Surgical Specialists.
The UK Clinical Services Advisory Group report (1998) described the complex
relationship between the specialties of plastic, and 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.
Plastic Surgeon.
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. (Definition from the 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 surgery 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. (Definition form the 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 oral and maxillofacial surgery from
other surgical specialties.
The oral and maxillofacial surgeon has responsibility for the following;
This list is taken from - the Development of Oral and Maxillofacial Surgery
Services in the Eastern Health Board Region, published by Eastern Health Board,
February 1999. Note: this list is not exclusive.
Following the first full orthodontic assessment, which occurs at around 6 and a
half 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,
that is the 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, the 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.
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 Ear, Nose
and Throat 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 Ear, Nose and Throat surgeon until they are
10 years of age.
The Paediatric Dental Surgeon provides dental care or guidelines for care to
promote good dental health. They may remove teeth that have erupted incorrectly.
Orthodontist.
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 or 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 6 and a half 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.
The speech and language therapist advises on important aspects of speech and
language development. A speech and language therapist should see children with
cleft lip and palate at around six to nine months for assessment of communication
skills. The speech and language therapist 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, that is, 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 speech and
language therapist will work closely with parents, providing exercises and drills,
which should be carried out at home.
The speech and language therapist 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.
Audiologist.
Psychologist.
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.
Social Worker.
Cleft Co-ordinator.