Cleft lip and palate is a common congenital malformation. The general incidence of cleft lip and palate in newborns is 1:600-1000.
There are many reasons for the developmental arrest of the mesodermal tissues in the early embryonic period, which can be summarized into two categories: genetic and environmental causes.
(1) Defects in morphology, function, and psychological and social behavior: morphological defects involve the lip, palate, nose, teeth and jaws, and functional defects include breathing, eating, swallowing, speech, and hearing.
(2) The treatment of these multifaceted deficits has a timing issue and changes with growth and development and medical intervention, and cannot be cured with a single treatment. These two characteristics determine the complexity of treatment. The treatment of a broad spectrum of morphological, functional and psychosocial abnormalities requires the involvement of multidisciplinary specialists and a phased and sequential approach.
Prior to the emergence of multidisciplinary teams, surgeons, speech-language pathologists, and dentists treated cleft lip and palate in a fragmented and independent manner, with cross-cutting treatment goals and specialists from one discipline often involved in unfamiliar disciplines. By the 1960s, well established cleft lip and palate treatment groups had been taught in developed countries and regions. With the establishment of a multidisciplinary group approach to chemotherapy, communication between experts in various fields increased, professional limitations decreased, a better understanding of the problem was achieved, and the level of treatment improved significantly. In China, the first national symposium on cleft lip and palate treatment was held in Dalian in 1993, and the participants reached a consensus on carrying out serial cleft lip and palate treatment, and gradually formed our serial treatment procedures.
There are various terms reflecting the current characteristics of vertical chronological and horizontal multidisciplinary participation in cleft lip and palate treatment, such as team, team approach, multidisciplinary team care, etc.; in China, it is called “sequential treatment”. Literally, the word “sequence” can best reflect its essence. The word “sequence” means order and sequence, which means the sequence of time; the word “column” means column of ranks, which means multiple disciplines are involved in this case. The “sequence” is the organized work of each participating discipline according to the characteristics of different periods of cleft lip and palate. Each English term literally reflects only the meaning of multidisciplinary participation, but not the chronological content.
In foreign countries, the work of a team is usually carried out in a cleft lip and palate treatment center established on the basis of a pediatric department of a university hospital or a children’s hospital, with a relatively fixed number of members and a large number of participating disciplines. It is characterized by a combination of tangible and intangible treatment, with assessment and targeted treatment considering the overall physical and mental growth of the child, paying attention to counseling and education about cleft lip and palate only, and strengthening the psychological adjustment of the affected child and parents. At present, the development in China is very uneven, and some university-affiliated dental schools have established cleft lip and palate treatment centers, but in general, the “order” is well taught while the “column” is still lacking. Each medical unit has a more detailed schedule for surgery, orthodontics and treatment of ear disease for cleft lip, cleft palate, cleft alveolus, secondary deformities and jaw deformities, but pediatrics, genetics, nursing, psychology and other disciplines are rarely involved. On the other hand, many hospitals engaged in the treatment of cleft lip and palate can only perform one or two procedures and cannot yet talk about sequential treatment. There are two main factors that limit and affect the high level of treatment. One is the economic and cultural factor. The incidence of cleft lip and palate in China is higher in rural than in urban areas, and many patients cannot afford the cost of treatment, or even carry the disability for life. Many patients just have cleft lip and cleft palate surgery and call it a day. There are also patients whose parents do not know or understand the meaning and content of comprehensive treatment. Secondly, there are not enough technical forces engaged in specialized medical treatment. There are many patients with cleft lip and palate in China, which are widely distributed, and the number of physicians who can engage in high-level treatment is relatively insufficient. A considerable number of physicians who do cleft lip and palate treatment work do not have a high enough theoretical and technical level, only know what they know but do not know why, or the technical operation is rough. In some remote areas, there are still people who are not qualified to perform surgery at all. There was also an incident two years ago in the northwest where the anterior maxillary prominence of a patient with bilateral cleft lip was removed, leaving the patient with permanent regrets.
The development of serial cleft lip and palate treatment and the continuous refinement of traditional treatment techniques are closely related to the renewal of modern health concepts. Both doctors and patients are no longer satisfied with simply closing the cleft; all abnormalities such as alveolar cleft, orofacial fistula, scarring, lip profile, nasal profile, dental and maxillofacial morphology, and speech are no longer tolerated. Even minor abnormalities can cause adverse psychological and social reactions in patients. The demand for more effective treatment is increasing and involves a wider range of disciplines. This is the driving force. Based on the original foundation, the sequential treatment of cleft lip and palate in China is bound to gradually become more standardized and rational.
