The outcomes of the cleft surgery are variable and depend on many factors. First of all, the quality of the tissues and the size of the cleft play an important role in how the surgery affects the growth of the maxilla . According to the Eurocleft project, the experience of the surgeon and the facilities of the center where the operation is performed are critical .
In 2006, our cleft center in Brno introduced a new surgical protocol: the neonatal operation of the lip and palatal closure performed on patients before reaching one year of age. This surgical approach is also followed in some other countries . The timing of cleft lip repair continues to be debated; it varies according to the protocol of the respective centers. Operating on the lip in the neonatal period, due to the high elasticity of the tissues, can work as a natural nasoalveolar molding, helping the two alveolar segments to get closer .
The hypothesis that anesthesia in the neonatal period can be more dangerous than when administered at the age of three months may be one of the reasons for some centers not to repair the lip neonatally. However, major advances have been made in neonatal anesthesia and surgery, and more recent studies have indicated that an anesthesia itself does not convey a greater additional risk in the neonatal period than at three months in patients without risk of complications [17, 18]. Pediatric anesthetic and intensive care support in a specialized center are necessary, and close postoperative monitoring is required [19, 20]. A recent study evaluating whether the general anesthesia in early infancy affects neurodevelopmental outcomes demonstrated that children who underwent anesthesia in infancy, started school life with no neurodevelopmental risk factors .
A study carried out in the Czech Republic by Petráčková et. al who compared the outcomes of two groups of patients with clefts who were operated on neonatally and at a later time showed that the earlier anesthesia did not have a negative impact on the intelligence quotient compared to later anesthesia. Moreover, the earlier cleft lip repair showed a significantly positive impact on the psychosocial development of some children .
Regardless of the timing of the surgery, either neonatally or later, surgical treatment of children with unilateral cleft lip and palate will always have an effect on the growth of the maxilla and interdental relationships. As a natural consequence, a surgical intervention leaves scar tissue which restricts the physiological growth of the jaws [23, 24, 25].
It is desirable to assess the outcome of the primary surgery as early as possible so that the effects of the timing and the surgical techniques can also be evaluated . Besides dental models, several other methods exist for the assessment of dental occlusion such as lateral cephalograms, photographs of study models or even extraoral photographs. The accuracy of extraoral photographs for evaluating the growth of the maxilla has been questioned . However, the use of intraoral photographs for the evaluation of the interdental relationships has been accepted .
The 5 Year Olds´ index according to Atack is a simple, useful and well-known method for the assessment of maxillary growth and dental occlusion, “clean“ from any secondary interventions such as orthodontic or orthopedic treatment or secondary alveolar bone graft surgery. This index allows the assessment of the surgical outcome at the age of five years. The 5 Year Olds´ index has been proven as a reliable method for the evaluation of the interdental relationships and comparison of the results between different cleft centers . Moreover, by using this index the need for early treatment in young children can be identified.
In this study, the 5 Year Olds´ index demonstrated favorable outcomes of neonatal cleft lip repair and one-stage palatal closure carried out at the age from 6 to 13 months: 57% of cases will require only simple orthodontic treatment, 24% will need more complex orthodontic treatment and 19% will require orthodontic-surgical treatment. It is important to emphasize that prior to the time of the assessment, none of the patients had received any orthodontic or orthopedic treatment.
These favorable results may be due to the fact that all the operations were always performed by one surgeon using the same surgical protocol in all subjects . The surgeries were carried out with the presence of experienced pediatric anaesthesiologists and support of a modern pediatric intensive care unit. The Eurocleft study [29, 30, 31] showed that the centers that follow the same protocol of long-term care and have a small number of skilled plastic surgeons demonstrate the best outcomes.
The comparison of the results of our study with those reported by other cleft centers employing different protocols showed that neonatal cleft lip repair and one-stage palatal closure led to satisfactory results in five-year old children, only with a minimal number of patients with poor long-term outcomes. However, the impact of the surgery on the growth of the jaws must also be assessed at older ages, particularly in the peak growth period at the age of 12–14 years .
In conclusion, we believe that the neonatal approach performed by skilled plastic surgeons in the centers experienced in neonatal surgery leads to satisfactory results in patients with UCLP without severe risks of complications.