Updated Evidence in Management of Cleft Lip and Palate: Simple Review Article
Sami Al Issa1*, Mohammed Majeed A Alwaily2, Enas Mubarak Al Hadi2, Ali Abdullah A Businnah2, Mohammed Ahmed Bin Hadi Alkadi2, Abdulaziz Ibrahim Alshehri2
1Department of Medical Burn Unit and Plastic Surgery, Security Forces Hospital Program, Riyadh, Saudi Arabia. 2College of Medicine, Najran University, Saudi Arabia.
The most common oro-facial congenital deformity reported in live newborns is a cleft of the lip, palate, or both. The objective of this study was to the updates in management, and outcomes of cases of cleft lip and/or palate. PubMed and EBSCO Information Services will be chosen as the search databases for the publications used within the study. Topics concerning the updates in management, and outcomes of cases of cleft lip and/or palate, published in English around the world. No software will be utilized to analyze the data. The anomaly is characterized by the lack of continuity of tissues creating the lip, alveolus, and soft and hard palate. The severity ranges from a small notch in the lip to an ample fissure extending into the roof of the mouth and nose. Cases of cleft lip or cleft palate (or both) will need care from a multidisciplinary team of authorities from a ‘cleft and craniofacial anomalies service’. If a cleft lip or palate was detected during pregnancy, it can also be mentioned to a cleft team before birth.
Keywords: Cleft lip, Cleft palate, Craniofacial team, Cleft lip and/or palate.
The most common oro-facial congenital deformity reported in live newborns is a cleft of the lip, palate, or both. Cleft lip and palate are widespread problems that affect more than 10 million people worldwide . Clefts of the face structures and/or clefts of the oral tissues, such as a hard palate, are a varied collection of malformations . According to reports, as the world's population grows and life expectancy rises, the number of people living with oro-facial clefts will rise dramatically . Orofacial clefts affect people of all races, genders, and socioeconomic classes, and they differ from country to country. Each of these cases necessitates many surgical operations and complicated medical treatments, and the patient, along with his or her family, frequently faces major psychological issues . Cleft lip and palate can be caused by a variety of factors. The majority of instances, however, are assumed to be caused by a link between hereditary predisposition and certain environmental chemicals, and it can also be caused by chromosomal abnormalities in persons born with genetic disorders, which affect 10 million people worldwide , whoever, Strong family history of cleft lip and palate, exposure to specific environmental elements such as smoke, alcohol, prescription medicines, and illegal drugs, consanguinity between parents, and mother's age at the birth time are all risk factors for cleft lip and palate .
The signs and symptoms of cleft rely on a range of factors and circumstances, including the cleft's shape and severity, in addition to whether it affects both the lip and the palate [7, 8]. Cleft lip and palate, with or without cleft palate is the second most prevalent birth deformity in the U.s, almost one in 940 births is affected, with cleft lip with or without cleft palate affecting one in every 1574 children . The exact number of oro-facial clefts as a result of a birth defect is unknown in Saudi Arabia. an absence of public polls on the issue and a recording system .
In a subsequent investigation, the researchers will illustrate the characteristics and frequency of non-syndromic estrogen cleft (NSOFC) and assess the effects of familial connection on NSOFC phenotype in three major Saudi cities. NSOFC was found in 1.07/1000 newborns in Riyadh and 1.17/1000 infants nationwide; cleft lip (CL) was 0.47/1000 infants, cleft lip and palate (CLP) was 0.42/1000 children, and cleft palate (CP) was 0.28/1000 infants. Cleft palate was found to be a unique predictor of association (p=0.047, hazard ratio: 2.5, 95% confidence interval: 1 to 6.46), more commonly in first consanguineous marriages .
A multidisciplinary team should handle kids with cleft lip and palate to provide the most optimal care possible (Bill, 2006). A complete diagnosis, treatment program, and follow-up should be provided by the management team. The cleft team often includes orthodontics, craniofacial surgeon, dermatologist, prosthodontist, a voice coaches, an audiologist (ENT experts), a psychologists, and a pediatricians . Repairing the birth defect (lip, palate, and nose), achieving natural speech, language, hearing, functional occlusion, and excellent dental health should all be therapeutic goals for a kid with cleft lip and palate. In addition, it had better improved psychological and developmental results . However, CLP patient management guidelines differ from one hospital to the next. Between 1996 and 2000, 194 different surgical methods for unilateral cleft alone were used, according to the Eurocleft study .
