- Received July 11, 2023
- Accepted August 10, 2023
- Publication January 19, 2024
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- DOI 10.18231/j.ijodr.2023.044
-
CrossMark
- Citation
Protocols for management of cleft lip and palate around the world
- Author Details:
-
Sonia Chauhan *
Sonia Chauhan *
Introduction
The therapeutic approach for cleft lip and palate patient is multidisciplinary and the cleft team is composed by the craniofacial surgeon, otolarygeologist, geneticist, anesthesiologist, speech –language pathologist, nutritionist, orthodontists, prosthodonist, psychologist ,neurosurgeons, ophthalmologist. Patient with cleft lip and palate require a continued follow-up throughout their development in order to achieve desirable treatment goals like normal facial esthetics, airway patency, normal speech and hearing, normal masticatory function and normal psychosocial development.
Discussion
The handling of cleft lip and palate cases varies across different treatment centers around the world. There are different treatment protocols which are followed across the globe and are based on established data and facts regarding the treatment outcome followed by different centers. Various protocols which are followed across the world are enumerated below:
OSLO protocol [1], [2]
The early beginnings of Oslo’s team approach to the management of cleft patients can be traced to the early 1930s. at that time Granhaug Speech Therapy Institute provided a small amount of specialized care for patient with clefts repaired at the University hospital in Oslo and formed a link with the ENT department of the same institution.
In 1935 the prosthodontist, Arne Bohn initiated a collaboration with the speech therapists. Later Egil Harvold, the orthodontist joined the group in 1945. Finally Wilhelm Loennecken, one of the first two Norwegian plastic surgeons, returning from training in England in 1948 , settled in Oslo and virtually all children with clefts were subsequently referred either to him or to the other plastic surgeon in Bergen.
Following is the treatment protocol for unilateral cleft lip and palate according to the OSLO Cleft Team.(Department of Plastic Surgery, University Hospital of Oslo, Norway)([Table 1], [Table 2]) [1]
UCLP, 1953, 1961, 1968, 1977
|
Lip and hard palate |
Le Mesurier and Vomer Flap ( 6 months) |
Millard and Vomer flap (6 months) |
Millard and Vomer flap(3 months) |
|
Posterior Palate |
Von Langenbeck 3-4 years Gradually reduced |
Von langenkeck (18 months) |
Von Langenkeck (18 months) |
|
Alveolus |
|
Cancellous bone graft 8-11 years (initially and also in older subjects) |
Orthodontic intervention
|
Timing |
Procedure |
|
Neonatal-2 years |
No orthopedic or orthodontic treatment |
|
Mixed dentition |
Cross-bite correction, minor incisor position correction, maxillary expansion |
|
Permanent dentition |
Comprehensive orthodontic treatment |
Following is the treatment protocol for bilateral cleft lip and palate according to the OSLO Cleft Team:( Department of Plastic Surgery, University Hospital of Oslo, Norway) ([Table 3], [Table 4]) [2]
BCLP, 1953, 1962, 1974, 1997
|
Lip and hard palate |
One stage straight line and Vomer flap (6 months) |
Two stage straight line and Vomer flap (3 months) |
|
Posterior palate |
Von langenbeck 3-4 years gradually reduced |
Von langenbeck (18 months) |
|
Alveolus |
|
Cancellous bone graft 8-11 years (initially and in older subjects) |
|
Timing |
Procedure |
|
Neonatal-2 years |
No orthopedic or orthodontic treatment |
|
Mixed dentition |
Cross-bite correction, minor incisor position correction,maxillary expansion |
|
Permanent dentition |
Comprehensive orthodontic treatment |
Schweckendiek protocol(1951)[3]
In this technique the soft palate is closed during infancy by means of primary veloplasty. The residual cleft in the hard palate remains. Cleft becomes narrower with growth of the palate without causing compression of the jaw. Thus both articulation and maxillary growth remains undisturbed.
