Interdisciplinary Management of Cleft Palate: Dental, Nursing, and Anesthesia Perspectives
Abstract
Background: Cleft lip and palate (CL/P) are among the most common congenital craniofacial anomalies, resulting from the failure of embryonic facial prominences to fuse. This defect creates a communication between the oral and nasal cavities, leading to significant functional impairments in feeding, speech, and hearing, and can occur in isolation or as part of a broader genetic syndrome.
Aim: This article synthesizes the interdisciplinary management of cleft palate, aiming to outline the comprehensive care pathway from prenatal diagnosis through longitudinal rehabilitation. It emphasizes the need for a coordinated team to address the complex anatomical, functional, and psychosocial challenges.
Methods: A comprehensive review of the embryology, epidemiology, and pathophysiology of cleft palate is presented. The evaluation and management strategies are detailed, encompassing prenatal imaging, systematic postnatal assessment, and a timeline of surgical interventions (e.g., lip repair at ~3 months, palatoplasty by 12-15 months). Key techniques like the Furlow Z-plasty and V-Y pushback are discussed.
Results: Successful management requires a lifelong, interprofessional approach. Outcomes are generally favorable for isolated clefts with timely intervention, leading to near-normal function and life expectancy. However, complications such as oronasal fistulae, velopharyngeal insufficiency, and midfacial growth disturbances can occur, necessitating secondary procedures and continuous monitoring of speech, hearing, and dental development.
Conclusion: The prognosis for individuals with cleft palate is optimized through dedicated, coordinated care from a multidisciplinary team that addresses surgical, dental, audiological, speech, and psychosocial needs from infancy to adulthood.
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References
Kini U. Genetics and orofacial clefts: a clinical perspective. Br Dent J. 2023 Jun;234(12):947-952.
Dixon MJ, Marazita ML, Beaty TH, Murray JC. Cleft lip and palate: understanding genetic and environmental influences. Nat Rev Genet. 2011 Mar;12(3):167-78.
Compagnucci C, Martinus K, Griffin J, Depew MJ. Programmed Cell Death Not as Sledgehammer but as Chisel: Apoptosis in Normal and Abnormal Craniofacial Patterning and Development. Front Cell Dev Biol. 2021;9:717404.
Hammond NL, Dixon MJ. Revisiting the embryogenesis of lip and palate development. Oral Dis. 2022 Jul;28(5):1306-1326.
Acevedo FMA, Doe Ketemepi GV, Hernandez BY, Lambert RG, Lopez DM, Gonzalez MR. Bilateral Tessier no. 7 cleft with an accessory maxilla and osseous choristoma: a case report. J Surg Case Rep. 2023 Jan;2023(1):rjac616.
Angulo-Castro E, Acosta-Alfaro LF, Guadron-Llanos AM, Canizalez-Román A, Gonzalez-Ibarra F, Osuna-Ramírez I, Murillo-Llanes J. Maternal Risk Factors Associated with the Development of Cleft Lip and Cleft Palate in Mexico: A Case-Control Study. Iran J Otorhinolaryngol. 2017 Jul;29(93):189-195.
Kirschner RE, LaRossa D. Cleft lip and palate. Otolaryngol Clin North Am. 2000 Dec;33(6):1191-215, v-vi.
Gritli-Linde A. Molecular control of secondary palate development. Dev Biol. 2007 Jan 15;301(2):309-26.
Burg ML, Chai Y, Yao CA, Magee W, Figueiredo JC. Epidemiology, Etiology, and Treatment of Isolated Cleft Palate. Front Physiol. 2016;7:67.
Worley ML, Patel KG, Kilpatrick LA. Cleft Lip and Palate. Clin Perinatol. 2018 Dec;45(4):661-678.
Abbott BD. The etiology of cleft palate: a 50-year search for mechanistic and molecular understanding. Birth Defects Res B Dev Reprod Toxicol. 2010 Aug;89(4):266-74.
IPDTOC Working Group. Prevalence at birth of cleft lip with or without cleft palate: data from the International Perinatal Database of Typical Oral Clefts (IPDTOC). Cleft Palate Craniofac J. 2011 Jan;48(1):66-81.