2.Stage assessment and treatment focus
The division of treatment stages for children is not consistent among treatment centers, but it is similar. Here, there are seven age stages: fetus, newborn from birth to 4 weeks, infant from 1 to 12 months, toddler from 1 to 5 years, preschooler, school-age child from 5 to 13, adolescent from 13 to 18 years and adult from 18 years and above. Each stage has its own focus with changes in condition and treatment.
(1) Fetal stage
The main tasks in this stage are.
(i) Ultrasound identification of cleft lip and palate with associated malformations.
(ii) Counseling, advising and reassuring the parents of the child.
③Family education and support regarding fetal treatment options.
(iv) elective intrauterine repair surgery (this program is not yet ripe for implementation).
(2) Neonatal stage – birth to 4 weeks
The main tasks in this period are.
(i) Conducting the first evaluation.
(ii) Confirmation of combined malformations, especially with a precise knowledge of the maxillary alveolus.
③ Treatment of associated disorders.
④ promotion of near normal feeding and growth by providing a pacifier with a palatal obstruction device to assist the child’s feeding.
⑤ provide family education to support adaptation.
(6) discussing early planning for surgery and treatment.
(3) Infancy – 1 to 12 months
The work during this period is summarized as follows
(i) respiratory assessment.
(ii) feeding, growth and development assessment.
(iii) Identification of associated disorders and deformities.
④ Encouragement of physical enhancement.
⑤ providing information on etiology and risk of recurrence
⑥Promoting family adaptation to the affected child.
(vii) Ear and hearing assessment.
⑧ provide education on the impact of cleft palate on speech.
(ix) Initiation of speech-language assessment and early intervention.
(x) Initial cleft lip and palate repair surgery. (b) For anteriorly inclined premaxillae, preoperative support traction not only facilitates normal development of the alveolus, but also effectively reduces tension on both sides of the cleft lip and prevents cleft lip repair from splitting the incision after surgery.
(4) Toddlers and preschoolers – 1~5 years old
The work during this period is summarized as follows
(i) respiratory tract assessment.
(ii) Feeding, growth and development assessment.
(iii) Promotion of physical enhancement.
④Identification of cleft lip and palate related malformations and syndromes, as cleft lip and palate malformations are multi-locus genetic defects according to current relevant genetic investigations, so monitoring and evaluation are still needed.
⑤ Ear and hearing examination and treatment.
(vi) Evaluation of speech and language expansion and initiation of intervention therapy.
(vii) Continuation of surgical repair.
(viii) Continuation of dental evaluation and treatment.
(5) Early and late school-age children – 5 to 13 years old
The work in this period is summarized as follows.
(i) respiratory assessment.
(ii) Growth and developmental assessment.
(iii) Continued physical fitness enhancement.
④continued identification of cleft-related deformities and syndromes.
⑤ assessment of educational progress, including behavior and self-concept.
(vi) Ear and hearing evaluations.
(vii) phonological-linguistic evaluation, including palatopharyngeal function.
(viii) Surgical repair of secondary deformities, surgery to restore palatopharyngeal function, and alveolar implants. However, for those who use posterior pharyngeal wall flap surgery, the age needs to be controlled above 12 years.
(⑨) Occlusal evaluation and orthodontic treatment.
(6) Adolescents – 13 to 18 years old
The work in this period is summarized as follows
(i) respiratory evaluation.
(ii) Growth and development, especially height assessment.
(iii) Provision of information to the patient regarding the risk of recurrence.
④ identification of psychosocial issues related to independence, self-image and future occupation
(v) Assessment of persistent ear disorders and hearing deficits.
(vi) Speech-language assessment, including the patient’s desire for treatment.
(vii) Undertaking revision surgery for secondary deformities of the lip and nose and orthognathic surgery.
(viii) Continuing dental treatment, including dental implants and orthodontics.
(7) Adulthood – after 18 years of age
Adult patients may not receive the treatment they deserve due to financial problems or the belief that treatment has been completed. In fact, adults with cleft lip and palate may have problems that have arisen at all previous stages that were either not previously mentioned or not satisfactorily addressed, including unrepaired clefts, facial deformities, dental malformations, speech abnormalities, and hearing defects. Therefore all of the above mentioned treatment group services are needed, including syndromic evaluation. Based on previous treatment experience, the likelihood of speech rehabilitation in cleft palate patients over 6 years of age is 0. However, after our animal studies and improvements in surgical methods and longer periods of rehabilitation instruction, speech training, etc., good results have been achieved in the adult group. For this reason, the concept of sequential treatment of cleft lip and palate will be improved and updated in the future implementation and conclusion of our work.