Cleft Services: Epitome of Teamwork
Cleft lip and palate (CLP) children present a variety of challenges, nevertheless
management provides great rewards. This is why I chose to do my elective following a cleft
surgeon and the cleft team. Those thinking of paedodontic, orthodontic or maxillofacial
specialties, prepare to test your team working skills...
In this entry, I hope to highlight aspects of the Hodgkinson et al report[1] with respect to the
cleft team and dental speciality roles.
CLP is a common feature in developmental syndromes taught to dental students, occurring
in ~1/700 births of multifactorial origin ultimately disturbing the complex morphogenesis of
the palate.
CSAG (Clinical Standards Advisory Group) investigates NHS services. In the 1998 CSAG
CLP report, the cleft services in the UK were relatively poor in comparison with the rest of
Europe concerning patient outcome and documentation. Previously cleft services were
numerous and scattered across the UK without focussed collaboration of cleft teams. After
the report was accepted by the government, major reorganisation of services followed with
the establishment of 9 major centres by 2002.
Centralisation of cleft services is considered the international model whereby complete care
is delivered seamlessly and with regular auditing. This structure facilitates direct access to all
the key subspecialist services through the multi-disciplinary clinic setting which has
underpinned the successes to the service re-design in the UK.
The UK was identified as falling short in comparison to Europe, for example in the UK,
successful alveolar bone grafts were only 60% compared 97% in Europe. Additionally, each
cleft surgeon was only seeing very few cases per year which was deemed insufficient for the
aim of high quality care.
Embryologically, the upper lip and palate develop by fusion of the medial nasal prominence
(pre-maxilla) and the maxillary processes during weeks 5-9 in utero. Palatal shelves then
develop down the sides of the tongue and, when the tongue drops later in development, the
shelves extend horizontally. This occurs due to differences in tension between the shelves
and tongue. The shelves then fuse along the midline and between the primary and
secondary palates.
Superficially, the cleft defect can appear small however the defect becomes more extensive
further back (see figure 1). CLP are mostly diagnosed prenatally from ultrasound, however
some cleft palates are diagnosed after birth. Presenting complaints include aesthetic
concern, feeding difficulties and delayed speech development.
Fig.1 Cleft lip and palate diagram[2]
Hodgkinson et al[1] mention all the team is present from the
beginning and as the child ages there are shifts in focus and
involvement from different specialities. The cleft team involves
dental, medical, surgical, language, nursing and support staff.
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Dental aspects
Ideal involvement of the paedodontist is as soon as the child’s deciduous teeth erupt to
ensure minimal dental complications and also maintains optimum oral hygiene for surgical
wounds to heal.
Embryologically, the maxillary primal dental lamina forms from the ecto-mesenchymal
interaction between the mesenchyme and oral epithelium – from which, individual tooth
germs form, this begins in the 7th week in utero. In a cleft affecting the alveolar bone, the
patient may develop one or more of many oral anomalies. These include, supernumerary
teeth, hypodontia, misshapen roots and/or crowns, enamel hypoplasia and ectopic teeth.
The paedodontist may find an increased incidence of dental decay in comparison to other
non-cleft siblings. Future surgeries, orthodontics, restorative and orthognathic treatment may
find difficulties as a consequence of early destruction of the childs’ dentition.
Orthodontics
Orthodontic intervention can occur throughout the childs’ early years into adulthood. The
patients’ treatment tolerance must be taken into consideration and therefore treatment is
confined to “discrete episodes”.
See table 1 for examples of orthodontic involvement:
(Table 1: adapted from Hodgkinson et al[1])
Alveolar bone grafting
Successful early surgery and speech and language therapy help approximate the premaxilla and maxillary segments. However, where the alveolar segments remain separate,
bone grafting facilitates reconstruction of the absent bone. By providing bone in this region,
the developing canine has bone to erupt through and occupy. By age 7-8 years the canine
has half developed and timing of the bone graft must be careful. Too early, the canine does
not sufficiently occupy the graft and the bone resorbs. Too late, the canine is further through
to complete development and therefore increased likelihood of insufficient tooth movement
later on.
Ideal timing of the graft enables efficient tooth movement plus the capability to establish the
“ideal arch form”. Completion of the canine movement is normally scheduled between 9-10
years of age.
The bone graft is autogeneous cancellous bone from the hip (obtained by the cleft surgeon
during the same surgery) which is then packed into the alveolar defect made visible by
raising a mucoperiosteal flap. The defect is over-packed into the canine fossae and
underneath the nasal alar to ensure the canine successfully erupts through. The erupting
canine through the graft consolidates the bone.
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Facial growth
The pre-maxilla is asymmetrical in unilateral cleft patients with it being tilted upwards on the
cleft side and deviation of the nasal septum to the cleft side.
It is during foetal development that distortions of the pre-maxilla and nasal septum is evident;
a result of “altered tongue positioning, muscular activity and swallow patterns”.
Antero-posterior growth can show discrepancies between maxilla and mandibular growth
rates. It has been suggested that this could be a feature of the cleft and/or as a result of
early surgery.
These discrepancies can be corrected using orthodontics and surgery however
advancement of the maxilla might need to be limited in order to strike a compromise
between aesthetics and speech.
Conclusion
Discussing with the surgeon I shadowed, recent auditing seems to suggest that
centralisation has enabled positive trends in case outcomes and collaboration of the cleft
team and also that parents of affected children are prepared to travel for such specialist care.
Furthermore, although the rewards can be great, the consequences of poor collaboration
and teamwork can result in anything from delayed treatment to an emotional rollercoaster
ride for families to further surgery.
References:
[1] Hodgkinson. PD, S. Brown, D. Duncan, C. Grant, A. McNaughton, P. Thomas, CR.
Mattick. 2005. Management of children with cleft lip and palate: A review describing the
application of multidisciplinary team working in the condition based upon the experiences of
a regional cleft lip and palate centre in the United Kingdom, Fetal and Maternal Medicine
Review, 16(1), pp. 1-27.
[2] DukeHealth.org, Care Guides: Plastic Surgery: The Nature of Clefts,
http://www.dukehealth.org/health_library/care_guides/plastic_surgery/cleft_lip_and_palate/th
e_nature_of_clefts, Duke University Health System, accessed on 20th July 2012.
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