In many cleft clinics, the therapeutic program now includes pre-surgery osteopathic manipulation and nasoalveolar contouring. to improve the treatment result. Presurgicalorthopaedics reduces the tension on the reconstructed lip by appointing the maxillary alveolar segments. For cleft deformities, The Latham appliance is a pre-surgery orthopedic active device. Its lengthy repercussions are as follows: up for dispute. The appliance's major goal is to lessen the anatomic difficulty in cleft deformities in order to get a greater operative result. The device has been proven to be successful in extending and correcting the maxillary segment, retruding elongated premaxilla, aligning bilaterally alveolar ridge, lowering fistula rates, and reducing strain on surgical closures. However, its lengthy influence on maxillary development or occlusion has yet to be determined .
The purpose of the study was to update the care and results of lip and/or palate deformity patients.
MATERIALS AND METHODS
Information will be gathered between June 1 and June 30, 2022.
Because they are elevated sources, PubMed and EBSCO Information Services will be utilized as search databases for the papers used in the study. PubMed is one of the internet's biggest digital libraries, created by the National Center for Biotechnology Information (NCBI), a division of the United States National Library of Medicine. Issues covering management updates and results of lip and/or palate cases published in English throughout the world. The search terms categories were "Updated Management, Cases Results, lip and/or palate," and these would be utilized in combination. Each incorporated study's reference list will be examined for further supporting data. To confirm the veracity of the results, each member's results will be double-revised.
During the article selection process, studies and their findings will be double-reviewed to ensure that we enroll research that is relevant to the goal of our study and to avoid or eliminate inaccuracies in the results. The data will be analyzed without the use of any program. The information will be gathered using a specified form that includes (Author's name, year of publication, research kind, objective, and results).
The Causes of Cleft Lip and Palate
The origins of cleft lip and palate (or both) are unclear, while inherited (genetic) factors may play a modest influence in some cases. One in every three newborns born with a cleft lip or cleft palate might require the assistance of a relative who has the same or a comparable disease, an associated chromosome problem, or an associated genetic disorder. A parent whose been birth with a cleft lip or palate has a slight chance of passing the issue on to their kid. In the diagnosis of cleft lip, it must be differentiated from acute primary hepatitis stomatitis, aphthous ulcers, pemphigus, pemphigoid, and erosive lichen planus are among conditions that can occur .
Children who were born with a cleft lip and palate often breastfeed (or bottle-feed) effectively. Some newborns nurse better with the cleft facing upwards. The breast substance normally plugs the cleft space and enables effective suckling. Infants with cleft palates frequently struggle to generate enough suction to suck milk from the breast or formula. If a newborn does have a cleft lip and a cleft palate they may be unable talented to squeeze the breast or teat effectively enough to push milk from the breast or flask. Newborns with cleft palates frequently require specific bottles and teats to be given to feed successfully. For newborns with cleft lip and cleft palate, there are several bottles available, including the SpecialNeeds feeder, the Pigeon cleft palate teat and gentle squeeze bottle flask, and the Chu Chu teat with soft squeeze bottle flask .
Treatment of Cleft Lip
The three biggest concerns in newborns with a cleft lip are feeding problems, the risk of aspiration, and airway blockage .
The treatment of cleft lip and palate patients requires a longstanding commitment. Medicinal therapy will primarily pay more attention on the things resulting from all sorts of associated genetic problems, as well as dietary requirements. NAM can be used in the first several weeks to months of infancy with the guidance of an orthodontist. This includes designing an orthodontic appliance to shape a prognatic premaxillary area and alveolar processes to a better and desirable location. It will enables the displacement of the alveolar processes, medial movement of the alar region, and columellar length increment, this further allows simpler surgical correction of cleft lip and nasal cleft malformation in future. They all require need periodic orthodontist modifications . Lip taping is another treatment adjunct that can help reduce the severity/width of the cleft early on (Frequently performed on people with less obvious clefts) as well as lip adhesion (Approximate the border of the cleft lip without affecting the lip breakthrough or destroying the tissue necessary for permanent closure. This is often discarded in patients with wide clefts who are not NAM candidates due to social or geographic factors.) .
