Cleft Lip and Palate
What is Cleft Lip and Palate?
Cleft Means Gap
A cleft lip is a separation of the two sides of the lip. The separation often includes the bones of the upper jaw and/or upper gum. A cleft palate is an opening in the roof of the mouth. Cleft lip and palate is a condition, which occurs when the two sides of the lip or roof of the mouth (palate) does not completely fuse together, as the unborn baby was developing. The lip and palate develop separately so it is possible for a child to have a cleft lip, a cleft palate or both. The size of the cleft lip may range from a small notch in the upper lip (Fig. 1.1) to an opening that extends into the base of the nostril (Fig. 1.2). The cleft may be single sided or may occur on both sides.
Cleft lip : At times parts of the face do not grow fully and meet each other in the midline, leaving a gap (Fig. 2.1).
Fig. 2.1 Cleft of lip
Complete cleft : When the deformity spreads back across from the jaw bones where tooth buds are hidden to hard palate and even soft palate it is called complete cleft (Figs 2.2 and 2.3).
Fig. 2.2a, b, and c Cleft of lip extending into hard palate and soft palate.
Fig. 2.3 Cleft of lip extending into hard palate and soft palate.
Bilateral/Unilateral cleft : If the upper lip that is formed in three parts, the middle, and the two halves on the sides do not attach to each other, and if the defect is on both the sides called bilateral or at times it may be on either side then it is called unilateral cleft lip (Figs 2.3, 2.4 and 2.5).
Fig. 2.4a and b Cleft of lip on both sides.
Fig. 2.5 Cleft of lip on both sides extending into hard and soft palate.
Fig. 2.6 Cleft of soft palate extending into hard palate.
Cleft of soft palate : At times the cleft may be limited only to the soft palate while the rest of the palate and lip/face may be normal (Fig. 2.6).
Problems associated with cleft
- Feeding problems, baby cannot suck milk
- Flow of milk through nasal passages during feeding causing recurrent chest infections
- Failures to gain weight
- Speech difficulties
- Recurrent ear infection
- Missing teeth or extra teeth, poorly formed front teeth
- Malaligned teeth
- Change in nose shape
How often is Cleft Lip and Palate?
You are not the only parent to have such a child. Approximately one child out of 1000 live births in India is born with this facial deformity. The majority of children born with cleft lip and palate are otherwise normal with no associated syndromes. However, a few may have associated disease affecting several systems called syndromic clefts. Cleft lip and palate occurs more frequently in males and cleft palate alone occurs more frequently in females. The incidence of cleft palate has some racial predictions.
Why am I the chosen one???
Why did God choose me???
Why My Child Has Cleft Lip/palate?
While your baby is growing in the mothers womb, parts of the skull, face and head gradually grow together. Cleft lip and palate occur when some of these areas do not join up fully before birth. These defects do occur during first few weeks of life.
Why some children have this deformity?
The real cause of this problem is usually unknown. Cleft deformity can be familial. Probably it’s causes involve a combination of genetic and environmental factors. Environmental factors, which may increase the risk of clefting are:
- Smoking and alcohol use during pregnancy,
- Poor maternal nutrition,
- Vitamin B deficiency,
- Excessive exposure to radiation,
- Anti-abortificant drugs, and
- Certain medications such as those used to control nausea
Please take care of yourself when we are inside — it’s a safer world out there!!!
Cleft lip and palate has familial tendency too.
Indian Social Scenario
India is said to be a land of religious beliefs, superstitions and myths associated with all kinds of diseases. In such a social scenario, a child born with a birth defect of the face maybe considered bad omen. The mother is blamed and the problems become compound if it’s a baby girl. The rural scenario is sad due to the lack of knowledge regarding cleft lip and palate.
Many parents may not disclose the child born with cleft lip or palate; however, the urban scenario is a little better. This may not be the case with the educated and affluent families. They start consulting doctors, surgeons and others collecting information about the health, safety and longevity of their child. Yet they need guidance, to follow the correct course of treatment for better outcome.
Unfortunately, little information is available in India in print or media and there are no cleft palate help lines or trained social workers or specialist nurses to handle such a family and child. In Indian medical setting perhaps, we need to educate people and bring awareness among medical, paramedical and all health professionals about:
- What are the problems of a child born with cleft?
- How soon can we have his/her surgery to repair the lip and palate?
- Can he/she grow like other normal children?
- Will he/she be able to speak and eat normally?
Treatment of such a child is required from the day a child is born till adulthood. Several specialists have an important role in the management. Let us meet them and see what they are supposed to do for you.
Do not forget that for better results of the treatment to make child look and grow like normal with minimum physical and financial burden, it is recommended to follow treatment at cleft specialized centres which follow “ intererdisciplinary team approach”. That means that all the important specialists should see the child together whenever needed and plan the treatment in consultation with each other. They may carry on the treatment independently thereafter, but must at some point meet to evaluate treatment outcome and discuss further treatment whenever the need be there.
Interaction with the right professionals regarding awareness of long term treatment and guidance with various other specialists is needed from time to time. Choose a team of specialists which works closely and has also the availability or referral to supportive specialists as and when required (Figs 6.1 and 6.2).
The Interdisciplinary Team
Interdisciplinary treatment approach works best for the cleft child. There could be a large number of experts in the team with the best of expertise and knowledge. What is really needed is understanding and cooperation among them in order to provide best care for the child.
