Introduction
The therapeutic approach for cleft lip and palate patient is multidisciplinary and the cleft team is composed by the craniofacial surgeon, otolarygeologist, geneticist, anesthesiologist, speech –language pathologist, nutritionist, orthodontists, prosthodonist, psychologist ,neurosurgeons, ophthalmologist. Patient with cleft lip and palate require a continued follow-up throughout their development in order to achieve desirable treatment goals like normal facial esthetics, airway patency, normal speech and hearing, normal masticatory function and normal psychosocial development.
Discussion
The handling of cleft lip and palate cases varies across different treatment centers around the world. There are different treatment protocols which are followed across the globe and are based on established data and facts regarding the treatment outcome followed by different centers. Various protocols which are followed across the world are enumerated below:
OSLO protocol 1, 2
The early beginnings of Oslo’s team approach to the management of cleft patients can be traced to the early 1930s. at that time Granhaug Speech Therapy Institute provided a small amount of specialized care for patient with clefts repaired at the University hospital in Oslo and formed a link with the ENT department of the same institution.
In 1935 the prosthodontist, Arne Bohn initiated a collaboration with the speech therapists. Later Egil Harvold, the orthodontist joined the group in 1945. Finally Wilhelm Loennecken, one of the first two Norwegian plastic surgeons, returning from training in England in 1948 , settled in Oslo and virtually all children with clefts were subsequently referred either to him or to the other plastic surgeon in Bergen.
Following is the treatment protocol for unilateral cleft lip and palate according to the OSLO Cleft Team.(Department of Plastic Surgery, University Hospital of Oslo, Norway)(Table 1, Table 2) 1
UCLP, 1953, 1961, 1968, 1977
Table 1
OSLO protocol for unilateral cleft lip and palate
Orthodontic intervention
Table 2
OSLO protocol for orthodontic managementofunilateral cleft lipand palate
Following is the treatment protocol for bilateral cleft lip and palate according to the OSLO Cleft Team:( Department of Plastic Surgery, University Hospital of Oslo, Norway) (Table 3, Table 4) 2
BCLP, 1953, 1962, 1974, 1997
Table 3
OSLO protocol for bilateral cleft lip and palate orthodontic intervention
Table 4
OSLO protocol for orthodontic management of bilateral cleft lip and palate
Schweckendiek protocol(1951)3
In this technique the soft palate is closed during infancy by means of primary veloplasty. The residual cleft in the hard palate remains. Cleft becomes narrower with growth of the palate without causing compression of the jaw. Thus both articulation and maxillary growth remains undisturbed.
Jolleys protocol (1954)4
According to Jolley when treating a patient with cleft it is difficult to decide which should be preserved whether function and appearance. In his opinion appearance could be sacrificed in order to preserve the function.
All India Institute of Medical Sciences, India cleft lip and palate protocol (1970) 5
AIIMS located in South Delhi,India is an autonomous institute which is a tertiary care centre too. The combined cleft clinic was established in the orthodontic unit in the 1970’s.
Table 7
AIIMS protocol for cleft lip and palate
The zurich approach (1976) 6
The management of cleft lip and palate at Zurich University Dental Institute emphasized on the early orthopedics to take advantage of intrinsic growth potential which would allow the natural growth of maxillary segments to maximum extent.
Table 8
The zurich approach
Bergen protocol (1977) 7
The Bergen protocol is utilized since 1977 and is based on intermittent periods of active treatment followed by phases of fixed retention. The treatment procedures are coordinated between the Department of Plastic and Reconstructive Surgery, University Hospital of Bergen; the Cleft lip and Palate Center at the Department of Orthodontics and Facial Orthopedics, Faculty of Medicine and Dentistry, University of Bergen; and the Eikelund Center for Speech Pathology. This treatment is cost-effective and requires minimal patient cooperation.
Following is the treatment protocol for cleft lip and palate according to the Bergen Cleft Team: (Department of Plastic and Reconstructive Surgery, University Hospital of Bergen).
Table 9
Bergen protocol for cleft lip and palate
Warsaw protocol (1980) 8
Warsaw Institute of Mother and Child (IMC) proposes one stage approach of cleft treatment.
Malek & psaume protocol (1983 9
This technique is based on the concept that in complete cleft lip and palate the tongue has a tendency to fall into the naso pharyngeal region. Thus the tongue does not apply the required pressure on the maxillary segment.
Denmark protocol (1990)10
Treatment of cleft patients in Denmark is centralised in two centers: for the eastern part of the country in Copenhagen and for the western part of the country in Aarhus.
Table 12
Denmark protocol for cleft lip and palate.
Oxford cleft palate protocol (1996) 11
The Oxford Cleft palate Study team assessed the cleft patient. The multidisciplinary assessment included: Speech, maxillofacial growth evaluation, palatal assessment and hearing status.
Table 13
Oxford cleft palate protocol
Brazilian protocol (2003) 12
This protocol based on a survey conducted on the Brazilian Society of Plastic Surgeons where surgeons work in co-ordination with the members of other departments to provide the best possible results for the patients.
Protocol for cleft lip and palate in China (2009) 13
This protocol for cleft lip and palate was deduced after carrying out a survey in 44 dental institutes through a questionnaire. The management of cleft patients involves oral and maxillofacial surgeons, plastic surgeons, pediatric surgeons, and otorhinolaryngologist, speech-language pathologists and orthodontists.
United states protocol (2009) 14
The following protocol are followed by majority of the surgeons in the United States. Surgeons repair clefts in one stage by using Furlow palatoplasty and the Bardach style with intravelar veloplasty.
Table 16
United States protocol for cleft lip and palate
New York protocol (The Hansjo¨rg Wyss department of plastic surgery at New York University Medical Center 2018) 15
This protocol usually emphasizes on the correction of nasal asymmetry which usually remains after the primary repair of the lip.
Clinical practice guidelines (Netherland) 2021 16
Clinical Practice Guidelines were formulated to give the standardized treatment to the patients of cleft lip and palate throughout Netherland. These guidelines were made to the Guidelines Advisory Committee of the Dutch Association of Medical Specialists’ Quality Council and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument which is widely accepted for assessing the quality of guidelines.
Table 18
Netherland protocol for cleft lip and palate
Protocol for cleft palate in Japan (2022) 17
The following protocol has been deduced after observing the treatment protocol at 3 cleft centers in Japan.
Standard treatment guidelines 2022 (India) 18
According to Indian Academy of Paedritics. There are six procedures in repair of CLP.
Conclusion
The management of cleft lip and palate varies among different countries around the globe. Treatment of cleft involves a multidisciplinary approach. The communication between the care giver and taker should be smooth at each level of treatment to maximize the benefit and minimize the apprehension regarding treatment. Different countries should collaborate and share their clinical experiences regarding the future in the management of cleft cases to enhance the skills related to different techniques thereby leading to best time management and enhancing the esthetic appearance and boosting the psychological morale of patients.