Involvement of surgical procedure for the first cleft lip is generally performed between the ages of 3 and 5 months. The "Rule of 10s" is a good rule of thumb to follow when determining the appropriate age for basic cleft lip repair. Assuming the infant is 10 weeks old, weighs ten pounds, and hemoglobin has reached 10mg/dL, surgical repair is considered safe in the absence of additional complications exist .
The surgical details of numerous established surgical procedures for primary repair of unilateral (Millard fix rotation advancement, Fisher overhaul, and Mohler fixes) and bilateral (Mulliken fix) cleft lips are outside the scope of this article. The primary aim of all maintenance procedures, however, is to re-develop a functioning orbicularis oris muscles, enhance the upper lip depression (philtrum) and lip, and reduce obvious damaging. Some surgeons use gingivoperiosteoplasty in primary cleft repair, which involves the development of mucoperiosteal flaps along an alveolar segment that includes extensive undermining so as to enhance bone formation across the periosteum, although it’s not considered as a common procedure [7, 20]. Because most of the children suffer from otitis media, it’s crucial that an ENT physician must be engaged in their treatment. Ventilation tubes are placed after cleft lip surgery, however, children continue to experience eustachian tube dysfunction for many years .
From the time of surgery until they reach adulthood, these patients are monitored by a variety of specialists. Concurrent cleft palate repair is best done between the ages of 9 and 12 months, with close speech examination and follow-up in the range of two-three years to diagnose any affiliated challenges in swallowing or speech. A cleft palate can cause speech and swallowing problems due to anatomic anomalies caused by the soft palate's failure to grow and develop against the later pharyngeal wall and divide the nasopharynx from the oropharynx (referred to as velopharyngeal insufficiency) . When the permanent maxillary dogs emerge, the orthodontist will perform alveolar bone grafting, which is often done with cancellous bone from the iliac crest to fill the alveolar gap. Following that, depending on the patient's needs, procedures with an ear, nose, and throat specialist or a plastic surgeon for nasal cleft deformity correction and scar reviews, and orthodontics, are completed at different ages. The requirement for orthognathic surgery to establish distinct pattern osteotomies in the jawbone or midface/maxilla to repair various skeletal abnormalities connected to cleft lip deformity will be assessed at the age of skeletal maturity, often between the ages of 16 and 18 years old .
Treatment of Cleft Palate
Treatment Planning 
The Cleft palate is definitively managed with surgical intervention. Repair is frequently staged, with the lip being addressed first, followed by the palate. The decision to perform the first surgical treatment is based on the oft-quoted law of tens: "10 pounds, hemoglobin of 10, and age more than 10 weeks." There are several surgical treatments for repairing cleft lip and palate. The Millard rotation-advancement approach for one-sided cleft lip and the Mulliken procedure for bilateral cleft lip are the two most widely performed lip repairs. Palatoplasty for the cleft palate with cleft lip and cleft palate alone is done later, between the ages of 9 and 15 months. Straight-line repair, the Furlow double Z-plasty, and Veau-Wardill-Kilner V-Y pushback are all repair methods .
Preoperatively, the lip is routinely taped from around one week of birth until surgery for a cleft palate and cleft lip. This aids in reducing the size of the cleft and improving symmetry. Nasoalveolar moulding (NAM) is a more aggressive alternative to lip taping that can result in a superior aesthetic and functional result following surgery. NAM entails the insertion of a close-fitting prosthesis from a maxillary imprint that is Used twenty-four hours a day and the modified every week or biweekly basis. NAM may enhance nasal regularity and alveolar alignment significantly. However, it is a considerable time and effort strict adherence for families, and noncompliance can have serious implications [6, 23].
Lip adhesion is a surgical option for very broad clefts in order to attain a smaller cleft at the time of healing. It is rarely utilized since it necessitates more surgical operation. It is frequently done as early as four-six weeks of age. Lip bonding is accomplished with the elevation of rectangular mucoperiosteal lip flaps that are carried medially with absorbable junctions .
The reconstruction of the levator veli palatini muscle, which works to raise the palate during a swig, is the most important step in any of the palatoplasty treatments. Inadequate or failed reattachment of the muscle may result to velopharyngeal inadequacy or rather it fails in closure. This causes nasal reflux and hypernasal conversation throughout the swallow .
