Background and aims Between 1997 and 2014, 3 protocols have been used in out cleft unit for primary repair of unilateral cleft lip and palate. During the Scandcleft randomized controlled trial closing the soft palate and lip at 4 months and the hard palate at 12 months (Protocol 1) was compared with closing the entire palate at 12 months (Protocol 2). Protocol 3 comprises closure of the lip and hard palate with a vomer flap at 4 months and the soft palate at 10 months. The purpose of this study was to compare subsequent velopharyngeal competence at age of 3 and 5 years. Patients and methods The study consisted of 160 non-syndromatic patients with a unilateral cleft lip and palate. Protocol 3 was retrospectively compared with Protocols 1 and 2 within the previously published Scandcleft study. Results At 3 years of age, normal or borderline competent velopharyngeal function was found in 68% of patients in Protocol 1, 74% of patients in Protocol 2, and 72% of patients in Protocol 3. At 5 years of age, the corresponding figures were 84%, 82%, and 92%. 21% of patients in Protocol 1, 4% in Protocol 2, and 23% in Protocol 3 had palatal reoperations before the age of 5 years. Conclusion No significant differences emerged in velopharyngeal competence at age 3 years between the 3 protocols. Palatal reoperations were performed earlier in patient groups 1 and 3, explaining the difference in the velopharyngeal competence rate at the 5-year time-point.

Speech of Patients With Unilateral Complete Cleft Lip and Palate: Comparison of Three Different Surgical Protocols for Primary Repair.

Objective To assess the electromyographic activity of the masseter and temporal muscles in cleft patients who underwent 1-stage palate repair versus 2-stage palate repair. Methods Thirty-two patients with nonsyndromic complete unilateral cleft lip and palate operated by 2 different protocols for palate repair, 1-stage (group 1, n = 16) versus 2-stage with delayed hard palate closure (group 2, n = 16) were available in the retrospective longitudinal study. Standardized electromyographic records of the masseter and anterior portion of temporal muscles were obtained with 2 repetitions during mastication and rest. Results No statistically significant (all P > 0.05) differences were observed in the electromyographic data between the groups 1 and 2. Conclusion There were similar electromyographic activity of masseter and temporal muscles during mastication and at rest after 1- and 2-stage palate closure.

Electromyographic Activity of the Masseter and Temporal Muscles in Patients With Nonsyndromic Complete Unilateral Cleft Lip and Palate: 2-Stage Versus 1-Stage Palate Repair.

The main purpose was to assess and compare nasal cavity (NC) volumes among adults with unilateral (UCLP) and bilateral cleft lip and palate (BCLP) and in noncleft controls (CON), by means of cone-beam computed tomography (CBCT) three-dimensional reconstructions. Forty-five scans of individuals with class III skeletal pattern, matched by age, were gathered in 3 groups: UCLP (n = 15), BCLP (n = 15) and (CON) (n = 15). The NC volume was assessed three-dimensionally, using Dolphin 11.8 software. Descriptive normally distributed data was presented as mean (±SD). Comparisons of NC volume among groups was performed using ANOVA test (P ≤ 0.05). The NC mean volumes corresponded to 14.7(±2.2) cm3 (UCLP), 17.1(±2.2) cm3 (BCLP) and 18.1(±3.8) cm3 (CON), respectively. UCLP individuals presented a significantly reduced NC volume when compared to controls (P = 0.006). No differences were observed between UCLP versus BCLP or BCLP versus CON. The intraclass correlation coefficient suggested a high intra- and inter-examiners agreement (>.075). Individuals with unilateral cleft lip and palate presented reduced NC when compared to individuals without cleft lip and palate. CBCT scans can be considered a highly accurate tool for morphometric assessments of craniofacial structures.

Adults With Unilateral Cleft Lip and Palate Present Reduced Internal Nasal Volumes: Findings of a Three-Dimensional Morphometric Assessment in Cone-Beam Computed Tomography Scans

This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate (CL ± P) in the United Kingdom (UK).Data forms completed at the time of surgery included details on timing, technique, and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires.Data were obtained from the Cleft Collective, a national longitudinal cohort study.Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children.The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips (UCL) were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips (BCL) were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bimodal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties (P < .001) and a 5 to 7-day postoperative regime used more commonly for soft palatoplasties (P < .001). Perioperative steroids were used more commonly in palatoplasties than cheiloplasties (P < .001) but tranexamic acid use was equivalent (P = .73).This study contributes to our understanding of current cleft surgical pathways in the UK and will provide a baseline for analysis of the effectiveness of utilized protocols. 

Current Surgical Practice for Children Born with a Cleft lip and/or Palate in the United Kingdom

OBJECTIVE To determine differences in burden of care between nonsyndromic patients with unilateral cleft lip and palate undergoing treatment at American Cleft Palate-Craniofacial Association (ACPA)-accredited centers and nonaccredited centers in New York State. DESIGN A retrospective review of the New York Statewide Planning and Research Cooperative System database from January 2001 to December 2014 was performed using ICD-9 and CPT coding. PATIENTS, PARTICIPANTS This study included patients with unilateral cleft lip and palate who underwent both lip and palate repairs during their first  6 years of life. Exclusion criteria included orofacial cleft syndromes, follow-up under  6 years, and one-stage combined cleft lip and palate repairs. RESULTS Eighty-eight patients were treated at cleft centers, and 29 patients at nonaccredited centers (  n = 117). Age at primary palatoplasty (13.0 months vs 18.1 months;   p = .019), total number of cleft operations (2.3 vs 2.7;   p = .012), and total number of primary cleft-specific procedures (2.2 vs 2.5;   p = .0049) were significantly lower for patients treated in cleft centers. Age at primary cheiloplasty (4.8 months vs 4.6 months;   p = .865), post-cheiloplasty length of stay (1.2 days vs 1.2 days;   p = .673), post-palatoplasty length of stay (1.5 days vs 1.9 days;   p = .211), average hospital admissions (2.2 vs 2.3; p = 0.161), and total complication rates (34.1% vs 21.1%; p = 0.517) did not differ significantly between cleft centers and noncenters. CONCLUSIONS This data demonstrates some significant differences in overall 6 year burden of care for nonsyndromic patients with unilateral cleft lip and palate treated at ACPA-accredited cleft centers versus nonaccredited centers.