Ysunza PA, Pamplona MC, Repetto G. Cleft Palate, Interdisciplinary Diagnosis, and Treatment. Biomed Res Int. 2015;2015:701850.
Smith B, Guyette TW. Evaluation of cleft palate speech. Clin Plast Surg. 2004 Apr;31(2):251-60, ix.
Duarte GA, Ramos RB, Cardoso MC. Feeding methods for children with cleft lip and/or palate: a systematic review. Braz J Otorhinolaryngol. 2016 Sep-Oct;82(5):602-9.
Celie KB, Wlodarczyk J, Naidu P, Tapia MF, Nagengast E, Yao C, Magee W. Sagittal Growth Restriction of the Midface Following Isolated Cleft Lip Repair: A Systematic Review and Meta-Analysis. Cleft Palate Craniofac J. 2024 Jan;61(1):20-32.
Logjes RJH, Mermans JF, Coerts MJ, Lissenberg-Witte BI, Breugem CC, Don Griot JPW. Long-term speech outcome in patients with Robin sequence after cleft palate repair and tongue-lip adhesion: A 21-year retrospective analysis. J Craniomaxillofac Surg. 2023 Apr;51(4):209-216.
Abramson ZR, Peacock ZS, Cohen HL, Choudhri AF. Radiology of Cleft Lip and Palate: Imaging for the Prenatal Period and throughout Life. Radiographics. 2015 Nov-Dec;35(7):2053-63.
Frederick R, Hogan AC, Seabolt N, Stocks RMS. An Ideal Multidisciplinary Cleft Lip and Cleft Palate Care Team. Oral Dis. 2022 Jul;28(5):1412-1417.
Crockett DJ, Goudy SL. Cleft lip and palate. Facial Plast Surg Clin North Am. 2014 Nov;22(4):573-86.
Elmendorf EN, D'Antonio LL, Hardesty RA. Assessment of the patient with cleft lip and palate. A developmental approach. Clin Plast Surg. 1993 Oct;20(4):607-21.
Suryadevara AC, Tatum SA. Floating the uvula: an intraoperative method for detecting bifidity. Int J Pediatr Otorhinolaryngol. 2007 Jan;71(1):175-7.
Kwinter A, Dworschak-Stokan A, Paradis J, Husein M. Association between symptomatic submucous cleft palate and otologic disease: A retrospective review. Int J Pediatr Otorhinolaryngol. 2018 Dec;115:77-81.
Finkelstein Y, Wexler DB, Nachmani A, Ophir D. Endoscopic partial adenoidectomy for children with submucous cleft palate. Cleft Palate Craniofac J. 2002 Sep;39(5):479-86.
Reiter R, Haase S, Brosch S. [Submucous cleft palate--an often late diagnosed malformation]. Laryngorhinootologie. 2010 Jan;89(1):29-33.
Martin S, Slevin E, Hill C. THE OCCULT SUBMUCOUS CLEFT - IMPROVING DETECTION BY EDUCATION. Ulster Med J. 2019 Sep;88(3):181-182.
McGuire E. Cleft lip and palates and breastfeeding. Breastfeed Rev. 2017 Mar;25(1):17-23.
Breh R, Singodia P, Sarangi S. Naso-alveolar molding for newborn cleft lip and palate. Bioinformation. 2022;18(5):492-495.
Viswanathan N, Vidler M, Richard B. Hearing thresholds in newborns with a cleft palate assessed by auditory brain stem response. Cleft Palate Craniofac J. 2008 Mar;45(2):187-92.
Yates D, Allareddy V, Caplin J, Yadav S, Markiewicz MR. An Overview of Timeline of Interventions in the Continuum of Cleft Lip and Palate Care. Oral Maxillofac Surg Clin North Am. 2020 May;32(2):177-186.
Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. American Cleft Palate-Craniofacial Association. March, 1993. Cleft Palate Craniofac J. 1993 Mar;30 Suppl:S1-16.
Fanelli D, Kim D, King TS, Weller GE, Dalal PG. Recovery Characteristics in Neonates Following General Anesthesia: A Retrospective Chart Review. Cureus. 2021 Jul;13(7):e16126.
