Managing a cleft baby is an extended commitment for the healthcare industry because the treatment is growth and time-bound, starting from prenatal counselling all the way up to orthognathic surgery and rhinoplasty during adulthood. File photograph
| Photo Credit: The Hindu
Cleft lip and palate, a congenital disorder affecting 1 in 700 live births, is a significant healthcare burden in India. The condition leads to mental agony for the patients and their families. Maternal iron deficiency, alcoholism/smoking, and consanguineous marriages are the most common causes for cleft lip/palate. It shouldn’t be surprising to note that all of these fall very much in the realm of preventable factors.
Managing a cleft baby is an extended commitment for the healthcare industry because the treatment is growth and time-bound, starting from prenatal counselling all the way up to orthognathic surgery and rhinoplasty during adulthood. The family is often distressed and confused on seeing the newborn with cleft lip/palate. The onus is on the cleft care team to transform this feeling to hope and clarity as early as possible.
Feeding cleft babies requires modified techniques to prevent aspiration, and the parents should be trained appropriately. As soon as the baby attains adequate weight and fitness to tolerate general anesthesia, their lip is surgically corrected, offering the first psychosocial breakthrough. We often find the parents and the family gaining confidence and trust after this phase, and they understand the need to wait for timely interventions in a phased manner.
Every case is different
One must accept that although the anomaly has common presentations to a large extent, every case is different in terms of severity and complexity. Complex clefts are often difficult to repair in a precise manner requiring additional interventions. Nasoalveolar moulding (NAM) is one such innovation to reduce the width of the cleft and enhance the shape of the nose, rendering surgical lip corrections more aesthetic. It involves fabrication of a custom appliance that could be fit on newborns with challenging clefts and distorted noses. Although originally described using conventional techniques employed in dentistry, digital technology has off-late improved the way we perform NAM. The cleft team can now acquire an instant photo-scan of the babies’ oral cavity, prepare a 3-D printed replica and fabricate an NAM device without traumatising the baby by contact.
The palate, also called the roof of the mouth plays a crucial role in swallowing and speech. Most often, children begin to utter words around the 10th month of their life and it is during this phase that their palates need to be corrected. Once their cleft palate is anatomically corrected, they have a better chance of learning to pronounce words the right way, often with the help of speech therapy. Innovative assessment tools, such as nasopharyngoscopy and electromyography, enable speech therapists to accurately diagnose and treat velopharyngeal dysfunction (VPD). Newer techniques, including electropalatography and ultrasound biofeedback, facilitate more effective and targeted treatment of speech disorders associated with cleft palate.
The canine teeth are considered the cornerstones of the smile, and need to be in proper alignment in the upper jaw. Unfortunately, due to clefting, they often fail to erupt in a desirable time and position. Alveolar bone grafting involves filling up the bony voids caused by clefting of the upper jaw and this is performed around 8 to 10 years prior to the eruption of the canine teeth, to restore continuity of the jaw bone as well as to facilitate the eruption of the teeth. Although the commonly-used donor site for grafting happens to be the hip bone (Iliac crest), research advances have facilitated the use of bioactive scaffolds, mesenchymal stem cells and growth factors like bone morphogenic proteins (BMP), vascular endothelial growth factors (VEGF) and platelet derived growth factors (PDGF) to enhance outcomes in alveolar bone grafting.
The use of VR
Virtual Surgical Planning (VSP) and Virtual Reality (VR) have revolutionized cleft and craniofacial surgery more than many other sub-specialties at the moment. In general, VSP improves accuracy, reduces operating time, enhances patient safety by identifying potential risks and offers better outcomes. From simulating the cleft lip and rehearsing operations at the skills lab prior to the main surgical theatre, to planning the defect size and bone requirement in alveolar bone grafting, VSP/VR are potentially useful tools for a surgical team. Even the orthognathic surgery, meant to be performed during early adulthood of a cleft patient, could be planned using VSP, and the outcomes discussed with the patient prior to surgery. This provides them with a chance to look at their future faces and decide on alternative approaches rather than accepting whatever is offered.
We are of the strong opinion that cleft care involving the integration of AI in VSP along with augmented reality will positively influence the dynamics in a medically strong country like India. These advances will enhance the standard of care in aesthetically and functionally challenging anomalies involving the face.
(Dr. J. Naveen Kumar is professor and head of oral and maxillofacial surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai [email protected])
Published – March 10, 2025 03:21 pm IST