Six-year Burden of Care for Nonsyndromic Unilateral Cleft Lip and Palate Patients: A Comparison Between Cleft Centers and Noncleft Centers.

Background Adequate dentofacial growth is an objective of unilateral cleft lip and palate treatment. No study exists, comparing the dental arch of 5-year-old relationship after 2 treatment protocols: one with single-stage palatoplasty and another with delayed hard palate closure (DHPC). The authors hypothesized that the DHPC protocol provides better dentofacial growth. Methods A single-center, single-surgeon Randomized Clinical Trial was performed to evaluate the maxillomandibular relationships in 2 groups. The intervention group (GI) underwent palatoplasty with DHPC between ages 3 and 4 years; the control group (CG) underwent complete palatoplasty between 9 and 15 months. The authors evaluated oronasal fistulae rates.The dental arch relationship was evaluated via blinded panels using the Five Year Old Index.Kappa statistics were calculated to assess reliability. Trials were statistically tested with the t test and chi-squared test. Results Sixty-four patients constituted the study sample. The incidence of oronasal fistulae was 9.4% (GI) and 6.7% (CG). Sixty-two models with an average age of 55 months were available for analysis. Good intra- and inter-rater reliabilities (0.73-0.93 and 0.60-0.94, respectively) were obtained. Average index scores ranging from 2.04 (GI) to 2.76 (CG) were significantly different (P = 0.007). Significant between-group differences (P = 0.006) were found in scores, 1 and 2 in the GI (74%) and CG (52%). When the distributions were compared by the median, a difference was found (P = 0.024) in score, 1 between the GI (31.2%) and CG (3.3%). Conclusions Although the DHPC protocol yielded better outcomes relating to dentofacial growth, other protocols should be investigated and findings verified by other researchers.

Unilateral Cleft Lip and Palate Surgical Protocols and Facial Growth Outcomes.

INTRODUCAO: As cirurgias primarias, queiloplastia e palatoplastia, interferem na morfologia e na fisiologia do complexo maxilofacial, provocando alteracoes em seu crescimento nos portadores de fissura transforame incisivo unilateral (FTIU). Este estudo tem por objetivo avaliar precocemente os efeitos das cirurgias sobre o crescimento maxilofacial, por meio da relacao dos arcos dentarios desses pacientes. METODO: Foram avaliados 45 pacientes portadores de FTIU submetidos a cirurgias primarias de labio e palato. Foi realizado estudo comparativo de modelos dos arcos dentarios deciduos em que a relacao maxilomandibular foi avaliada por 2 ortodontistas, que aplicaram o indice Atack. RESULTADOS: Dentre os pacientes analisados, 44,4% se encontravam nos escores 1 e 2, apresentando condicoes mais favoraveis de crescimento maxilomandibular. O escore intermediario (escore 3) correspondeu a 40% da amostra e os escores 4 e 5, a 15,6%, apresentando tendencia a crescimento desfavoravel. A media obtida aos 4 anos de idade foi de 2,62 + 0,98. Ao relacionar os escores 1 e 2 com outros estudos, houve diferenca significativa (P = 0,023) comparativamente a serie de Bongaarts, que apresentou os melhores resultados. Nos resultados para os escores 3, 4 e 5, observaram-se proporcoes semelhantes as de tres dos estudos relacionados e melhores em relacao ao primeiro a utilizar o indice Atack na avaliacao de suas cirurgias primarias. CONCLUSOES: A aplicacao do indice Atack possibilitou a analise dos resultados de cirurgias primarias sobre o crescimento maxilofacial e a comparacao destes com os dados obtidos por centros de referencia para tratamento da FTIU.

/pdf/avaliacao-do-crescimento-craniofacial-em-portadores-de-3xbnlmm64j.pdf

Avaliação do crescimento craniofacial em portadores de fissuras labiopalatinas submetidos a palatoplastia em tempo único

Objective A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptions to cleft care protocols during and after COVID as a priority learning area of need. Design A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptions to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organisations involved in comprehensive cleft care. Results Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinised and COVID adaptions, specifically in the pre and peri-operative periods, were highlighted. Second, surgical operations and access to services were prioritized according to their relationship to functional outcomes and time-sensitivity. The operations assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft services assigned the highest priority were new-born assessments, paediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention. Conclusions A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

/pdf/adapting-cleft-care-protocols-in-low-and-middle-income-5aodo7ixms.pdf

Adapting cleft care protocols in low- and middle-income countries during and after COVID-19: a process-driven review with recommendations

Objective
 A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need. 
 Design
 A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care. 
 Results
 Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention. 
 Conclusions
 A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

https://doi.org/10.1177/10556656211069827

Rui Manuel Rodrigues Pereira

Papers

Unilateral Cleft Lip and Palate Surgical Protocols and Facial Growth Outcomes.

Avaliação do crescimento craniofacial em portadores de fissuras labiopalatinas submetidos a palatoplastia em tempo único

Adapting cleft care protocols in low- and middle-income countries during and after COVID-19: a process-driven review with recommendations

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations