Craniofacial team

A craniofacial team is a team of medical specialists that treat children and adults who have facial deformities such as cleft lip, cleft palate, and cleft lip with cleft palate.

Upon diagnosis, the patient should be referred to a craniofacial team. In practice, often, it is the pediatrician who diagnoses the child immediately after birth. Within the craniofacial team, the child is referred to the ENT-specialist in case of hearing problems, to the speech pathologist in case of speech problems, etc. Mutual consensus on treatment by different specialists is important.

After referral, the child may be seen by a surgeon, who will recommend appropriate surgical procedures. X-rays and lab research may be necessary.

Team meetings and smaller team consultations are held, mostly involving one or two specialists who monitor and supervise a child for a longer period of time. Mutual team consultation results in a better treatment since often more than one target area is treated at once.

Cleft lip and palate

Cleft lip and cleft palate are congenital disorders of the craniofacial complex that occurs early during pregnancy and is present at birth. A cleft lip occurs when the two sides of the lip are separated, including the gum and or the upper jaw.^[1] A cleft palate occurs when the shelves of the palate fail to meet or fuse, resulting in an opening in the roof of the mouth. Cleft lip and cleft palate may affect early feeding, speech , dentition, hearing, velopharyngeal function and psychosocial development. Due to the multifaceted nature of this disorder, a timely coordinated approach by an interdisciplinary cleft palate or craniofacial team is essential to the management and care of this population. According to the American Cleft Palate-Craniofacial Association (ACPA), a cleft palate team provides assessment and treatment for cleft lip and cleft palate only, while a craniofacial team provides assessment and treatment for craniofacial anomalies and associated syndromes.^[2] The minimal requirement for a cleft palate team is a surgeon (see below), an orthodontist, and a speech-language pathologist.^[2] Involvement of other professionals such as audiologists, psychologists (or other mental health professionals), otolaryngologists, pediatricians and general dentists, geneticists, social workers, pediatric nurse practitioners, and radiologists is not uncommon. Most children with a cleft palate evidence early, and usually treatable middle ear disease (otitis media).

The surgeon

Either an Oral and Maxillofacial Surgeon, Otolaryngologist, or a Plastic surgeon. The surgeon is a critical member of the cleft palate team. Their role is to create a functional lip and palate that appears as normal as possible and provides support for the lip and base of the nose. This may, in some cases, require more than one surgery, including initial closure of the lip, initial closure of the palate, lip and nose revision, alveolar bone grafting, and if necessary, closure of orinasal fistula, and/or further palatal or pharyngeal surgery to eliminate hypernasal speech.^[3] Orthognathic surgery to align the upper and lower jaws may also be performed when the child is in his or her teens. The timing of these surgeries range from birth to the teenage years, and is based upon discussions with the orthodontist and surgeon.

The orthodontist

Craniofacial orthodontics is the sub-specialty of orthodontics that focuses on the multidisciplinary and interdisciplinary treatment of patients with birth defects such as cleft lip and palate. These conditions often require coordinated surgical and medical interventions or extraordinary behavioral management to make orthodontic treatment practical and effective. Braces treatments for cleft lip and palate patients tends to be more complex, takes more time and clinical resources, and requires working with multiple dental, surgical and medical providers to get the best results. Current practice standards call for a coordinated plan of care between the fellowship-trained craniofacial orthodontists and plastic-craniofacial surgeons - among other specialists - in order to achieve excellent and esthetic facial results.

The orthodontist whose specialty is the growth and development of the craniofacial complex, is one of the first cleft palate team members the family may encounter. The orthodontist’s evaluation of the newborn will help determine the timing of required surgeries as the child develops.

The speech-language pathologist

The speech-language pathologist is also an essential member of the cleft palate team. Children with cleft palate, while having no trouble with normal language development, can often have delayed speech development due to their mouth's unusual anatomy. The speech-language pathologist will be involved in parent education, newborn feeding instruction, and evaluation and treatment of speech, language, voice and resonance disorders.

The evaluation and treatment of a child with cleft lip +/- palate requires ongoing services from a team of various professionals in a coordinated timely manner. Successful rehabilitation of the child is dependent on continued care by these professionals. Note that not all children with orofacial anomalies will require the care of a cleft palate team. For example, some children with submucous, or occult clefts of the palate, who do not have an impairment of speech/hearing may not need this service.

