Evaluation of Early Stage Cleft Lip and Palate Using 3D-Ultral Sonography Screening Evaluation of Early Lip Palate Using Screening.

Congenital cleft lip palate occurs heterogeneously worldwide. Out of the one-hundred and thirty million newborns worldwide, 3.6 million identified with a disability, 7.6 million (approximately 5.8%) being born with a congenital anomaly. Additionally, 7.5% of them are registered with having cleft lip palate. In Mongolia, the statistics from the Mongolia Health Department reported that in 2012 cleft lip palate occurred among 1 out of 1072 individuals in Mongolia [1]. Over the years, there have been many measures taken to ameliorate these issues around the world. Recently, the sophisticated three-dimensional ultra-sonography equipment is evaluable in pediatric science. Thanks to this equipment, we are able to detect the orofacial defects and diagnose infants properly in advance. The purpose of this study is to evaluate the lip and palate of a fetus by using three-dimensional ul-tra-sonography in the second and third trimester of gestational period. Our research aims to detect fetus defects in the early stage of birth and diagnose it in advance [9]. Due to the lack of research on the above-mentioned issues in Mongolia, we decided to conduct this research by using three-dimensional ultra-sonography to detect and diagnose congenital cleft lip palate. By doing this research, we will be able to better assist those suffering from congenital malformation in Mongolia.


Introduction
Out of the one-hundred and thirty million newborns worldwide, 7.6 million (approximately 5.8%) are born with a congenital anomaly. Of those new born, vance [8]. Due to the lack of research on the above-mentioned issues in Mongolia, we decided to conduct this research by using three-dimensional ultra-sonography to detect and diagnose congenital cleft lip palate. By doing this research, we will be able to better assist those suffering from congenital malformation in Mongolia.

Aim of Study
The purpose of this study is to evaluate the lip and palate of a fetus by using three-dimensional ultra-sonography in the second and third trimester of gestational period.
Objective of Study • Understand the micro and macro structure indicators of the cleft of the fetus during the second and third trimester of the gestational period and compare it with sample cleft indicators by using the three-dimensional ultra-sonography.
• To study the micro and macro structure indicators of the palate of the fetus during the second and third trimester of gestational period and compare it with sample palate indicators by using the three-dimensional ultra-sonography.
• To study the specific structure and development of cleft and palate.

Practical Significance of Study
The significance of this researcher is to detect congenital cleft lip and palate in the early stage, evaluate the development of lips and palate and determine morphometry indicator of lip and palate of the fetus. Based on previous studies, we understand that the muscular epithelium fiber of the upper lip grows toward the lateral process within 20 weeks and creates muscular complex. If an infant is diagnosed with malformed clefts before 20 weeks during gestational period, a fetal surgical operation must be performed in order for the infant to recover without any scars.

Methodology
This research was conducted using an epidemiological analytical case-sectional method from the Biomedical University of Mongolian National University of Medical Science (MNUMS).The study includes a total of 34 fetal cadavers between 15.3 -40 weeks of age. We received the fetal cadaver from the Maternity and Infant hospital in Ulaanbaatar, Mongolia on November 28 th , 2013 post our approval from the ethic committee. The cadaver samples were stored at the Biomedical University MNUMS. The cause of death of these cadavers was due to non-malformation causes, there were no anomalies related to the development of lips and palate. In addition, 128 fetuses between weeks 19 -32 were involved in this study in order to detect the characteristics of lips and palate using a Open Journal of Applied Sciences Three-dimensional ultra-sonography. The cadavars were examined between the time our research received approval (November 28 th , 2013) until the end time of our research (May 2014) at the Tod Delgetse Gynaecological Hospital in Ulaanbaatar, Mongolia. Only cadavers who were in between a 24-hour period post death were included in this study, if the cadaver had passed the 24-hour period and show a sign of body decae, they were excluded from the study. The research participants were selected using a randomized spot check method. This research was conducted and assessed using the following research methods: fetometric measurement, morphometric measurement, histological method and conclusion method.