|
Procedure |
Timing |
|
Two stage repair |
Early the soft palate repair leaving the hard palate open Prosthetic rehabilitation of the fistula Hard Palate closure by 15 years |
Jolleys protocol (1954)[4]
According to Jolley when treating a patient with cleft it is difficult to decide which should be preserved whether function and appearance. In his opinion appearance could be sacrificed in order to preserve the function.
|
Procedure |
Timing |
|
Surgical correction of the muscle of the palate |
Shortly following birth. |
|
Repair of the lip |
Few weeks later |
|
Repair of cleft palate |
By 18 months using simplest technique |
|
Prosthesis for anterior cleft closure |
3 years |
|
Final repair of the hard palate |
5-10 years |
All India Institute of Medical Sciences, India cleft lip and palate protocol (1970) [5]
AIIMS located in South Delhi,India is an autonomous institute which is a tertiary care centre too. The combined cleft clinic was established in the orthodontic unit in the 1970’s.
|
Procedure |
Timing |
|
Palatal obturator /Feeding appliance |
0-1 year |
|
Primary cleft lip surgery |
3 months |
|
Palate repair |
9 months -1 year |
|
Tympanostomy |
6 months -1 year |
|
Speech therapy/ Pharyngoplasty |
3 years-6 years |
|
Bone grafting jaw |
9 years -11 years |
|
Orthodontics |
7 years -18 years |
|
Orthognathic Surgery and Rhinoplasty |
15years- 18 years |
The zurich approach (1976) [6]
The management of cleft lip and palate at Zurich University Dental Institute emphasized on the early orthopedics to take advantage of intrinsic growth potential which would allow the natural growth of maxillary segments to maximum extent.
|
Timing |
Procedure |
|
Feeding Plate (Soft and hard acrylic Resin) |
24-48 hours after birth |
|
Grinding the feeding plate |
Every 4-6 weeks |
|
Feeding plate to be replaced |
After 4-5 months |
|
Surgical closure of lips |
5-6 months |
|
Obturator |
10-12 months |
|
Velar closure for speech development |
18 months |
|
Speech |
3-8 years |
|
Hard Palate Closure |
6-8 years |
|
Interceptive Orthodontics |
7-9 years |
|
Orthodontic treatment |
11-15 years |
Bergen protocol (1977) [7]
The Bergen protocol is utilized since 1977 and is based on intermittent periods of active treatment followed by phases of fixed retention. The treatment procedures are coordinated between the Department of Plastic and Reconstructive Surgery, University Hospital of Bergen; the Cleft lip and Palate Center at the Department of Orthodontics and Facial Orthopedics, Faculty of Medicine and Dentistry, University of Bergen; and the Eikelund Center for Speech Pathology. This treatment is cost-effective and requires minimal patient cooperation.
Following is the treatment protocol for cleft lip and palate according to the Bergen Cleft Team: (Department of Plastic and Reconstructive Surgery, University Hospital of Bergen).
|
Procedure |
Timing |
|
Orthopedic intervention of maxilla |
0-3 months |
|
Closure of lip and anterior hard palate (Millard flap and single layer vomeroplasty) |
3 months |
|
Closure of soft palate and residual palatal clefts(von Langenbeck technique) |
12 months |
|
Interceptive orthopedics (Transverse expansion and protraction) |
6-7 years |
|
Alignment of maxillary incisors |
8-11 years |
|
Secondary Alveolar bone grafting |
12-16 years |
|
Conventional orthodontics in permanent dentition |
16-17 years (girls) |
|
Dental adjustment before orthognathic surgery for correcting major skeletal jaw discrepencies |
18-19 years (boys) |
Warsaw protocol (1980) [8]
Warsaw Institute of Mother and Child (IMC) proposes one stage approach of cleft treatment.
