The designation labio-maxillo-palatal cleft is used to describe two types of congenital malformations of the palate. The mechanisms that create them occur in the early weeks of fetal life by an alteration of embryological message delivery that researchers have been able to analyze. But they have not as yet been able to discern the multi-factorial causes of this alteration.

Morphological embryology and its chronology are important because researchers use an understanding of them to distinguish between different entities of clefts on the basis of the stage of palatal formation in which they began to develop: the numerous molecules involved In cell development are already well known, but researchers have not yet precisely identified those that are associated with the various stages of palatal morphogenesis. But it is clear that genetic alterations, which are now being pin-pointed, trigger developmental malfunctionings that are later intensified by faulty interactions in the fetal-maternal environment because.

Conclusion: Although researchers are progressively gaining a better understanding of the mechanisms of the intra-uterine formation of labio-maxillo-palatal clefts, we have not yet acquired the broad range of data that would make it possible to correct defective palatal formation before birth.

Any attentive observer of families who have a child afflicted with a cleft lip whether or not associated with a palatal cleft would be certain to be impressed by the importance of the psychological context of their interpersonal exchanges and the risks of a breakdown in the parent-child relationship adversely affecting the child’s development. The birth of a child with a cleft lip inevitably becomes a painfully stressful and traumatic event for its parents.

In the framework of the Programme Hospitalier de Recherche Clinique (PHRC) we have evaluated the psychological perceptions of parents of cleft lip and palate patients during the child’s first year of life in a multi-disciplinary and multi-group prospective study. Our goal is to analyze both the child’s psychic suffering and the parent-child relationship. We compared the results obtained in four hospital centers using different surgical protocols, distinguishing between the sub-groups of parents who had learned of the defect from an in utero examination and parents who did not become aware of the cleft until the child was born.

We analyze for the parents the psychic and psychological dimensions of the deformity and its correction, touching on the importance of a prenatal diagnosis, the development of a relationship with the child, self-images, and the quality of life as well focusing on the infant’s distress and eventual recovery from it. The results of this study should make it possible for health care workers to construct new ways of attenuating, insofar as possible, the psychological impact of the deformity on parents and their children and to improve long term care for these patients.

Over the last 50 years, the dominant conception of the etiology of facial clefts postulated that they resulted from a mesodermal deficit that accounted for the primary hypoplasia and the unpredictable nature of subsequent oro-facial growth. Because of this notion, rigid dogmatic interdictions, with no allowance for nuanced treatment adjustments were issued banning sub-periosteal and sub-perichondrial dissections as well as the undertaking of any nasal surgery during the growth period. These prohibitions have had a grave braking effect on the development of treatment for cleft lip and palate patients.

With a new comprehension of the important role that the dynamics of fetal ventilation plays in the development of the airways and its influence on maxillary growth researchers no longer have any doubt that normal growth mechanisms operating under abnormal anatomic conditions created by the cleft are the actual causes of the malformations and the facial growth deficit suffered by children born with clefts. It now seems likely that the nasal septum plays only a passive role in growth, as Moss believed, rather than the active one that Scott as well as Delaire defined, calling it the driving force of maxillary development. They advocated re-inserting the lateral muscles on the anterior nasal spine. But practitioners who limit their functional approach to this procedure risk being deceived. In addition this focusing on muscles distracts us from what is essential, nasal ventilation, whose rehabilitation beginning with the first operation and preservation throughout treatment are absolutely necessary to ensure the normal unfolding of a cleft palate patient’s facial growth.

To achieve this goal surgeons must complete anatomic reconstruction with precisely timed, ambitious surgery carefully designed to control scar formation. Whether their procedure is unilateral or bilateral surgeons make this correction of the nasal malformation best if they operate when patients are six months old and close the lip defect at the same time. During this procedure surgeons close the soft palate defect using the Sommerlad technique taking advantage of the shrinking of the hard palate gap that closes enough to allow for simple, complete surgical elimination of the cleft in two layers without leaving dense scar tissue or denuded areas. By the time patients are 4 years old orthodontists have expanded the anterior maxilla to establish good canine function and surgeons can close the alveolar cleft with a gingivoperiosteoplasty and an iliac graft. Each procedure conserves the width of the piriform orifice, the nasal fossae and the anterior, incisor-canine sector of the arch. Nasal ventilation, as well as symmetrical, centered mastication, is required for normal facial growth.