Schalet G, Langlie J, Kim M, Thaller S. The Rule of 10s for Cleft Repair: A Historical Review of the Literature. J Craniofac Surg. 2023 May 01;34(3):884-887.
Shi B, Losee JE. The impact of cleft lip and palate repair on maxillofacial growth. Int J Oral Sci. 2015 Mar 23;7(1):14-7.
Shkoukani MA, Chen M, Vong A. Cleft lip - a comprehensive review. Front Pediatr. 2013 Dec 27;1:53.
Shaffer AD, Ford MD, Losee JE, Goldstein J, Costello BJ, Grunwaldt LJ, Jabbour N. The Association Between Age at Palatoplasty and Speech and Language Outcomes in Children With Cleft Palate: An Observational Chart Review Study. Cleft Palate Craniofac J. 2020 Feb;57(2):148-160.
Greives MR, Camison L, Losee JE. Evidence-based medicine: Unilateral cleft lip and nose repair. Plast Reconstr Surg. 2014 Dec;134(6):1372-1380.
Aminpour S, Tollefson TT. Recent advances in presurgical molding in cleft lip and palate. Curr Opin Otolaryngol Head Neck Surg. 2008 Aug;16(4):339-46.
Agrawal K. Cleft palate repair and variations. Indian J Plast Surg. 2009 Oct;42 Suppl(Suppl):S102-9.
Leow AM, Lo LJ. Palatoplasty: evolution and controversies. Chang Gung Med J. 2008 Jul-Aug;31(4):335-45.
Witt PD, Marsh JL, McFarland EG, Riski JE. The evolution of velopharyngeal imaging. Ann Plast Surg. 2000 Dec;45(6):665-73.
McDowell F. The classic reprint: Graefe's first closure of a cleft palate. Plast Reconstr Surg. 1971 Apr;47(4):375-6.
Goldwyn RM. Johann Friedrich Dieffenbach (1794-1847). Plast Reconstr Surg. 1968 Jul;42(1):19-28.
Naidu P, Yao CA, Chong DK, Magee WP. Cleft Palate Repair: A History of Techniques and Variations. Plast Reconstr Surg Glob Open. 2022 Mar;10(3):e4019.
Goldwyn RM. Bernhard Von Langenbeck. His life and legacy. Plast Reconstr Surg. 1969 Sep;44(3):248-54.
RUDING R. CLEFT PALATE: ANATOMIC AND SURGICAL CONSIDERATIONS. Plast Reconstr Surg. 1964 Feb;33:132-47.
Iwasaki K, Yamamoto YS, Masuda M, Nalabothu P, Ohkubo F, Kadomatsu K, Maki K. Longitudinal Follow-Up of Facial Growth of Patients With Unilateral Cleft Lip and Palate Following Modified Veau-Wardill-Kilner Palatoplasty. Cleft Palate Craniofac J. 2022 Mar;59(3):291-298.
Romeo GP, Aronovich S. Primary Palatoplasty. Atlas Oral Maxillofac Surg Clin North Am. 2022 Mar;30(1):27-36.
Bonanthaya K, Jalil J, Sasikumar AV, Shetty PN. Furlow Palatoplasty for Velopharyngeal Dysfunction Management: Auditing and Predicting Outcomes. Cleft Palate Craniofac J. 2022 Sep;59(9):1097-1106.
Boseley M, Bevans SE. Double-reversing z-plasty (Furlow palatoplasty). Adv Otorhinolaryngol. 2012;73:145-8.
Chorney SR, Commesso E, Tatum S. Incidence of Secondary Surgery after Modified Furlow Palatoplasty: A 20-Year Single-Surgeon Case Series. Otolaryngol Head Neck Surg. 2017 Nov;157(5):861-866.
Qamar F, McLaughlin MM, Lee M, Pringle AJ, Halsey J, Rottgers SA. An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty. Cleft Palate Craniofac J. 2023 Jul;60(7):865-874.
Lignieres A, Anderson B, Alimi O, Cepeda A, Seitz A, Obinero CG, Teichgraeber JF, Nguyen PD, Greives MR. Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate? Plast Reconstr Surg. 2024 Jan 01;153(1):139e-145e.