Data collection
Before conducting our research, data was collected on pregnant women from Tod-Delgets Hospital (Clear Screening Hospital). The hospital is a private hospital located in Ulaanbaatar, Mongolia. Based on the data collected, we selected a total of 218 pregnant women based on the following criteria: women in the second trimester (19 -22 weeks) and third trimester (weeks 29 -30), women giving birth to one child and pregnant women without any diseases. In order to study the structures of lips and palate of 34 cadavers, a total of 102 medicinal preparations were made by micro-morphometric and histological measurements. The measurement of lips and palate were conducted using Accuvix A 30 ultrasonic devices and a three-dimensional ultra-sonography device at Samsung Medicine Company in Ulaanbaatar, Mongolia. The Accuvix A 30 ultrasonic devices had a frequency range of 6 MHZ and was used to detect defected cleft lips and palate. These liner devices were used to detect malformation of lips and palate. During the study we detected congenital malformations which showed an excess fluid in the fetus and others with a lack of fluid. Statistical data was analyzed using SPSS 20 statistical program.

Insert Method
Cadavers who did not die of non-malformations of digestive system and other disorders (later morning sickness, disorders of maternal organ) the above-mentioned disorders are allowed to participate in the research for fetus chronic oxygen deficiency and placental disorders. The autopsy of the cadaver was used within 24 hours. There were no element changes in the structure of lips and palate by the analysis of autopsy.
Subtraction Method -We are not allowed to conduct research on the below mentioned cadavers such as: -Cadavers with orofacial defects and defects of digestive system. We didn't use the deteriorated autopsy (after 24 hours) Gazette Formula In order to detect the duration of gestation period, we used the Gazette formula according to Käferstein F, Abdussalam M (1999) [9]. If the fetus length is 25 cm, the square root is valuable. If the fetus length will be 25 cm or the length is divided into 5. The length of body is multiplied by 5.6 and divided by 28 [10].

Voltage Formula
The sample of the study was estimated by the approximate accuracy (R) avtandilob method out of which 50% had an error, 90% had a probability. The accreditation criteria were 2.0 (t). In case of reference, quantities 16 unit of materials were used [11] ( The biparietal diameter should be measured on an axial plane that traverses the thalamus, cavum septum and pellucidin. The calipers should be placed at the outer edges near the calvarial, near the inner edges of the clavarial wall.
Fetal head circumference AS depicted in Picture 2 the fetal head circumference incised size was measured from the outer head circumstance.

Abdominal Circumference
After identifying the location and position of the fetus, the oval shaped amphalic artery was located at 1/3 space from the anterior of the abdominal wall. As soon as the "Picture 3" of the stomach was visible, we detected and identified the anterior and posterior oblique transvers size and the abdominal circumference was measured.

Length of femoral bone
The femoral bone was measured using a straight line depicted in "Picture 4", the upper and lower edges of mappings were identified.

Length of palate
The length of the fetus palate is measured from the incision of the foramen to the uvula using a straight line. Picture 5 below depicts the measurement of the palate.

Width of palate
The width of the fetus palate is measured from the right corner of the jaw to the left corner of the jaw. "Picture 6" depicts the measurement procedures.

Height of upper lip
The height of the upper lip as shown in "Picture 7" was measured along the sagittal plane from the median nasal septum to the edge of the front lip.

Fetometric Measurement
In order to conduct a Fetometric measurement, we first gathered general information on the fetus. The following information was recorder on the fetus's registration file: fetus height, weight, age, sex, number of samples taken and samples dates. The fetus weight was measured using an electronic weigh of JW-1. Open Journal of Applied Sciences The height of the fetus was measured in a vertical position (form head to toe) using a narrow tape divided into millimeter. The purpose of this measurement is to assess the fetus's weight.

