Cleft lip and cleft palate

Cleft lip and cleft palate are malformations of the face and mouth that occur very early in pregnancy when the baby is developing inside the mother. A split occurs when there is not enough tissue in the mouth or lip area and the existing tissue does not fit together properly.

A cleft lip is a physical split or separation of the two sides of the upper lip and looks like a narrow opening or space in the skin of the upper lip. This separation often extends beyond the base of the nose and includes the maxilla and/or upper gingival bones.

A cleft palate is a cleft or hole in the palate. A cleft palate may involve the hard palate (the bony front of the palate) and/or the soft palate (the soft back of the palate).

Cleft lip and cleft palate may occur on one or both sides of the mouth. Since the lip and palate develop separately, cleft lip without cleft palate, cleft palate without cleft lip, or both are possible.

Who has a cleft lip and a cleft palate?

Clefts are more common in children of Asian, Hispanic, or Native American ancestry. Twice as many boys as girls have cleft lip with or without cleft palate. However, compared to boys, twice as many girls have cleft palate without cleft lip.

What causes cleft lip and cleft palate?

In most cases, the cause of cleft lip and cleft palate is unknown. These conditions cannot be avoided. Most scientists believe that clefts are caused by a combination of genetic and environmental factors. A newborn is more likely to develop a cleft if a sibling, parent, or relative has had a problem.

Another potential cause may be related to medications the mother may have taken during pregnancy. Some medicines can cause cleft lip and cleft palate. These include: antiepileptic/anticonvulsant drugs, acne medications containing Accutane, and methotrexate, a drug commonly used to treat cancer, arthritis, and psoriasis.

Cleft lip and cleft palate can also result from exposure to viruses or chemicals during the development of the fetus in the womb.

In other situations, cleft lip and cleft palate may be part of another medical condition.

How are cleft lip and cleft palate diagnosed?

Because the cleft causes very obvious physical changes, cleft lip or cleft palate is easy to diagnose. A prenatal ultrasound can sometimes determine if a baby has a cleft. If the cleft was not detected on ultrasound before the baby was born, a physical examination of the mouth, nose, and palate confirms the presence of a cleft lip or palate after the baby is born. Sometimes diagnostic tests may be done to determine or rule out the presence of other abnormalities.

What problems are associated with cleft lip and/or palate?

Nutrition problems. With the separation or opening of the palate, food and liquids can pass from the mouth through the nose. Luckily, bottles and nipples are available that are specifically designed to keep fluid flowing into the stomach. Children with cleft palate may need to wear an artificial palate to help them eat properly and provide adequate nutrition before undergoing surgery.
Ear infections/hearing loss. Children with cleft palate are at an increased risk of ear infections because they are more prone to fluid buildup in the middle ear. If left untreated, ear infections can lead to hearing loss. To prevent this from happening, children with cleft palate usually have special tubes placed in their eardrums to help drain fluids, and their hearing should be checked once a year.
Problems with speech. Children with cleft lip or cleft palate may also have difficulty speaking. The voices of these children are difficult to carry, the voice may take on a nasal tone, and speech may be difficult to understand. Not all children have these problems, and for some, surgery may completely resolve these problems. In other cases, a specialist doctor called a speech therapist will work with the child to eliminate speech problems.
Dental problems. Children with clefts are more prone to more cavities and often have missing, extra, misshapen, or misaligned teeth requiring dental and orthodontic treatment. In addition, children with cleft palate often have a defect in the alveolar process. The alveolus is the bony upper portion of the gum that contains the teeth. A socket defect can (1) displace, tilt, or rotate permanent teeth, (2) prevent permanent teeth from emerging, and (3) prevent ridge formation. These problems can usually be corrected with oral surgery.

Who treats children with cleft lip and/or palate?

Due to the high number of oral health and medical problems associated with cleft lip or palate, a team of doctors and other specialists is usually involved in the care of these children. Members of the cleft lip and palate team typically include:

Plastic surgeon to evaluate and perform necessary surgeries on the lip and/or palate
An otolaryngologist (an ear, nose, and throat doctor) to evaluate hearing problems and consider treatment options for hearing problems
An oral surgeon to reposition segments of the upper jaw when needed, to improve function and appearance and to repair the cleft of the gum
An orthodontist to straighten and reposition teeth
A dentist to perform routine dental care
A prosthodontist to make artificial teeth and dental appliances to improve the appearance and to meet functional requirements for eating and speaking
A speech pathologist to assess speech and feeding problems
A speech therapist to work with the child to improve speech
An audiologist (a specialist in communication disorders stemming from a hearing impairment); to assess and monitor hearing
A nurse coordinator to provide ongoing supervision of the child's health
A social worker/psychologist to support the family and assess any adjustment problems
A geneticist to help parents and adult patients understand the chances of having more children with these conditions

The medical team works together to develop a care plan to meet the individual needs of each patient. Treatment usually begins in early childhood and often continues into early adulthood.

How to treat cleft lip and cleft palate?

A cleft lip may require one or two surgeries depending on the degree of correction required. The first surgery is usually done when the baby is 3 months old.

Cleft palate repair often requires multiple surgeries over the course of 18 years. The first palate repair surgery is usually done when the baby is 6 to 12 months old. The initial surgery creates a functional palate, reduces the chance of fluid in the middle ear, and helps the proper development of the teeth and facial bones.

Children with cleft palate around the age of 8 may also need bone grafting to fill in their upper gum line so it can support permanent teeth and stabilize the upper jaw. About 20% of children with cleft palate need further surgery to improve speech.

Once the permanent teeth are out, braces are often needed to straighten the teeth.

Additional surgeries may be performed to improve the appearance of the lip and nose, close holes between the mouth and nose, help with breathing, and stabilize and align the jaw. The final correction of the scars left by the original operation is unlikely to be made until adolescence, when the facial structure is more fully formed.

What is the outlook for children with cleft lip and/or cleft palate?

While cleft lip and/or palate can take years to heal and require multiple surgeries depending on the condition, most children with the condition can recover to normal appearance, speech, and eating habits.

Dental care for children with cleft lip and/or palate

In general, the needs of children with clefts for preventive and restorative dental care are the same as for other children. However, children with cleft lip and cleft palate may have special problems with missing, misshapen, or misaligned teeth that require careful monitoring.

Early dental care. Like other children, children born with cleft lip and palate need proper brushing, good nutrition, and fluoride treatment to have healthy teeth. Proper brushing with a small, soft-bristled toothbrush should begin as soon as teeth erupt. If a soft toothbrush for children does not clean teeth enough due to the reshaped mouth and teeth, a dentist may recommend teething. The denture is a soft sponge with mouthwash on the handle, which is used to wipe the teeth. Many dentists recommend scheduling the first visit to the dentist around the age of one, or even earlier if there are certain dental problems. Routine dental care can begin at about 1 year of age.
Orthodontic care. The first visit to the orthodontist may be scheduled before the child's teeth erupt. The purpose of this visit is to evaluate the growth of the face, especially the development of the jaw. After teething, the orthodontist can further assess the child's short-term and long-term dental needs. After the permanent teeth erupt, orthodontic treatment can be performed to straighten the teeth.
Prosthodontic care. The orthopedic dentist is a member of the cleft palate team. He or she can make a dental bridge to replace missing teeth, or make special devices called "phonetic bulbs" or "palatal lifts" to help close the nose from the mouth so that speech sounds more normal. The prosthetist coordinates the treatment with a maxillofacial or plastic surgeon and a speech therapist.