Qiu CS, Fracol ME, Bae H, Gosain AK. Prophylactic Use of Buccal Fat Flaps to Improve Oral Mucosal Healing following Furlow Palatoplasty. Plast Reconstr Surg. 2019 Apr;143(4):1179-1183.
Hamamoto J. Bilateral cleft lip repair. Ann Acad Med Singap. 1988 Jul;17(3):352-7.
Thomson RM, Jovic T, Drake D, O'Neill T. Nasolabial appearance of bilateral cleft lip repair at five years of age. Comparing techniques of modified advancement-rotation (Delaire) with Manchester repair: a retrospective cohort study. Br J Oral Maxillofac Surg. 2021 Dec;59(10):1214-1219.
Stanton E, Kondra K, Jimenez C, Shakoori P, Yen S, Urata MM, Hammoudeh JA, Magee WP. Premaxillary Setback in Bilateral Cleft Lip and Palate Repair. Cleft Palate Craniofac J. 2024 Mar;61(3):416-421.
Bangun K, Halim J, Tania V. Repair of Protruding Bilateral Cleft Lip and Palate With Staged Premaxilla Setback Osteotomy, Cheiloplasty, and Palatoplasty in Trisomy 17p Patient: A Review of Syndromic Clinical Characteristic. Cleft Palate Craniofac J. 2023 May;60(5):621-626.
Seifeldin SA. Is alveolar cleft reconstruction still controversial? (Review of literature). Saudi Dent J. 2016 Jan;28(1):3-11.
Rochlin DH, Park J, Parsaei Y, Kalra A, Staffenberg DA, Cutting CB, Grayson BH, Shetye PR, Flores RL. Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity. Plast Reconstr Surg. 2023 Dec 01;152(6):1088e-1097e.
Hibi H, Yamada Y, Ueda M, Endo Y. Alveolar cleft osteoplasty using tissue-engineered osteogenic material. Int J Oral Maxillofac Surg. 2006 Jun;35(6):551-5.
Losquadro WD, Tatum SA. Direct gingivoperiosteoplasty with palatoplasty. Facial Plast Surg. 2007 May;23(2):140-5.
Wood RJ, Grayson BH, Cutting CB. Gingivoperiosteoplasty and midfacial growth. Cleft Palate Craniofac J. 1997 Jan;34(1):17-20.
Aljohani M, Yates J, Ashley M, O'Malley L. Evaluation of Quality of Life in Adult Individuals With Cleft Lip and/or Palate. 2021 Mar-Apr 01J Craniofac Surg. 32(2):505-508.
Antonarakis GS, Patel RN, Tompson B. Oral health-related quality of life in non-syndromic cleft lip and/or palate patients: a systematic review. Community Dent Health. 2013 Sep;30(3):189-95.
Lindeborg MM, Shakya P, Rai SM, Shaye DA. Optimizing speech outcomes for cleft palate. Curr Opin Otolaryngol Head Neck Surg. 2020 Aug;28(4):206-211.
Kucukguven A, Calis M, Ozgur F. Assessment of Nutrition and Feeding Interventions in Turkish Infants with Cleft Lip and/or Palate. J Pediatr Nurs. 2020 Mar-Apr;51:e39-e44.
LIMOLI TM. Cleft palate prosthesis. Oral Surg Oral Med Oral Pathol. 1948 Nov;1(11):1056-73.
Baldacci S, Gorini F, Santoro M, Pierini A, Minichilli F, Bianchi F. Environmental and individual exposure and the risk of congenital anomalies: a review of recent epidemiological evidence. Epidemiol Prev. 2018 May-Aug;42(3-4 Suppl 1):1-34.
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Copyright (c) 2024 Mohammed Ahmed Eissa Hakami, Amal Mohammed Ibn Mandeel, Waad Saad Aldossari, Amnah Ahmed Alkhateeb, Faris Badullah Saleh Alharbi, Soaad Jadaan Almotery, Fahad Abdulaziz Alkhamis, Sultan Hamoud Awwadh Almutairi, Ohood Mahdi Hussain Mobaraki, Abdulrahman Ali Ahmed Hazazi, Norah Yousef Ali Osaisy, Layla Saleem Almousa, Abdulrahman Hamed Saud Alsharari
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