The originator of cleft lip repair is recognized worldwide as a famous Chinese doctor from the Jin Dynasty (316 AD). The modern concept of treatment has been developed through the continuous improvement and understanding of the traditional single surgical procedure. A three-dimensional treatment model, including orthopedic-surgical-orthodontic-phonetic, was developed to restore normal anatomical and physiological functions. Thecleftlipandpalateteamapproach is a concept based on this model in order to achieve the desired therapeutic effect. Sequential treatment means treating the corresponding morphological, physical and psychological defects of the patient from birth to adulthood, with each stage of growth and development. It also means to use the most appropriate method to obtain the best results at the best time of treatment, forming the procedure. In short, the Cleft Lip and Palate Sequential Treatment is a well-established implementation system involving multidisciplinary specialists (TEAM) to treat patients with cleft lip and palate in a comprehensive manner, at the appropriate age of the patient and according to certain procedures.
The multidisciplinary specialists that make up the Team include maxillofacial surgeons, pediatricians, orthodontists, oral medicine, plastic surgeons, prosthodontists, otolaryngologists, orthognathic surgeons, speech pathologists, medical imaging specialists, nursing specialists, geneticists, psychologists, aesthetic medicine specialists, as well as social and public health workers.
Basic content
The sequential treatment of cleft lip and palate from morphology to function, from cleft to many complications caused by cleft, from patients to relatives, from clinical to social includes many contents, but the main basic contents should include seven aspects such as surgical treatment, orthopedic and orthodontic treatment, speech therapy, treatment of middle ear disorders and hearing loss, treatment of dental and periodontal diseases and psychological treatment its specific time is as follows.
1.Surgical treatment
(1) Cleft lip: At present, it is considered ideal to operate unilateral cleft lip at 3 months after birth and bilateral cleft lip at 6 months after birth, Millard’s rotary advancement method and Tennison’s lower triangular flap method are the most commonly used surgical methods for cleft lip.
(2) Cleft palate: The purpose of cleft palate surgery is to close the cleft and restore the normal anatomy of the palate necessary for speech. Early surgery (before 1-2 years of age) may affect the normal development of the jaws, yet ideally restore their phonological function; late surgery (3-5 years of age) affects development less, but the phonological outcome is not yet ideal. It is a common opinion that restoration of phonological function is the primary goal, and the jaw deformity caused by surgery can be corrected by orthodontic and orthognathic treatment. Therefore, it is advocated that cleft palate surgery be performed 8-18 months after birth, before the phonological function is well developed.
(3) Cleft alveolar process: Cleft alveolar process surgery is a combination of bone grafting and gingival flap repair of the cleft. (ii) To make permanent teeth erupt in normal position. ③ Eliminate the collapsed deformity of the lip and the base of the nose. ④Close the oro-nasal fistula.
(4) Cleft lip and nose deformity: the rectification of cleft lip and nose deformity is currently a hot spot of research for scholars at home and abroad. Because the damage to nasal cartilage and periosteum from early surgery can affect the development of nose, leading to growth disorder and distortion deformity. Therefore, surgery should be postponed until after the completion of nasal development at the age of 16 to 18. Some scholars also advocate simultaneous correction at the time of early cleft lip repair.
(5) Correction of jaw deformity
The purpose of orthognathic surgery is to correct the malformed jaws to improve the patient’s appearance, and the surgery is usually performed around the age of 16 to 18, but the psychological factors of the patient should be taken into consideration.
2.Orthodontic and orthopedic treatment
Orthopedic and orthodontic treatment is mainly to correct the malocclusion of the teeth and maxilla of cleft lip and palate patients, with the aim of restoring good occlusal function and improving facial appearance. Orthodontic and orthodontic treatment for cleft lip and palate is generally divided into four treatment stages: pre-eruption, milk teeth, mixed teeth and permanent teeth. The pre-eruption treatment is also called presurgicalorthopaedics, which can correct the misaligned jaws and induce the normal development of the jaws. Orthodontic treatment of the mastoid period is still controversial and may not be a routine part of serial treatment. The mixed dentition period is mainly for the correction of retrusion and traumatic coaptation. The permanent dentition is the final stage of orthodontic treatment for cleft lip and palate, and in principle there are no special differences in treatment with non-cleft individuals. It is usually started after the age of 12 and aims to restore functional occlusal balance and ideal cosmetic appearance.
3.Prosthetic treatment
Prosthetic treatment for cleft lip and palate includes prosthetic restoration to restore the integrity of the dentition, obstructive appliance restoration to eliminate orofacial fistula, and phonetic orthodontic appliance restoration to improve speech function.
Patients with cleft alveolus, the permanent tooth embryo in the cleft area is mostly missing, and if the gap is too large after orthodontic treatment, prosthetic restoration should be performed. The indications for obstructive appliance restoration mainly include: ① those who have difficulty in feeding early infants. (ii) Those who are in poor physical condition or whose cleft palate is too wide to be repaired surgically. (iii) Those who have failed palatoplasty and lack sufficient tissue for further repair.
After adulthood, those whose speech treatment effect is still unsatisfactory due to some factors can isolate the oral and nasal cavity with the help of speech orthosis and restore the opening and closing movement of the palate to improve the speech function.
4.Speech therapy
The restoration of speech function in cleft lip and palate patients is not only related to the complete postoperative palatopharyngeal closure, but also related to poor compensatory habits of the tongue and jaw during speech, the former of which needs to be solved by reoperation, while the latter needs to be corrected by speech training. Speech therapy efforts generally begin early. Before the child is half a year old, the speech pathologist gives the parents proper instruction on speech-related issues and jointly discusses the development of a training program to correct the child’s speech. Speech therapy is important throughout the preschool years, including evaluation, surgical treatment, diagnosis, testing of palatopharyngeal closure function, and speech training. Our department currently has a full-time phonetician who is engaged in voice training, mainly for children after January after cleft palate surgery, poor voice after correction of tongue tie shortening, and patients with unexplained poor voice.
5.Treatment of middle ear disorders and hearing loss
The high incidence of exudative otitis media and hearing loss in children with cleft palate is mainly related to the dysfunction of the eustachian tube. Long-term studies have shown that cleft palate repair can improve the function of the eustachian tube. The earlier the age of surgery, the lower the incidence of otitis media. Therefore, during the sequence of cleft lip and palate treatment, middle ear function should be checked frequently, and in case of exudative otitis media and hearing loss, specialist treatment should be sought from an otologist.
6.Treatment of teeth and periodontal disease
Due to the abnormal oral anatomy and low self-cleaning function of cleft lip and palate patients, the incidence of dental and periodontal diseases in cleft lip and palate patients is higher than that of normal people. In order to preserve the normal structure of dentition and periodontal tissue and prevent the occurrence of dentition and periodontal disease, it is necessary to implement appropriate preventive and therapeutic measures, including scaling, sulcus closure, general treatment of dental caries and periodontal disease and special treatment to restore the normal structure of the oral cavity.
7.Psychological treatment
Margrit believes that the psychological treatment of cleft lip and palate patients in childhood and adolescence and the psychological treatment of both parents in early childhood should be given sufficient attention in the sequential treatment of cleft lip and palate. The importance of psychotherapy in the cleft lip and palate sequence should be given adequate attention. Currently, there is no dedicated cleft lip and palate psychopathologist in China, therefore, the work of psychotherapy should be the responsibility of each Team member. The West China University of Medical Sciences Stomatology Hospital has initially established a pre- and post-operative psychological assessment and treatment team for cleft lip and palate, with specially trained and trained heart counselors, and initial promising results.