|
Procedure |
Timing |
|
Lip and soft and hard palate closure |
6-12 months |
|
Alveolr bone grafting |
8-12 years |
Malek & psaume protocol (1983 [9]
This technique is based on the concept that in complete cleft lip and palate the tongue has a tendency to fall into the naso pharyngeal region. Thus the tongue does not apply the required pressure on the maxillary segment.
|
Procedure |
Timing |
|
Use of orthodontic plate to prevent further closure of the cleft. |
2months |
|
Soft palate repair for better tongue position |
3 months |
|
Lip and hard palate repair |
6 months |
Denmark protocol (1990)[10]
Treatment of cleft patients in Denmark is centralised in two centers: for the eastern part of the country in Copenhagen and for the western part of the country in Aarhus.
|
Procedure |
Timing |
|
Lip repair (Tennison Procedure) and hard palate repair (Vomer plasty) |
10 weeks |
|
Palatoplasty (Push –back procedure) |
22 months |
|
Speech evaluation |
5 years |
|
Orthodontic procedure (maxillary expansion) |
Mixed dentition (6-12 years) |
|
Alveolar bone grafting (2°) |
Permanent dentition (12-16 years) |
Oxford cleft palate protocol (1996) [11]
The Oxford Cleft palate Study team assessed the cleft patient. The multidisciplinary assessment included: Speech, maxillofacial growth evaluation, palatal assessment and hearing status.
|
Procedure |
Timing |
|
Soft palate repair (early closure) 3 or 4 flap Wardill kilners procedure |
6-18 months |
|
Soft palate repair (late closure) Short Veau Flap |
6-22 months |
|
Hard palate repair (early closure) |
6-18 months |
|
Hard palate repair (late closure) –Vomer flap |
30-57 months |
Brazilian protocol (2003) [12]
This protocol based on a survey conducted on the Brazilian Society of Plastic Surgeons where surgeons work in co-ordination with the members of other departments to provide the best possible results for the patients.
|
Procedure |
Timing |
|
Lip repair |
After 3 months |
|
Palate repair |
18 months |
|
Alveolar bone grafts |
After 8 years |
|
Secondary operations |
After 15 years |
Protocol for cleft lip and palate in China (2009) [13]
This protocol for cleft lip and palate was deduced after carrying out a survey in 44 dental institutes through a questionnaire. The management of cleft patients involves oral and maxillofacial surgeons, plastic surgeons, pediatric surgeons, and otorhinolaryngologist, speech-language pathologists and orthodontists.
|
Procedure |
Timing |
|
Cleft lip repair |
3-6 months |
|
Cleft palate (Primary Repair) |
Before 3 years |
|
Alveolar cleft Repair |
9-11 years |
United states protocol (2009) [14]
The following protocol are followed by majority of the surgeons in the United States. Surgeons repair clefts in one stage by using Furlow palatoplasty and the Bardach style with intravelar veloplasty.
|
Procedure |
Timing |
|
One-stage repair techniques using Bardach style and the Furlow palatoplasty |
6 and 12 months of age |
|
Discharge uncomplicated cases |
After 48 hours ostoperative Management |
|
Resumption of breast-feeding |
Immediately after surgery |
|
Promote syringe or cup feeding |
Post surgery |
|
Avoid hard foods |
3 to 6 weeks after surgery |
|
Arm restraints |
For 2 weeks |
New York protocol (The Hansjo¨rg Wyss department of plastic surgery at New York University Medical Center 2018) [15]
This protocol usually emphasizes on the correction of nasal asymmetry which usually remains after the primary repair of the lip.
|
Procedure |
Timing |
|
Presurgical infant orthopedic (Naso Alveolar Moulding Terapy) |
1-2 months |
|
Lip repair using either Millard technique or Mohler modification along with primary rhinoplasty |
3 months |
|
2-flap palatoplasty |
11-24 months |
Clinical practice guidelines (Netherland) 2021 [16]
Clinical Practice Guidelines were formulated to give the standardized treatment to the patients of cleft lip and palate throughout Netherland. These guidelines were made to the Guidelines Advisory Committee of the Dutch Association of Medical Specialists’ Quality Council and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument which is widely accepted for assessing the quality of guidelines.