The person who specializes in the care of new born children is called neonatologist. However, in many cities, towns and villages a paediatrician may perform the duties of a neonatologist. He is usually the first person to notice the defect as soon as a child is born and would be the in charge of new born baby’s health and medical problems. He would also monitor heart, lungs and other systems of the body to rule out if cleft lip and palate are the only defects or they are associated with other anomalies. He may seek expert opinion from a heart specialist or a geneticist. Your doctor will also monitor regular feeding and weight gain and health of the baby.
Many cleft centers have a specialist nurse trained to handle new born with congenital defects of face and cleft lip and palate. A nurse educates parents of the cleft child to feed and use of devices required to feed a child with cleft lip and palate. She will also communicate with surgeons during and after surgery of the cleft child.
The cleft surgeon handles surgery of small children born with cleft of the lip and palate. He is either a Plastic surgeon or an Oral surgeon who has special expertise in surgery of this defect of face.
- If the surgery involves both, lip and the palate then extra care is required in handling the lip, which is yet to grow to the full size of an adult. First surgery is often restricted to repair of lip and front part of jaw, done usually around 10 weeks.
- The cleft lip and palate surgery is extremely delicate and a good surgery is one which brings about good esthetics and in the long run speech is not severely affected and so there is least inhibition in the growth of upper jaw.
- The cleft surgeon will also undertake surgery later in life to close the remaining gap in the palate. The surgery on palate is done around 12 months to 18 months of age.
- Surgery to undertake a bone graft at about 9 to 11 years is necessary followed by another surgery of the lip and nose to give them a better shape in adulthood.
- The above may also involve operations on the soft palate to make it longer for better speech.
A clinical psychologist counsels parents to overcome and deal with psychological issues consequent to a baby with a defect of face. He also helps the child to overcome any difficulties in social behavior, low self esteem and social adjustment in life. Do not avoid consulting him if you feel the need for it would be a benefit for you and your child.
Speech And Language Therapist
A speech and language therapist helps the child overcome speaking and language problem. He/She would assess the nature and severity of speech and communication problems of the child asking you to undertake several tests to analyze the severity of the problem. The therapist may like to give you certain speech and articulation advice and exercise.
Audiologist and ENT Surgeon
The audiologist and/or ENT surgeon helps you to assess the hearing problems in the child.
- Take the child for testing hearing ability with audiologist and consult with ENT surgeon.
- Recurrent middle ear infection/blockage of the tube connecting throat with the middle ear causes inadequate hearing capacity of the child.
- Consequences are delayed/improper speech: The development of speech is in response to hearing.
Dental Surgeon Or Child Dental Specialist: Paedodontist
The dentist takes care of dental health and gives you advice on hygiene and how to prevent dental decay. He/She will also be watchful of the developing dentition and any dental irregulaties and refer you accordingly to an Orthodontist.
The Orthodontist is the specialist dental surgeon who will take care of the dental irregularities and will work as a watch dog to see how the jaws are growing as the face grows big towards adult size. He may in some cleft teams be a team leader and service coordinator for your child’s problems with all other specialist. The following features are watched out by the Orthodontist:
- Normal and abnormal eruption pattern of teeth
- Irregularities in the teeth
- Extra teeth
- Missing teeth
- Shape and health of teeth
- Assess the growth of the face and jaws
- Any rehabilitation required e.g.: Plate to cover post surgical defect/measures to expand upper jaw if it is narrow in proportion to the lower jaw. It is called Obturator.
- Alignment of crooked teeth/malaligned teeth with the orthodontic braces (removable and fixed barces).
- Co-ordination with the oral surgeon regarding bone grafting and institution of comprehensive orthodontic care.
- To make a periodic review to prevent any relapse of corrections from occurring.
- Coordinate and prepare teeth and jaws with Oral and maxillofacial surgeon in case the child needs secondary surgery of jaws.
- Coordinate with plastic surgeon when patient needs secondary surgery/ies of lip nose or other such cosmetic surgeries.
Oral And Maxillofacial Surgeon
An oral surgeon is the one who undertakes surgical procedures on the face or mouth particularly on the jaws and associated structures.
- In cases with severe growth deficiency harmonising jaw relation is not possible alone with orthodontic treatment. Here the oral surgeon has to undertake surgery to achieve good balance of the face. Such procedures are carried inside the mouth to avoid scar formation on face.
Orthognathic Surgery :
It is done mostly after growth is complete say during early adulthood. These are called Orthognathic Surgery which is preceded and followed by orthodontic treatment for final settlement of dentition. Such surgeries are usually done after puberty is complete.
The Prosthodontist is the specialist dental surgeon who deals with rehabilitation of teeth by making artificial teeth and prosthesis.
The followings procedures are often done by a Prosthodontist or a Dental Specialist:
- Rehabilitate cleft defect by making a plate for those patients where it is not possible to repair by surgery or failed due to surgery.
- Replace missing teeth with implants or such options
- Restoration of malformed teeth with crowns, or laminates or esthetic fillings or such procedures.
- Make special appliances called speech bulb to help and improve speech.
The clinical geneticist helps parents making them aware of the chances of having another baby with cleft or not.
Want to Know More?
At e-DantSeva we are always available to answer any questions you have about your dental health and the choices that are available to address specific conditions. If you have any questions involving your dental health feel free to write to us at nohpindia[at]gmail[dot]com
For website technical support or any problem regarding the website kindly write to us at edantsevanohp[at]gmail[dot]com