Parents want their children’s’ faces, the most visible part of their bodies, one that marks their identity throughout life, to be perfect. To satisfy this understandably urgent desire, a high quality of primary treatment for cleft lip and palate is essential and must satisfy a double objective: restore normal morphology and normal function. The functional, morphological, and esthetic prognoses depend on the character of the defect, whether it stands alone or is associated in a syndrome with other malformations. Important sequellae flow from the quality of the initial repair, as a consequence of the surgery and other therapies as well as from the deformity itself.

Before the year 2000, the Maxillo-facial and Plastic Surgery Service at the Armand Trousseau Hospital of the Pierre and Marie Curie Faculty of Medicine adhered to the protocol that Malek had described, making an initial repair of the soft palate at 3 months and then a cheiloplasty, with upper and lower triangles, and closure of the hard palate at 6 months. Since then we have adopted the more functional approach that Talmant described, integrating systematic nasal surgery and the type of lip surgery that Millard suggested without leaving any residual exposed bone after closure of the osseous cleft. We then perform gingivo-periosteal surgery with bone grafts on patients when they were between 4 and 6 years of age, after orthodontic therapy had been completed. This constitutes the last stage of primary treatment.

The therapeutic approach we have been using on our service, which has evolved of over the last 20 years, has come to define its principal objective as integration of extensive rehabilitation into the very first stages of our multi-disciplinary therapy so as to minimize the establishment of faulty functioning of phonation, lip competence, and ventilation while avoiding any intervention that would have a harmful impact on facial growth. This multi-disciplinary approach, which integrates surgical evaluation and protocol, is indispensable and fully justifies treatment of patients with cleft lip and palate at accredited centers.

Labio-maxillary-palatal clefts, which are caused by fetal nasal buds failing to fuse with the maxillary bud, disrupt the ensemble of the structures that support and interact with the nose and upper jaw creating a rupture of balance that becomes an increasingly exacerbating vicious circle. In correcting these defects practitioners must effect a compromise between the need to re-unite separated parts – under as little tension as possible – and the need to preserve the interrupted potential for growth in the affected facial region. They must carry out this compromise in the double sense of topography and chronology.

Adhering to this therapeutic philosophy, the Nancy protocol closely associates orthopedic preparation and surgical treatment of patients to obtain:

     – high quality morphology,

     – an unblocked, sufficiently broad maxilla,

     – correct nasal breathing,

     – velo-pharyngeal competence.

We use a tibial periosteal graft to repair the oral cleft as an important element of our procedures.

Only competent centres are able to provide the full range of multi-disciplinary specialized therapies that cleft lip and palate rehabilitation requires. Despite some detail differences in conducting treatment, the agreed centres produced consensual treatment philosophy and observe equivalent therapeutic schemes. These sequences, to which orthodontics invariably contributes, are designed to favour the normal outcome of facial development and functions.

Beginning early in mixed dentition, orthodontic rehabilitation is designed to afford patients good dental occlusion through orthopaedic and orthodontic therapies. At the end of the growth period, orthodontics prepares for eventual final surgical and prosthetic repair.

We avoid extraction of permanent teeth as an adjunct to treatment because it has deleterious effect on final skeletal harmony. We prefer basic appliances for mechanical therapy, and after completion of active treatment, a prolonged retention. A trained orthodontist is able to complete the orthopaedic and orthodontic stages in cleft lip and palate repair if he fully understands and follows the general cleft lip and palate treatment scheme and effectively communicates with the competent rehabilitation team.

For many years TREFLE, The Ecully team treating labio-palatal clefts, has begun managing the care of patients with clefts at younger and younger ages. Both surgically and orthodontically we design our therapeutic interventions to change the environment of the cleft as rapidly as possible in order to improve patients’ functioning that will in turn have a beneficial effect on growth and esthetics. We have found that our patients treated in this way not only have improved appearance but also less likelihood of needing orthognathic surgery. We have also found that our patients do not routinely require early bone grafts, at about 6 years of age. We determine which children will require this intervention in a re-evaluation that we undertake after the completion of the primary phase of orthopedic and orthodontic therapy.

To make our technique as clear as possible throughout the course of this article we present the different stages of treatment of four children, Leslie, Jules, Nathan, and Élodie.