Anthropometrics Measurement
Anthropometrics measurements are measured on cadavers using an iron ruler and compass non-stretchable belt which was precisely divided into millimeters.
We used body length, height, head circumference and thoracic circumference in order to determine to measurement of the abdominal circumference of the cadavers. The cadaver's height was measured horizontally between the top of the head to the bottom of the feet. According to the standard of anthropometric measurement, we used calipers, an iron ruled, a non-elastic thin tape to measure the size, length, height, head circumference, chest circumference, and abdominal circumference of the cadaver. The circumference of the head was measured from the protruding forehead to the chest using a non-elastic tape. The tape was wrapped around the axillary bone and to the above the umbilical cord measuring the abdominal circumference [12].

Inference Method
The fetus was placed into 10% -12% of formula solution for 14 -21 days in order to prepare for strengthening of the cadaver. After this method has been approved by the staff at the anatomy department, we began our experiment once the cadaver was ready to be performed on as shown in "Picture 8". Before measuring the lips and palate, the cadavers were washed properly with flowing water.

Morphometric Measurement
According to the (L.G. Farkas) method of morphometric measurement, we used a compass and an iron ruler in millimeter scale to measure lips and palate [13]. Our measurement were recorded using the following labels:  [11]. The nucleus was painted blue and histological plasma was painted pink.

Results
When measuring the height of the upper lip of fetus in the second trimester, our measurement depicted in Table 2 shows the height of the upper lip was 6.0 ± 0.6 mm in the second trimester. In the third trimester, the height of the upper lip measurement had a result of 9.4 ± 1.0 mm. On the other hand, when we assessed the measurement of the upper lip based on gender we concluded to the following results; we measured a height of 6.0 ± 0.6 mm for male and 5.9 ± 0.7 mm for female in the second trimester and 9.4 ± 1.0 mm for male and 9.5 ± 0.9 mm for female fetus in the third trimester. In addition, there was no statistical significant difference that was observed between the male and female fetus. Therefore, comparing the second and third trimester, we concluded that there is not distinction of height of upper lip based on gender (Table 3). Open Journal of Applied Sciences Based on our evaluation, the size of upper lip prevalence was distributed equally between the second and third trimester ( Figure 1). Based on our results, we estimated precisely that the length of the fetal palate was evenly distributed between the second and third trimester ( Figure 2). Table 6 and Table 7 indicate the width of fetal palate based on age and gender groups. Based on our findings, the measurement of the width of the fetal palate was recorded as 13.2 ± 1.5 mm in the second trimester and 24.4 ± 2.9 mm in the third trimester. Based on our gender estimation, our results indicate the following 13.3 ± 1.4 mm for male and 13.2 ± 1.5 for female in the second trimester. As for the third trimester, the results state 24.4 ± 2.9 mm for male and 24.5 ± 3.0 mm for female in the third trimester. We did not identify any statistical significant differences when comparing the width of the fetal palate between the second and their trimester.
We examined the details of the width of the fetal palate prevalence by age. Our results show that the distribution of the prevalence was equal in both the second and third trimester (Figure 3).      in the third trimester. The results indicate that the width of philtrum was 4.6 ± 0.8 mm in the second trimester and 7.1 ± 1.2 mm in the third trimester. As for the length of philtrum, our results indicated that the length of the philter in the second trimester was 2.6 ± 0.8 mm and 3.6 ± 0.6 mm in the third trimester. Laterally, the length of upper lip was 4.7 ± 0.8 mm in the second trimester and 6.8 ± 1.5 mm in the third trimester. Looking at the height difference between the upper and lower lip, our results report 3.4 ± 0.4 mm in the second trimester and 4.4 ± 0.7 mm in the third trimester. Assessing the width of the mouth, our findings show the following measurement: 178.3 ± 3.8 in the second trimester and 191.3 ± 32 mm in the third trimester. As for the width of palate, we measured the palate to be 20.5 ± 2.5 mm in the second trimester and 35.6 ± 3.3 mm in the third trimester. Lastly, when observing the length of palate our measurements indicated, 17.4 ± 1.9 mm in the second trimester and 29.3 ± 3.5 mm in the third trimester.

