During early fetal development, the two sides that form the lips slowly fuse together at the center of the face. If any errors occur during this binding process, preventing the normal progression of fusion, a fissure or cleft occurs. When such a fissure occurs on the upper lip (primary palate) the condition is known as a cleft lip; when the fissure extends through the entire mouth structure to the hard palate or further inside to the soft palate (velum), the condition is known as a complete cleft of the lip and palate. When only the hard palate or soft palate (velum) is fissured, this is known as a cleft palate.
A. Hereditary Factors
While most exact causative factors are unknown, it is recognized that hereditary and environmental factors contribute to the condition. Hereditary chromosomal defects are known for many other congenital conditions; however, no specific chromosomal abnormality has been identified for a cleft lip or palate deformity at present.
- When both parents are normal: the probability of cleft first baby is one in 600.
- When both parents are normal and one child has a cleft: the probability of a second cleft child is one in 20.
- When both parents are normal and both the first and second child have clefts: the probability of a third cleft child is one in four.
- When one parent has a cleft lip: the probability of a cleft lip child is one in 20.
- When one parent and one child are cleft: the probability of another cleft lip child is one in four.
- When both parents have a cleft lip: the probability of cleft in the first born is one in four
Cleft in children is a question of probability, as there are many factors involved in gestation that cannot be prevented or predicted by medical know-how. Cleft children are not anyone’s “fault,” or the result of anything wrongs done by the parents. Parents have no reason to feel guilty about having a child with a cleft lip or palate.
B. Environmental factors, which may include:
- Viral infections, such as German measles.
- Medications, such as anti-cancer medications, anti-epilepsy medications, or steroids.
- Exposure to X-rays.
- Nutritional imbalance.
Statistically, approximately one in every 600 newborn babies will be born cleft. We may say that in the Philippines there are one cleft in every 500 newborns. There are some racial differences in the incidence of clefts
Feeding a cleft child need not be difficult. As long as the proper method, appropriate nipple, and correct position are combined with patient practice of feeding techniques, the cleft child can receive plentiful nutrition and enjoy the warmth of feeding like any other child. Here are some simple guidelines on feeding:
• Use a specialized cleft palate bottle.
• Place your baby in an upright, sitting position to prevent the formula from flowing back into the nose area.
• Keep the bottle tilted so the nipple is always filled with milk and pointed down away from the cleft. Your baby will move the nipple into the most comfortable position for him/her.
• As your baby feeds, some milk may escape through the nose. This is very common and expected, and it does not mean the baby is choking. Hold your baby in a more upright position as this will lessen the amount of milk coming through the nose.
• Babies with a cleft need to be burped more often because they take in more air while feeding. Watch for signs of discomfort; your baby will give you signs when it’s time to stop and burp.
Question 5: What are the important reasons why reconstructive surgeries for cleft lip and palate are needed?
Expert, careful reconstructive surgery can have far-reaching benefits for a cleft child’s appearance, speech development, improvement of hearing, facial growth, and psychosociological adjustment. Cleft lip and palate reconstruction surgeries generally include any one or combination of cleft lip repair and nose reconstruction, cleft palate repair, or alveolar bone graft. In addition, depending on circumstances, other surgical procedures or treatment may be indicated to improve appearance, oral function, and speech. There is a proper time for each type of surgery, and seeking a center with a well-trained team of personnel and an experienced surgeon at the proper time will yield the most desirable results. The number of surgical procedures, orthodontic treatment, speech therapy, etc. can be limited when conducted by a well-organized, qualified craniofacial center team.
Question 6: Aside from surgical procedures, what dental evaluation and corrective measures should be done for a successful treatment of cleft?
|1 to 3 months||NAM (Nasoalveolar Molding)|
|3 to 6 months||Cheiloplasty|
|12 to 18 months||Pediatric Dental Care Commences||Palatoplasty|
|2 to 3 years||Speech Assessment and Therapy|
Lip and Nose Revision
|7 – 11 years||Expansion and Crossbite Correction||
ABG (Alveolar Bone Grafting)
Lip and Nose Revision
|12 – 16 years||Comprehensive Orthodontics||Abbe Flap|
|17 years and above||
OGS (Orthognathic Surgery)
Lip and Nose Revision
1. Birth to Three Months (Preceding First Lip Repair) During the first visit, the seriousness of the baby’s cleft, and unilateral or bilateral collapse, will determine whether an orthodontic device will be used. This device, known as an intraoral moveable distractor device or nao-alveolar molding (NAM) plate, is an acrylic plate that extends toward the affected side of the nose in front of the upper palate. The device helps correct nose and dental arch shape, prevent continued cleft widening, and aids feeding.
2. Three Months to Six Years Like normal children, cleft children begin to teethe around six months as baby teeth begin to grow from the lower gum. At first, parents should help the child with cleaning the new teeth. Affected children six months and older may also take fluoride tablets as per doctor’s instructions to prevent caries. In some cities, fluoride is added to the normal drinking water. Teeth may grow in crooked, deformed, or not at all at the cleft site. Once the child is older, the appropriate orthodontic correction can be chosen according to the seriousness of such conditions. During this stage it is necessary to monitor skull and tooth growth, recording detailed data including tooth molds, skull x-rays, and internal and external oral imaging. Analyzing the skull and the direction and size of upper and lower jaw growth can go far towards expediting future correctional treatment. In the case of dental caries, pediatric dental care by a pedodontist should be instituted.
3. Six to 12 Years Permanent teeth begin to erupt at around the age of six. The first permanent teeth are the first molars, coming in behind the baby teeth. The first molars are vital for chewing functions, thus a doctor must verify whether the occlusion of the teeth is normal. Baby teeth will begin to fall out, to be replaced by permanent teeth. Underbite (when the upper teeth grow in behind the lower teeth, not ahead) and crookedness or rotation of teeth on the affected side often occur when new teeth grow in, in which case your orthodontist will begin early orthodontic treatment according to age and dental development in order to achieve proper alignment of upper and lower teeth. Early orthodontic treatment is undertaken in order to avert poor growth and poorly positioned or crowded teeth. This is in the interest of hygiene and in preparation for grafting. When the upper and lower teeth are properly aligned, orthodontic treatment is usually halted for a period until all permanent teeth have grown in, at which time a definitive final correction of all teeth is undertaken. If the child is cooperative, maintains good oral hygiene, and returns for regular visits, correction of all teeth can be completed within two years. Gumline deformities can be filled with implants before the incisors grow in at around age nine to 11 to facilitate the budding of the upper incisors and improve the shape of the nose. In addition, liquids will not leak into the nasal cavity through clefts in the gum. Patients with poor midface development and serious underbite may undergo upper maxilla lengthening surgery after the first permanent tooth appears. Through surgery and gradual lengthening of the upper jaw, the maxilla is brought forward, correcting the collapsed facial profile and occlusion. This approach is called distraction osteogenesis and may also be used for adult patients.
4. Ages 12 and Older Upper maxillary and lower mandibular growth is completed around the age of 18. In cases of moderate to serious underbite and poor midface development, craniofacial surgery can be undertaken to correct such conditions.
The child may need further treatments after their first cleft palate surgery as some speech difficulties may be habitual or structural in nature. A combination of speech therapy, secondary palate surgery, and orthodontic treatment may be needed especially in patients who have had their first palate repair at more than 2 years of age. Proper evaluation and coordination by the cleft team is vital in ensuring proper speech function.