit of 30% or more is not necessary. For patients with preoperative haematocrit of less than 30%, type and screen of donated blood should be adequate.

A comparative study of immediate wound healing complications following cleft lip repair using either absorbable or non-absorbable skin sutures

Objectives The aim of the study was to compare wound healing complications following the use of either absorbable or non-absorbable sutures for skin closure in cleft lip repair. Materials and Methods This was a randomized controlled trial conducted at the Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Idi Araba, Lagos State, Nigeria. Sixty subjects who required either primary or secondary cleft lip repair and satisfied all the inclusion criteria were recruited and randomized into two groups (Vicryl group or Nylon group). The surgical wounds in all subjects were examined on 3rd, 7th, and 14th postoperative days (POD) for presence or absence of tissue reactivity, wound dehiscence, and local wound infection. Results Hemorrhage, tissue reactivity, wound dehiscence, and local wound infection were identified as wound healing complications following cleft lip repair. The incidence of postoperative wound healing complications on POD3 was 33.3%. Tissue reactivity was more common throughout the evaluation period with the use of an absorbable (Vicryl) suture compared to a non-absorbable (Nylon) suture, although the difference was statistically significant only on POD7 (P=0.002). There were no significant differences in the incidences of wound dehiscence and infection between the two groups throughout the observation period. Conclusion There were no statistically significant differences in the incidences of wound dehiscence and surgical site wound infection following the use of either Vicryl or Nylon for skin closure during cleft lip repair. However, more cases of tissue reactivity were recorded in the Vicryl group than in the Nylon group on POD7. Particular attention must be paid to detect the occurrence of wound healing complications, most especially tissue reactivity, whenever a Vicryl suture is used for skin closure in cleft lip repair.