Microstructure and macrostructure of fetal lips and palate
Microstructure of fetal lips and palate in the Second trimester We examined micro preparations on 8 fetal cadaver's hard and soft lips and palate in the second trimester ( Table 9).
The Keratinized Squamous epithelium of the skin in the upper lip resulted to 26.2 ± 5.0 in the second trimester and the non-keratinized squamous epithelium of the mucous membrane was 51 ± 12.3 mm. The muscular membrane 567.4 ± 31.1 mkm was 567.4 ± 31.1 mm. The lips and gland ratio were 73.2 ± 11.1 × 129 ± 19.1 mm. Table 10 looks at the micro structure of a hard palate, our results showed that the size of cartilage was 243.3 ± 37/2 mm, the palate gland ratio was 163.7 ± 11.3 × 168.8 ± 38.1 mm and the Non-Keratinized Squamous epithelium of hard palate skin was 33.8 ± 8.9 mm in the second trimester.
On the other hand, when observing the characteristics of micro-structure of soft palate in the Second Trimester (mkm), our results indicate the following: 589 ± 29.7 mkm muscular tunic, 113.2 ± 20.1 × 155.7 ± 23.6 mkm palate gland ratio, and 28.8 ± 5.0 mm Non-Keratinized Squamous epithelium of the soft palate in the second trimester (Table 11).
According to our study on the micro-structure of lip in 15.3 weeks during   gestation, our research reveals that the skin portion of the mucous membrane and the muscular tunic were clearly distinguishable. In contrast, the multiple layer of the squamous epithelium was not clearly distinguishable. In other words, the squamous epithelium had not developed completely and was therefore not depicted inoperative images. In addition, the non-keratinized stratified squamous epithelium of mucous membrane was also not perceived clearly. Nevertheless, it is evident that the formation and release of gland occur in the mucous membrane. This study was able to observe that the glands production and secretion portion is located in the palate of the mucous membrane. Furthermore, we found that the muscular tunic and muscular fibers were similarly not formed completely. In conclusion, our research implies that we observed a fragmented formation of the platelet on the micro-structure of lip in 15.3 weeks during gestation (Pictures 10-12).
When conducting research on the microstructure of a 20-week fetal's of lips, the mucous, skin, muscular membrane appear to be clearly visible. The five-multilayered keratinized stratified squamous epithelial tissue of lamina in the lip was the same as the borders of the lip, showing no clear visibility. In other words, their images were developed incompletely. On the other hand, the multilayered non-keratinized stratified squamous epithelial tissue structure of lip during 20-week period, was also the same as borders, it was not visible at 15.3-week gestational period. The muscular secretion and exceptional parts of the muscular secretion which is located in the lamina began developing during 20-week of gestational period. The fetal muscular membrane and muscular fibers were not developed. During 15.3 week of gestational period, we observed the development of separated continuous laminae. The muscular membrane and the muscular fiber of a fetal during 20-week period of gestation developed in the laminae and were jointed with each other around different parts of the lips. At 20-week gestational period, the upper lip process combined with its muscular fibers were thickened and rolled. The mucous membrane layer of the upper lip borders appeared clearly (Pictures 13-17).
On the other hand, looking at the microstructure of 26-weeks old fetal's lips, the mucous and muscular membrane were visible during this period. Whereas a fetal during 20-week fetal lips, the epithelial tissue of lamina and the multilayer keratinized stratified epithelial tissue layers were not visible at the 20-week period. In comparison to the 26 weeks, the mucous and muscular membrane were Open Journal of Applied Sciences   Based on our research conducted on a fetal during 40 weeks of gestational period, we found that the fetal skin, mucous and muscular membrane were visible.
Looking at fetal during week 20 of gestational period, the fetal lips, epithelial tis-

