Paradigm Shift in Skeletofacial Reconstruction: Changing Traditional Cleft Care

Abstract

Among full-grown patients with cleft lip/cleft palate, a considerable subset presents visible skeletofacial deformities and cleft stigmata–related psychosocial problems requiring appropriate treatment.1 By merging many evolving principles and approaches, we explore a tripod concept–driven paradigm shift (Fig. 1) that would revolutionize the delivery of cleft-skeletofacial reconstructive care (Fig. 2).Fig 1.: The three key, closely interconnected concepts potentiate the essential steps and clinical workflow of skeletofacial reconstruction tailored to the specific requirement of each patient with cleft deformity. In the need-based, total-face appraisal with broad indication criteria, not only is the typical cleft class III deformity addressed but many other occlusal problems and maxillomandibular vertical, transversal, and asymmetric features can also be incorporated into the tailored therapeutic plan. The key perioperative care-related roles and responsibilities of each professional of the multidisciplinary team are coalesced in pursuit of the total face–based outcome, balanced with minimum morbidity. The craniofacial orthodontic, surgical, and health informatics professionals cooperate to achieve precise computer-assisted treatment, which efficiently provides detailed and realistic problem-oriented information to set the surgical feasibility.Fig. 2.: Algorithm showing the multistep cleft-skeletofacial reconstructive journey from the initial multidisciplinary-based consultation to integration into society. Yellow boxes represent the key, closely interconnected concepts that drive the changing of traditional cleft care, with reduction of the overall number of surgeries and treatment time and potential for attenuation of the physical, psychosocial, and economic burden of care. These concepts are provided in a structured integrated pathway with patient-centered care principle. By optimizing the perioperative care process to achieve a balance between the occlusion function and facial appearance, harmony, and symmetry, the cleft stigmata would be profoundly alleviated, with a concomitant improvement in the patient’s psychosocial well-being. Providers, payers, policymakers, and other stakeholders may recognize the value of this life-enhancing approach as an essential step in cleft care. The gradual incorporation of necessary organizational and implementational interventions would accomplish the complete rehabilitation of pertinent functional and facial appearance features that truly matter to a challenging cleft population.The traditional dental-driven reconstructive model is based mainly on the resolution of the typical cleft maxillary constriction and/or retrusion, requiring a long period of presurgical orthodontic therapy. By considering the accurate diagnosis of the actual full skeletofacial deformity, the total face–driven model allows virtually all properly identified occlusal- and skeletofacial-related issues to be corrected in a single surgical intervention, with a profound reduction of the requirement for revisionary surgeries. Furthermore, incorporation of the “surgery first” concept, a reversal of the traditional pathway,2 in cleft care provides an immediate postoperative improvement of oral function and facial appearance, reduces the treatment time, and also mitigates the orthodontia-associated psychosocial distress in a population of patients who have had a massive burden of orthodontic treatments since infancy.3 The total face approach demands a more complex composition of maxillomandibular movements than the traditional approach. Therefore, even a minor misdiagnosis of a deformity or misprediction of specific bone repositioning may result in intraoperative defects, with an increase of surgical time and obstacles preventing the achievement of the desired result. Unlike the conventional, two-dimensional, static planning technique, virtual planning has enhanced the possibilities for a precise and extensive identification and evaluation of skeletofacial morphological characteristics, with the anticipation of potential intraoperative problems which may be considered highly applicable and time-saving measures.4 Superior accuracy and cost-effectiveness outcomes have also been described as the advantages of three-dimensional simulation over two-dimensional planning.5 This reconstructive approach is a technically achievable procedure, but it can be associated with prolonged general anesthesia, increased blood loss, and complications. To successfully maximize the benefit–risk ratio of this surgical intervention, a comprehensive multidisciplinary approach is required. Instead of using regular normotensive anesthesia, the anesthetic team adopts multiple strategies (tranexamic acid in conjunction with a regional anesthetic nerve block and controlled hypotensive general anesthesia) to decrease the amount of intraoperative blood loss. Unlike conventional postoperative management with intermaxillary immobilization (i.e., intensive care unit, nasal trumpet, and nasogastric tube for overnight monitoring), the craniofacial-trained nurse specialists deliver surgical-focused postoperative care (early oral feeding and ambulation, with concentrated oral hygiene and wound care) in regular wards, with an increase of patient safety, reduction of hospital stay, and consequent decrease of the overall total treatment cost. Implementation of this tripod concept–driven model would reflect the full scale of cleft care and revolutionize the traditional planning, execution, and outcomes of cleft-skeletofacial reconstruction. Cooperation initiatives, conducted by governmental and nongovernmental agencies and public-private partnerships, may introduce strategic, health system–related, decision-making processes to guide specific investment plans and actions for promoting focused training, formal education, and the acquisition of facilities and equipment. This may appear to be a distant aspiration in some low-resource regions, but it may well be the most worthwhile goal to pursue. DISCLOSURE The authors have no financial or nonfinancial conflicts of interest related to the material discussed in this work. There was no funding for this work.

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