Survey of management of children with cleft lip and palate in teaching and specialist hospitals in Nigeria

Between unity and disparity: current treatment protocols for common orofacial clefts in European expert centres

There is considerable variability in the management of common orofacial clefts across Europe, reflecting differing opinions on optimal treatments. An updated overview of treatment protocols for orofacial clefts across 26 expert centres in the European Reference Network CRANIO is presented here. A structured questionnaire was distributed to map the surgical protocol and additional standard procedures for cleft palate (CP), unilateral cleft lip and palate (UCLP), and bilateral cleft lip and palate (BCLP). A surgical protocol was defined as the unique combination of a sequence of standard surgeries, their timing, and the surgical techniques employed. Overall, 33 unique surgical protocols for CP, 54 for UCLP, and 51 for BCLP were identified. Notable findings included the trend towards early hard palate closure, uniform timing of lip closure, and the popularity of primary cleft rhinoplasty. Nevertheless, practice variations were most pronounced in the timing of alveolar closure, the number of standard surgeries, and the application of additional standard procedures. This study highlights the diversity of treatment protocols across Europe, despite considerable convergence of treatment practices over time. To allow for further convergence, establishing objective criteria for protocol selection, adequate documentation of customizations, and consensus on the terminology of surgical techniques, are necessary.

Regional variations in cleft lip and palate repair techniques: A mixed-methods study of international volunteer surgeons

BACKGROUND

Despite the availability of multitudes of surgical techniques for cleft lip and/or palate (CLP) repair, the geographic distribution of their usage remains largely unknown. We investigated the technical preferences in CLP repair within an international cohort of volunteer surgeons.

METHODS

This was a mixed-methods study. A retrospective review of patients with CLP treated within the Operation Smile programs between 2021-2024 was conducted. Clinical records were reviewed for operative techniques. Surgeons who did not specify their technique were then surveyed to elicit specific preferences.

RESULTS

In total, 888 patients with CLP were included. Among them, 375 underwent primary unilateral cleft lip (UCL) repair (42.2%), 102 bilateral cleft lip (BCL) repair (11.5%), and 411 cleft palate (CP) repair (46.3%). The most frequently performed surgical techniques were the Fisher repair for UCL, Mulliken repair for BCL, and Bardach for CP. Regarding UCL and BCL techniques, no significant differences in preference were found between high-income country (HIC) and low-and middle-income country (LMIC) surgeons. For CP repair, the von Langenbeck technique was preferred by LMIC surgeons (44.7%), whereas the Bardach technique was preferred by HIC surgeons (57.6%) (p = 0.03). Novel modifications were reported 3 times for UCL repair, 7 times for BCL repair, and once for CP repair.

CONCLUSION

Our study was the first to document the global variations in CLP techniques. Most HIC and LMIC surgeons prefer the Fisher repair for UCL. For CP repair, the HIC surgeons prefer the Bardach technique, while LMIC surgeons prefer the von Langenbeck technique. A concerted effort to transmit knowledge across borders is essential for continued technical innovation.

Perspectives on the state of cleft lip and cleft palate patient care in Africa

PURPOSE OF REVIEW

Patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa.

RECENT FINDINGS

To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources.

SUMMARY

The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.

Global Trends in Knowledge, Attitude, and Awareness of Orthodontists Regarding the Management of Patients with Cleft lip and/or Palate: A Systematic Review

The aim of the present systematic review was to assess the trends in knowledge, attitude, awareness, and practice among orthodontists regarding the management of patients with cleft lip and/or palate.

An a priori protocol was developed as per the best practices of evidence-based medicine and registered in Prospero (CRD42022306107). The literature search was conducted electronically, using MeSH-terms, keywords, and Boolean-operators "AND" and "OR" in different combinations in multiple databases and screening of titles and abstracts followed by full-text evaluation was performed. The risk of bias (ROB) was assessed using Joanna Briggs Institute critical appraisal checklist.

Five studies were included in the qualitative synthesis and three of them showed a high ROB. When participants were questioned about which other specialists worked in the cleft team in addition to the orthodontists, 84% of them in one study reported it to be general dentists. Furthermore, the absence of an interdisciplinary team was reported in two studies from Africa. When asked about the percentage of their practice devoted to the care of patients with cleft lip and palate (CLP) one study reported that 52% of orthodontists had treated <10 such patients in their entire career.