Team members

Facial deformities require various specialist treatments. These range from surgery to psychology. A typical team:

• Craniofacial Surgeon. Commonly trained initially as a Plastic surgeon, Otolaryngologist or Oral and Maxillofacial Surgeon all of whom usually pursue training beyond their core residency. He/She has specific training and experience in corrective/reconstructive surgery of the craniofacial complex (Skull, face, jaws, etc.)
• Otolaryngologist (ENT). Ear, Nose and Throat Specialist. Many malformations involve defects in the airway passage, inflammation of the middle ear and/or hearing and speech defects. Such complaints are treated by the ENT-Specialist. He/she is also responsible for the hearing tests.
• Audiologist.
• Pediatrician. Familiar with all aspects of the child’s condition, the team pediatrician provides diagnostic evaluations, management of medical problems, and coordinates team care. An important role of the team pediatrician is communication with the primary care provider to monitor the child's overall health and development.
• Pediatric dentist.
• Craniofacial Orthodontist. As member of the craniofacial team the craniofacial orthodontist takes care of the non-surgical treatment of the malposition of the jaws. He/she is responsible for the pre and post operative treatment of jaw surgery and monitors growth by means of X-rays and plaster casts.
• Orthodontic technician. Responsible for the design and fabrication of fixed and removable orthopaedic and orthodontic appliances for the cleft patient from birth through to adulthood. He/she also fabricates dental study models that are used to monitor growth.
• Prosthodontist. Plans and fabricates an obturator to close defects that surgery is not capable of closing. Many patients with congenital deformities are missing teeth or have poorly shaped teeth and require a denture prosthesis.
• Speech pathologist. Evaluate and monitor speech development to help determine if speech therapy, prosthetic devices, or surgery are needed to improve speech skills.
• Psychologist. He/she monitors the child's development and teaches the child how to deal with the social aspects of a facial deformity. The psychologist also aids the parents when needed.
• Clinical Genetist. After thorough family research he/she will advise on heredity with regard to a syndrome. Sometimes a final diagnosis can be defined only after genetic examination (see also Genetic linkage).
• Social Worker. He/she is counsellor of the parents and family when there are problems resulting from the syndrome, treatment and/or hospitalisation. She/he acts as an advisor and is able to contact various official authorities, in and outside the hospital.
• Nursing Officer. From hospitalisation till discharge the nursing officer is responsible for the daily health care and nurture of the child. The nursing officer also advised the parents with feeding difficulties due to cleft.

All team members have deputies in order to guarantee continuity.

Duties of the team

• Craniofacial Team (CFT) evaluates at least 20 individuals with congenital anomalies or syndromes aside from Cleft.
• Prior to surgery, CFT assures that the patient has been scheduled or seen for a health evaluation by a primary care physician.
• Craniofacial surgery is provided in a facility with a pediatric intensive care unit. Facility has CT and MRI capability.
• Members must participate in continuing education programs for craniofacial evaluations and treatment.

Craniofacial Charities

Facing the World is a British charity that was founded to provide facial reconstructive surgery to children with severe facial disfigurements who are not able to receive treatments in their own countries. The entire Craniofacial Team donate their services and the charity fundraises to cover hospital, travel and accommodation costs.

In November 2006, there was an hour-long documentary on the British television network Channel 4 about Facing the World.

Bibliography

• Peterson-Falzone, S.J., Hardin-Jones, M.A., & Karnell, M.P. (2001). Cleft Palate Speech (3rd ed.). St. Louis, MO: Mosby.
• Strauss et al. (1998). Cleft Palate and Craniofacial Teams in the United States and Canada: National Survey of Team Organization and Standards of Care. Cleft Palate-Craniofacial Journal, 35, 473-480.
• The Cleft and Craniofacial Team, (1996) prepared by the Team Standards Committee, American Cleft Palate Craniofacial Association.[1]
• Parameters for the Evaluation and Treatment of Patients with Clefts and other Craniofacial Anomalies, (2007) prepared by the Team Standards Committee, American Cleft Palate Craniofacial Association. [2]

References

1. ^ Cleft Palate Foundation
2. ^ ^{a b} Strauss et al., 1998
3. ^ Peterson-Falzone, Hardin-Jones, Karnell, 2001

External links

• American Cleft Palate - Craniofacial Association Team information.
• European Collaboration in Craniofacial Anomalies (EUROCRAN) for professional workers in medicine and / or dentistry.
• Step-by-step photo examples of a New Jersey craniofacial team at work
• Cleft Lip and Palatum in Indonesia

Craniofacial teams in the United States

http://surgery.med.nyu.edu/plastic/

• Saint Peter's University Hospital New Brunswick, NJ
• Hasbro Children's Hospital of Rhode Island Cleft and Craniofacial Center
• Dallas Craniofacial Center at Medical City Children's Hospital, Dallas, TX
• Fourth Dimension Orthodontics & Craniofacial Orthopedics, Dallas, TX
• Children's Hospital Boston
• Driscoll Children’s Craniofacial and Cleft Center, Corpus Christi, Texas
• Seattle Children's Craniofacial Center
• Craniofacial/Cleft Surgery Center in Pittsburgh
• Craniofacial team, Connecticut Children's Medical Center
• Craniofacial team, Medical College of Georgia
• Loma Linda University Children's Hospital

Craniofacial teams in Europe

• Schisisteam UMC St. Radboud Nijmegen, the Netherlands