Conclusions
Based on the reserach, we conducted to better understand the micro and macro structure indicators of the cleft of the fetus during the second and third trimester images. In addition, the Non-Keratinized stratified squamous epithelium of mucous membrane was also not perceived clearly. Nevertheless, it is evident that the formation and release of gland occur in the mucous membrane. This study was able to observe that the glands production and secretion portion is located in the palate of the mucous membrane.
Week 20 When we conducted research on a 20-week fetal's microstructure of lips, the mucous, skin, muscular membrane appear to be clearly visible. Week 26 We conducted research on 26 weeks fetal microstructure of lips and sink mucous, and muscular membrane was visible during this period. Whereas the fetal during 20-week fetal lips, epithelial tissue of lamina, multilayer keratinized stratified epithelial tissue layers were not visible at the 20-week period. In comparison to the 26 weeks, the above-mentioned organs were visible while we conducted our research. When we took a look at the 26-week fetal lips mucous, multilayer non-keratinized stratified epithelial tissue structure compared to the 20-week fetal mucous membrane, multilayer non-keratinized stratified squamous tissue structure, the boarder layers were visible. We conducted research at 19 and 22 weeks of gestational period out of which 58 were males and 59 were females in the second trimesters. In the third trimester, 29 -32 weeks of gestational period out of which were 51 males and 50 females. During this gestational period, we conducted our research using a 3D ultra-sonography screening. In the second trimester, gestational period was 20.34 ± 0.77 weeks. In the third trimester, the gestational period was 30.84 ± 0.89 weeks.
Week 40 A 40-week fetal Non-Keratinized stratified squamous epithelial tissues boarder layers were more visible compared to Non-Keratinized stratified squamous epithelial tissue structure of a 26-week fetal.
The glands excretion which is located in the lamina of mucous membrane excreational and endocrinal portions were jointed completely and shows a positive development.
This image indicates the connection of muscular fibers without separation of a 26-week fetal muscular membrane compared to a 40-week fetal muscular membrane.
Overall, we found that the height of fetal upper lip was estimated to 6.0 ± 0.6 Open Journal of Applied Sciences mm in the second trimester, and in the third trimester it was estimated to 9.4 ± 1.0 mm. In both sexes: in female the fetal upper lip was estimated to 5.9 ± 0.7 mm in second trimester, in male it was 6.0 ± 0.6 mm also in second trimester.
For the third trimester: in female it was estimated to 9.5 ± 0.9 mm, in male it was 9.4 ± 1.0 mm. There was not any significant difference in measurement of upper lip by fetal sex. The length of palate in fetus was estimated to 16.7 ± 1.8 mm, and in the third trimester it was equal to 30.7 ± 2.1 mm. It compared by sex: in male it was estimated to 16.7 ± 1.8 mm, in female it was 16.6 ± 1.8 in the second trimester. However, the length was 30.5 ± 2.0 mm in male, and in female it was estimated to 30.9 ± 2.1 mm. In comparison of second and third trimester of fetal palate in terms of the length, there was not any significant difference.
1) The height of fetal upper lip in the second trimester was estimated to 5.9 ± 0.7 mm in female, and in male it was estimated to 6.0 ± 0.6 mm. For the third trimester: in female it was estimated to 9.5 ± 0.9 mm, in male it was 9.4 ± 1.0 mm. There was no significant difference in fetal sex.
2) The length of palate in fetus was estimated to 16.7 ± 1.8 mm in male, and in female it was 16.6 ± 1.8 mm in the second trimester. In the third trimester in male it was estimated to 30.5 ± 2.0 mm, in female it was equal to 30.9 ± 2.0 mm. There was no significant difference in both sexes.
3) The lift and palate are developed gradually and in 20 week of gestational period it forms and gets its adult shape, in micro anatomy. Particularly, in 20-week of gestation, the muscular layer at the fusion of processes were thickened fused with other muscular layer and formed the bundle of muscle tissue.