The present systematic review highlights the lack of knowledge and experience among orthodontists and orthodontic residents regarding the management of patients with CLP. Efforts must be made to design validated questionnaires and conduct methodologically sound studies in different geographical locations to develop adequate modules for improving the knowledge of orthodontists in this domain.

Trends of cleft surgeries and predictors of late primary surgery among children with cleft lip and palate at the University College Hospital, Nigeria: A retrospective cohort study

BACKGROUND

Cleft of the lip and palate is the most common craniofacial birth defect with a worldwide incidence of one in 700 live births. Early surgical repairs are aimed at improving appearance, speech, hearing, psychosocial development and avoiding impediments to social integration. Many interventions including the Smile Train partner model have been introduced to identify and perform prompt surgical procedures for the affected babies. However, little is known about the trends of the incidence and surgical procedures performed at our hospital. Nothing is also known about the relationship between the clinical characteristics of the patients and the timing of primary repairs.

OBJECTIVE

To determine the trends in cleft surgeries, patterns of cleft surgeries and identify factors related to late primary repair at the University College Hospital, UCH, Ibadan, Nigeria.

METHODS

A retrospective cohort study and trends analysis of babies managed for cleft lip and palate from January 2007 to January 2019 at the UCH, Ibadan was conducted. The demographic and clinical characteristics were extracted from the Smile Train enabled cleft database of the hospital. The annual trends in rate of cleft surgeries (number of cleft surgeries per 100,000 live births) was represented graphically. Chi square test, Student's t-test and Mann Whitney U were utilised to assess the association between categorical and continuous variables and delay in cleft surgery (≥12 months for lip repair, ≥18months for palatal repair). Kaplan-Meier graphs with log-rank test was used to examine the association between sociodemographic variables and the outcome (late surgery). Univariable and multivariable Cox proportional hazard regression was conducted to obtain the hazard or predictors of delayed cleft lip surgery. Stata version 17 (Statacorp, USA) statistical software was utilised for analysis.

RESULTS

There were 314 cleft surgeries performed over the thirteen-year period of study. The male to female ratio was 1.2:1. The mean age of the patients was 58.08 ± 99.65 months. The median age and weight of the patients were 11 (IQR:5-65) months and 8 (IQR: 5.5-16) kg respectively. Over half (n = 184, 58.6%) of the cleft surgeries were for primary repairs of the lip and a third (n = 94, 29.9%) were surgeries for primary repairs of the palate. Millard's rotation advancement flap was the commonest lip repair technique with Fishers repair introduced within two years into the end of the study. Bardachs two flap palatoplasty has replaced Von Langenbeck palatoplasty as the commonest method of palatal repair. The prevalence of late primary cleft lip repair was about a third of the patients having primary cleft lip surgery while the prevalence of late palatal repair was more than two thirds of those who received primary palatoplasty. Compared with children who had bilateral cleft lip, children with unilateral cleft lip had a significantly increased risk of late primary repair (Adj HR: 22.4, 955 CI: 2.59-193.70, P-value = 0.005).

CONCLUSION

There has been a change from Von Langenbeck palatoplasty to Bardachs two-flap palatoplasty. Intra-velar veloplasty and Fisher's method of lip repair were introduced in later years. There was a higher risk of late primary repair in children with unilateral cleft lip.

Cleft Lip and Palate Care in Nigeria: Current Status of Orthodontic Residents' Training in the Management of Children With Cleft Lip and Palate

This study aimed to assess and achieve an overview of the current status of training of orthodontic resident doctors working in Nigeria with regards to the management of children affected with cleft lip and palate (CL/P). Semistructured questionnaires containing 10 categories of questions relating to CL/P care were sent to 20 orthodontic resident doctors training to become specialists and working at 3 hospital training centers in Nigeria. Sixteen out of 20 (80%) questionnaires were eventually completed by the doctors and returned. Results were analyzed and reported as follows; 15 (94%) of the resident doctors had no orthodontic clinical experience in the management of children with CL/P and had never fitted a presurgical orthopedic appliance prior to the time the research was conducted. All the 16 resident doctors (100%) claimed to have been informed and taught in CL/P management by attending formal lectures and presenting seminars topics. Majority 15 (94%) of the resident doctors still did not have the required experience and research skills in the field of CL/P, while 14 (87.5%) of them had never attended craniofacial conferences before now. This study has revealed shortcomings in training of orthodontic residents as it concerns the management of children affected with CL/P in Nigeria. Trainers and orthodontic training institutions in Nigeria may need to restructure their training program to allow for more in depth training as it concerns management of children affected with CL/P.