Straight-line Repair with Intravelar Veloplasty or Two-Flap Palatoplasty
This method includes lifting mucoperiosteal flaps from the vomer on each side of the cleft. From the maxillary alveolus to the soft palate, nasal mucosal and oral mucosal flaps are elevated anteriorly. The flap's medial mucosal accessories are solely left intact over the soft palate. The flaps are then alternated medially and layered closed. The muscular attachments are lifted from the hard palate and placed in the midline more posteriorly at the soft palate to reestablish the levator muscle suspend. This method does not extend the palate .
Furlow Double Z-plasty
Furlow palatoplasty consists of Z-plasty or inversion of soft palatal muscle flaps in one layer to reconstruct the levator sling and transposition of mucosal blinkers in a second layer to rebuild the uvula. The Z-plasty procedure allows for palate expansion. To close the hard palate cleft, straight-line mucoperiosteal flaps are raised .
Veau-Wardill-Kilner V-Y Pushback
This procedure includes elevating bilateral mucoperiosteal flaps that link the mouth mucosa from anterior to posterior. The flaps' posterior add-ons remain intact. After that, the mucoperiosteal flaps are retroposed, or strapped back, and reapproximated at the midline. This enables palatal expansion. The nasal mucosal layer is predominantly closed in its place, leaving it vulnerable on its inferior or oral face, to shut by subordinate purpose .
In In certain circumstances, another surgical procedure may be required at a later date to repair the gum cleft with a piece of bone (bone grafting) - usually between the ages of 8 and 12. Enhance the looks and functionality of the lips and palate – this may be required if the primary surgical procedure did not heal adequately or ongoing speech difficulties still exist - enhance the form of the nose (rhinoplasty) and improve the appearance of the jaw - some children with a cleft lip or palate instinctively have a small or "set-back" inferior jaw .
Rehabilitation and Postoperative Care
Postoperative feeding in newborns with cleft lip and palate requires special consideration. Conservative feeding techniques, such as breastfeeding or bottle-feeding, are often not encourged in the post-operative period to reduce wound tension . Surgeons are more likely to recommend spoon-feeding as an alternate feeding approach. Aside from spoon-feeding, physicians all over the world have explored numerous additional methods like syringes, cups, soft nipples, and so on. Although a significant number of surgeons support the notion of an alternative feeding method, some are opposed to it. There is sufficient research demonstrating the baby's inconsolable wailing and writhing following the introduction of various feeding techniques in the postoperative period . This leads to inadequate nutrition, which has an impact on wound healing. Thus, significant alterations in feeding may result in weight loss in the newborn, rendering a particular alternate strategy ineffective. Other feeding strategies should thus be promoted in children that underwent cleft lip surgery to reduce undue stress on the surgical site, however, the problem of high wound dehiscence owing to the continuing standard feeding regimens has yet to be demonstrated .
Managing Hearing Issues
Children with cleft palates are more prone to develop glue ear, a disease in which fluid forms in the ear. This is due to the fact that the muscles in the palate are linked to the central ear. If the muscles do not function effectively as a result of the cleft, sticky secretions may form within the middle ear, reducing hearing. The youngster will have frequent hearing exams to rule out any potential issues. Hearing issues may improve following cleft palate surgery and, if necessary, can be corrected by putting tiny plastic tubes into the eardrums called perforations. These let the fluid in the ear drain. Hearing aids are sometimes optional .
Children with cleft abnormalities are best cared for by a dedicated team of professionals who are committed to them from diagnosis through adulthood. This craniofacial team collaborates to carry out a complex treatment plan. As a kid with a cleft grows and develops, certain patterns of treatment and clinical intervention emerge. The following is a synopsis of the treatment and interventions that children with cleft palates receive at our craniofacial facility.
ACKNOWLEDGMENTS: Many thanks to dr. Sami Al Issa; Consultant, Plastic and Craniofacial Surgeon, AOCMF Faculty Member, Medical Burn Unit and Plastic Surgery Department, Security Forces Hospital Program, saudi arabia, for his continuous help, support and encouragement to complete this work.
CONFLICT OF INTEREST: None
FINANCIAL SUPPORT: None
ETHICS STATEMENT: None