Multifaceted approach for treatment of Cleft Lip and Palate

Cleft lip and palate represent a major public health problem due to the possible associated life-long morbidity, complex etiology, and the extensive multidisciplinary commitment required for intervention. It affects about 1.5 per 1000 live births (250,000 new cases per year) worldwide, with tremendous variations across geographic areas and ethnic groups. It is considered a debilitating condition that is associated with significant feeding, hearing, speech, and psychological impairments. In this review, the epidemiology, and varied treatment protocols of cleft lip are discussed. The primary goals of surgical repair are to restore normal function, speech development, and facial esthetics. Different techniques are employed based on surgeon expertise and the unique patient presentations. Pre-surgical orthopedics are frequently employed prior to definitive repair to improve outcomes. The wide surgical, dental, speech, social, and medical involvement emphasize the importance of understanding the underlying determinants of these defects to allow optimizing the treatment options and predicting the long-term course of the affected individuals development. Optimal and early surgical intervention is necessary and folic acid supplementation proved to be a highly efficient preventive strategy. However, there are still many challenges to be addressed for cleft care especially in the developing parts of the world. Introduction The aesthetics of facial structure are used by humans to measure one's beauty, character, and overall “goodness.” Individuals born with cleft lip and/or palate are often stigmatized and face much psychosocial adversity. Social attitudes and beliefs have a direct impact upon the psychological development of these individuals. Orofacial clefts include a range of congenital deformities most commonly presenting as cleft lip with or without cleft palate (CLP) or isolated cleft palate. Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. Cleft lip and cleft palate are among the most common congenital malformations. Immediately after birth, individuals with cleft lip and palate (CLP) have facial deformation, feeding problems, and recurrent middle ear infection. The broad categories into which the presentations of CLP may be placed are incomplete cleft lip, cleft lip alone, cleft lip and alveolus, cleft lip and palate,isolated cleft palate, and minimal expressions of the defect such as bifid uvula and submucous cleft. The midline cleft is an extremely rare presentation. No single system of classification of CLP has been universally accepted, and thus, none is universally used. Clinicians often resort to descriptive terms and drawings to provide the specificity required in individual cases. Various efforts have been made to understand the etiology of CLP so as to predict its occurrence and to prevent it. In recent years, advances in genetics and molecular biology have begun to reveal the basis of craniofacial development, and a number of genes associated with CLP have been identified. An increasing number of studies are being done on the combined genetic and environmental causes of CLP. Treatment requires interventions from multiple disciplines. At the age of speech acquisition, speech therapy is often needed to correct problems resulting from muscular defects of the cleft. As the individual continues to grow, defects in tooth development and malocclusion require dental and sometimes surgical treatment. The lengthy series of treatments from birth to adulthood is a heavy burden for the patient, family, and society. This article provides an update on the multidisciplinary treatment approach for orofacial clefts. Incidence and Epidemiology Cleft lip and palate are among the most common of all congenital deformities, and the incidence appears to be slowly rising. The best data comes from Denmark, where the incidence rose from 1.45/1000 live births in 1942 to 1.89/1000 live births in 1981. This increasing incidence may in part be due to better reporting, but there is likely to be true increase, perhaps because of an increase in environmental teratogens, lower neonatal mortality and increased marriage and child bearing among cleft patients, due to better care. Nevertheless, information is available which shows that there are significant racial differences in incidence. Clefts of the lip and palate are most common in American Indians (3.7/1000 live births), then, in decreasing order of frequency, Japanese (2.7/1000), Maoris and Chinese (2.0/1000), Caucasians (1.7/1000) and blacks (0.4/1000). Although organized epidemiological surveys to evaluate the incidence of cleft lip and palate in India are yet to be carried out, more than two dozen studies have been done on new borns in the past 3 decades for Ashutosh et al. Multifaceted approach for treatment of Cleft Lip and Palate Indian Journal of Orthodontics and Dentofacial Research, April–June 2016;2(2):62-69 63 evaluating the incidence/prevalence of congenital malformations in them (including cleft lip and palate). According to roughest estimates, about 30,000 children afflicted with cleft lip and palate anomaly are born every year in India. Much of the data from India come from relatively small local hospital-based studies recording the prevalence of birth defects including Oral clefts. While the majority of these studies record figures for CL/P, many do no record isolated CP. Of those that do, the lowest figure, 0.32/1000, comes from a study by Singh and Sharma (1980) in New Delhi. The highest figure, 0.48/1000, comes from a small study in Kanpur by Mital and Grewal (1969). While a meta-analysis was carried out by Verma and Mathews (1983), this was methodologically flawed and included various prospective and retrospective studies of live births and stillbirths throughout India. However, the figures of 1.20/1000 for CL/P and 0.44/1000 for CP appear to be the best available estimates for Oral Cleft prevalence in the Indian subcontinent. Management of Cleft Lip and Palate3 Management of the cleft lip and/or cleft palate (CL/CP) patient is a process that starts in infancy and continues on into adulthood. Problems encountered in the CL/CP patient are complex and therefore best managed through a team of experts. The approach of the patient with cleft lip and palate is multidisciplinary, and the cleft team should be ideally composed by craniofacial surgeons, otolaryngologists, geneticists, anesthesiologists, speech-language pathologists, nutritionists, orthodontists, prosthodontists, and psychologists, and to be capable of treating even rare facial clefts with excellence, neurosurgeons, and ophthalmologists (Table 1). In this manner, it is possible to provide long-term follow up through the entire child’s development and achieve all of the following treatment goals: normalized facial aesthetic, integrity of the primary and secondary palate, normal speech and hearing, airway patency, class I occlusion with normal masticatory function, good dental and periodontal health, and normal psychosocial development. Table 1: Multi-Disciplinary Team for Cleft Lip and Palate Patients S. No. Experts Involved Role 1 Obstetrician Refers to plastic surgeon and pediatrician counseling the parents