|
Procedure |
Timing |
|
Genetic testing |
Before the first operation |
|
a) Single nucleotide polymorphism array |
|
|
b) Whole-exome sequencing |
|
|
c) Gene pane |
|
|
Primary cleft lip surgery |
6 months |
|
Soft Palate repair |
Before 1 year |
|
Hard Palate ( If optimal speech is persued use Furlow or Von Langenbeck technique) |
Before 1 year |
|
Hard Palate ( If optimal growth of maxilla is persued use combination of techniques except for Furlow double opposing Z-plasty and Wardill–Kilner pushback technique. |
Repaired later than 1 year |
|
Periodic audiology check-ups |
3-4 years |
|
Velopharyngeal dysfunction |
After 6 months of Speech therapy |
|
Bone grafting |
2/3 rd root formation of canine on cleft side |
|
Orthodontics |
|
|
a) Severe midfacial deficiency |
Maxillary protraction |
|
b) Mild midfacial deficiency |
No Maxillary protraction |
|
Orthodontic retention |
Retainer through life. |
|
Orthognathic Surgery |
|
|
a) Small Sagittal discrepencies |
Le Fort 1 osteotomy or setback procedure |
|
b) Large sagittal discrepancies |
Distraction Osteogenesis |
|
Rhinoplasty |
Columella and caudal septum of nose should be positioned correctly during primary lip repair |
|
Secondary nasal surgeries |
To be done when midface growth is complete. |
Protocol for cleft palate in Japan (2022) [17]
The following protocol has been deduced after observing the treatment protocol at 3 cleft centers in Japan.
|
Procedure |
Timing |
|
Lip Repair |
3-6 months |
|
Soft Palate Repair |
12-18 month |
|
Hard Palate Repair |
5-8 years |
|
Alveolar Bone Grafting |
8-10 years |
Standard treatment guidelines 2022 (India) [18]
According to Indian Academy of Paedritics. There are six procedures in repair of CLP.
|
Procedure |
Timing |
|
Lip repair |
3 months |
|
Pal B ate Repair |
9 months |
|
Palatal Expansion |
5-7 years |
|
Alveolar Bone Grafting |
9 years |
|
Rhinoplasty |
After 13 years |
|
Scar revision of lip |
14- 16 years |
Conclusion
The management of cleft lip and palate varies among different countries around the globe. Treatment of cleft involves a multidisciplinary approach. The communication between the care giver and taker should be smooth at each level of treatment to maximize the benefit and minimize the apprehension regarding treatment. Different countries should collaborate and share their clinical experiences regarding the future in the management of cleft cases to enhance the skills related to different techniques thereby leading to best time management and enhancing the esthetic appearance and boosting the psychological morale of patients.
Source of Funding
None.
Conflict of Interest
None.
References
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- Introduction
- Discussion
- OSLO protocol [1], [2]
- Schweckendiek protocol(1951)[3]
- Jolleys protocol (1954)[4]
- All India Institute of Medical Sciences, India cleft lip and palate protocol (1970) [5]
- The zurich approach (1976) [6]
- Bergen protocol (1977) [7]
- Warsaw protocol (1980) [8]
- Malek & psaume protocol (1983 [9]
- Denmark protocol (1990)[10]
- Oxford cleft palate protocol (1996) [11]
- Brazilian protocol (2003) [12]
- Protocol for cleft lip and palate in China (2009) [13]
- United states protocol (2009) [14]
- New York protocol (The Hansjo¨rg Wyss department of plastic surgery at New York University Medical Center 2018) [15]
- Clinical practice guidelines (Netherland) 2021 [16]
- Protocol for cleft palate in Japan (2022) [17]
- Standard treatment guidelines 2022 (India) [18]
- Conclusion
- Source of Funding
- Conflict of Interest