Cleft lip or palate refers to the separation due to non-fusion of the tissues of the upper lip and palate or roof of the mouth. Surgery is necessary to correct cleft lip and cleft palate.
Who treats cleft lip and palate?
The team of specialists that treat a cleft lip and/or palate include:
- dental specialists
- cosmetic surgeons
- hearing specialists or audiologists
- ear, nose and throat surgeons
- oral and maxillofacial surgeons
- speech pathologists and therapists.
Genetic counsellors and psychologists are also on the team treating cleft lip and palates.
Deciding on the extent of surgery required
Evaluation of the extent of cleft lip and palate - this determines the extent of surgery required.
There also needs to be a thorough examination of the baby along with chromosomal analysis to detect other genetic birth defects and syndromes affecting the baby.
Before surgery, babies may be advised to wear a prosthetic device to close the gap. It is called the OrthoCleft Retainer®.
This helps in bringing gum segments together and reduces the gap in the mouth, stretching the lip muscles, and giving the nose a more even shape. It helps the baby to suck well and feed adequately without gagging or choking on the milk.
The device is made of acrylic and wires. The retainer is fitted by an orthodontist when the baby is about a week old. The retainer is adjusted once a month until the third moth (when the first surgery is performed) to adjust for the growth of the baby.
The babies using the retainers have 20 to 30% less risk reconstructive surgeries and show a better outcome with surgical correction of cleft lip and palate.
Cleft lip surgery
The aim of surgery is to close the cleft and repair associated defects. Cleft lip repair needs a single surgery in most cases.
A curved incision is made on the lip beneath the nose. This allows the side of the lip to drop into a level position. On the other part of the lip an angled incision is made to allow it to advance and meet the remainder of the lip. The ends are then stitched up.
Sometimes a cleft lip affecting the nostrils may need correction and repair of the nostrils as well. Surgery to repair the nostrils takes place during the lip-repair surgery, with later revisions, if needed.
Cleft palate surgery
Cleft palate surgery aims at closing up the roof of the mouth, enabling a child to eat solid foods and develop normal speech. This is a more extensive surgery and may need more number of surgical sittings.
The repair begins when the child is 9 to 18 months old. This gives the upper jaw time to grow but takes place before speech skills begin to start.
The tissues of both sides are brought to the front. This is done at the roof of the mouth cavity as well as at the floor of the nasal cavity. The two layers include a layer of cartilage, bones and muscles between them. These are then repaired. Wider gaps need a higher number of surgeries for correction.
Additional cleft-palate surgeries usually take place when children are 18 months to 4 years of age.
Sometimes a bit of bone taken from elsewhere may be grafted at the gap to bridge the separation between the two ends. A flap from the pharynx may also be used to close the gap.
Further surgeries in older children
In older children who have not had repair further surgeries are needed. The Pin retention surgery is a same-day surgical procedure that helps to align the bony structures along the gums. This may be done 3 to 6 weeks after the repair of the cleft lip.
Prevention of middle ear fluid collection
Prevention of middle ear fluid collection, infections and hearing loss can be done using a tube equalizes the pressure. Pressure-equalizing tubes help prevent fluid from building up in the ear. The tubes remain for six months to a year, and then usually fall out.
Maintaining adequate nutrition
General measures of treatment include maintenance of adequate nutrition. The child should be fed with the head upright at about a 45° angle. Usually bottle feeding is needed. A special nipple may be needed in babies with cleft palates.
If milk or food is aspirated into the wind pipe there may be risk of severe respiratory distress. This is also seen in babies with Pierre Robin’s syndrome where there is a small lower jaw and the tongue falls backwards.
If unrecognized, this syndrome can result in death due to respiratory obstruction.
A speech development assessment is made at 3 and 5 years. Speech therapy may be needed in some children after surgical correction of the clefts.
Orthodontic treatment, which helps improve the alignment and appearance of teeth, may be required in some children.
Children with a cleft are more vulnerable to tooth decay, so it is important to encourage them to practise good oral hygiene. (1-5)
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)