The UK CSAG report (1998) described the complex relationship between the specialties of plastic and OMFS (oral and maxillofacial) surgery in the management of cleft patients. To resolve the matter, it was recommended that the respective professional bodies should review the cleft service and agree to delineate the areas of expertise so as to optimise the cleft service in the region and clarify training needs.
These recommendations are considered to be equally applicable to the cleft services in the [Eastern Health] Board’s region, as noted in the report Development of Oral & Maxillofacial Surgery Services in the Eastern Health Board Region, (Eastern Health Board, February 1999). A recommendation in the report stated that “the plastic and OMFS consultants in the [Eastern Health Board] region, together with their respective professional bodies, should agree to a methodology for integrating their combined expertise so as to provide a fully integrated quality cleft service for the region” (quote).
Plastic surgery can be defined as the branch of surgery concerned with restoration of form and function by reconstruction of congenital, traumatic and acquired conditions (British Association of Plastic Surgeons).
In the Eastern Health Board area primary surgery is performed by two cleft (plastic) surgeons who have specifically trained in cleft surgery and craniofacial surgery. Primary surgery entails lip and palate repair. Primary surgery is carried out at Temple Street and Crumlin paediatric hospitals. The plastic surgeon will also perform revision work and rhinoplasty (usually in the late teens) if required. In the Dublin cleft centres, the plastic surgeons head up the individual cleft teams.
Oral and maxillofacial surgeon
Oral and maxillofacial surgery (OMFS) is defined as that branch of surgery that deals with the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects of the human jaws and associated structures (British Association of Oral and Maxillofacial Surgeons).
Oral and maxillofacial surgeons require training in both dentistry and medicine. It is the dental training that differentiates OMFS from other surgical specialties.
The oral and maxillofacial surgeon has responsibility for the following (from Development of Oral & Maxillofacial Surgery Services in the Eastern Health Board Region, (Eastern Health Board, February 1999)
(note: list not exclusive);
- Surgery of the tooth bearing components of the jaw.
- Surgery prior to rehabilitation of the dentition.
- Correction of dentofacial anamolies (orthognathic surgery)
- Aesthetic facial surgery.
- Surgical treatment of other congenital abnormalities including clefts of the lip and palate.
- Craniofacial surgery.
- Oral pathology and oral medicine.
Following the first full orthodontic assessment, which occurs at around 6½ to 7 years, any supernumerary teeth which interfere with the proper development or eruption of second teeth are removed by the oral and maxillofacial surgeon.
In most cleft cases expansion of the maxilla and bone grafting of the alveolus (tooth bearing portion of the upper jaw) is necessary, with the expansion beginning at about 9 to 10 years of age. The purpose of the expansion is to bring the child’s teeth into correct relationship to each other. Following the expansion, the maxillofacial surgeon carries out the bone graft to replace the missing bony tissue. The procedure should be completed by the age of 10 to 11 years.
Major bony surgery to move forward the whole of the upper jaw, or to move the mandible (lower jaw) is required in a minority of those affected by a cleft. This is called orthognathic surgery and is carried out by the maxillofacial surgeon after careful planning and can often have dramatic results. This surgery takes place after the mid-face has fully developed, which usually occurs by age 15 years.
Ear, Nose and Throat (ENT) Surgeon
Up to 90% of children with cleft palates do have middle ear fluid and some degree of hearing loss. Very frequently this requires the intervention of the ENT surgeon. Surgical treatment consists of admission of a child to the hospital for a day, the administration of a general anaesthetic and drainage of the middle ear fluid or glue with the insertion of a grommet or ventilation tube. Unfortunately grommets may need to be inserted on a number of occasions until the child’s eustachian tubes start to function properly. In many cases, such children will need regular supervision by the ENT surgeon until they are 10 years of age.
Paediatric Dental Surgeon
The Paediatric Dental Surgeon provides dental care or guidelines for care to promote good dental health. They may remove teeth that have erupted incorrectly.
It is the role of the orthodontist on the cleft team responsible for your child to monitor the growth and assist the development of his/her teeth. The aim of orthodontic treatment is, where possible, to align all the teeth and close all residual spaces without the use of bridges or dentures.
The first full orthodontic assessment occurs at around 6½ to 7 years. For some children simple orthodontic treatment involving braces to straighten the teeth can now begin and no further treatment may be necessary. In children who have either bilateral clefts of the lip and palate or unilateral clefts of the lip and palate, expansion of the maxilla (preceding a bone graft) should start at about 9 to 10 years of age. It is achieved by fitting fixed appliances to the upper jaw which moves the dental arch back to its correct shape and in doing so, the underlying bone moves with the teeth. Full orthodontic alignment starts with the use of fixed braces when all the permanent teeth have erupted (usually by the age of 13 years).
Speech and Language Therapist
The speech and language therapist (SLT) advises on important aspects of speech and language development. A SLT should see children with cleft lip and palate at around six to nine months for assessment of communication skills. The SLT can informally assess the level of the child’s development and provide advice on ways to encourage normal speech and language development. The baby should be reviewed on a regular basis i.e. at least every three months over the next few years. From about three years of age, your child will attend a special Combined Cleft Palate Clinic where your child will have full speech and language assessment and hearing tests prior to the clinic. If a child has speech and/or language problems, they should attend regular speech and language therapy in the local community care clinic. The SLT will work closely with parents, providing exercises and drills, which should be carried out at home.
The SLT will also advise you on feeding issues if your baby is having problems. A child with a cleft palate should be seen by a speech and language therapist at about six months of age or earlier if there are feeding difficulties. Feeding and speech are closely linked so a speech and language therapist can help with both aspects.
It is not widely known, including among medical personnel, that speech and language therapists can help with feeding. Since cleft lip and palate is such a specialist area, not all speech and language therapists will be experienced in helping with feeding difficulties. They will, however, be able to refer you to a therapist who specializes in children with cleft lip and palate.
Particular attention should be paid to your child’s hearing in the first 2-3 years of life. Hearing tests will be carried out by an audiologist as part of the work of the combined cleft team.
Some parents may need help adjusting to having a child with a cleft lip and/or palate, and the psychologist on the cleft team can assist with that adjustment. The psychologist can also help parents by educating them to the psychological effects being born with a cleft may have on their child as they grow, so that they are in a better position to support their child at appropriate times. Equally, a person with a cleft may benefit from assistance in coping with major procedures, peer acceptance, speech difficulties, teasing and in developing their self-confidence. Usually this help is provided only when requested.
This is a person who provides counseling and resources to people.
The cleft co-ordinator maintains communication between the individual specialists, as well as with patients and their families, and ensures that all administrative activities of the team, including maintenance of databases and overseeing research are fulfilled.