Globalizing Cleft Orthognathic Surgery

ABSTRACT: Achieving good outcomes in the management of cleft lip and/or palate (CLP) goes well beyond primary cheiloplasty and primary palatoplasty. The central surgical tenet of CLP care is complete restoration of midfacial anatomy and physiology. As such, the cleft care timeline is based on specifically timed interventions guided by craniofacial developmental milestones. Orthognathic surgery is one of the final, and most impactful, interventions in the rehabilitation of patients with CLP. Even in high-income countries (HICs), the proportion of patients requiring orthognathic surgery can reach up to 70% in certain phenotypes-substantially higher than the portion needing surgery for velopharyngeal insufficiency. The benefits of orthognathic surgery in patients with CLP are many and include the following: correction of malocclusion which improves mastication and speech, improved temporomandibular joint function, prevention of excess dental wear and occlusal trauma, better breathing and sleep, and normalized facial appearance. These comprehensive benefits improve function and also psychosocial domains, including improved self-esteem and reduced perceived stigmatization as measured on patient-reported outcome measures. As CLP care is upscaled in low- and middle-income countries (LMICs), teams seek to expand locoregional capabilities in pursuit of comprehensive, sustainable care. Because the development of an orthognathic surgery program requires many inputs, successful deployment is an indicator of a highly functioning CLP team that is approaching the same level of care delivery as HICs. Orthognathic surgery programs are typically perceived as resource-intensive, requiring multiple subspecialists, advanced equipment, and substantial perioperative resources. This is true to an extent; however, programmatic components can be consolidated while preserving quality of care. The primary objective of this study is to provide a streamlined roadmap to assist in the deployment of LMIC-based orthognathic surgery programs. Secondary objectives are to highlight the ability of orthognathic surgery programs to positively impact patient outcomes and empower locoregional health care providers.