Cleft lip and cleft palate are variations of facial clefting, a type of congenital deformity caused by abnormal facial development during gestation. A cleft is a fissure or opening—a gap. It is the non-fusion of the body's natural structures that form before birth. Cleft lip and/or cleft palate occurs in 1 of every 700 babies born annually, making it the most common facial birth defect. Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. Most of these craniofacial clefts are even more rare.
Cleft lip and cleft palate are conditions affecting the upper lip, the nose, the alveolar process and the palate. Cleft lip can affect only a small portion of the lip and may present as a small gap (partial or incomplete cleft lip) or larger gap that extends into the nose (complete cleft lip). Cleft lip can occur as unilateral (one side) or bilateral (both sides) clefts. Cleft lip occurs during the formation of the face in fetuses when the maxillary and medial nasal processes fail to fuse completely. The shape of the nose may be affected, as well as the alignment of the teeth.
Cleft palate may involve both the soft and hard palates. Cleft palate occurs during the formation of the secondary palate when the lateral palatine processes, the nasal septum, and/or the median palatine processes fail to fuse completely.
Prenatal ultrasound often detects cases of cleft lip and/or cleft palate in utero; however, some cases may not be detected until the newborn examination. Cleft lip and cleft palate commonly occur as isolated conditions, but may occur in association with genetic disorders. Complications arising from cleft lip or palate include feeding difficulty, failure to gain weight, poor growth, conductive hearing deficits, and speech difficulties.
There are many causes of cleft lip and palate. Problems with genes passed down from one or both parents, drugs, viruses, or other toxins can all cause these birth defects. Cleft lip and palate may occur along with other syndromes or birth defects.
Traditionally, multiple surgeries are performed to provide a functional and an aesthetically acceptable correction of cleft lip and/or cleft palate. Repair of the defect is critical to meet the individual's nutritional needs and facilitate emerging expressive language skills. There is agreement in the medical literature that a long delay in repair is not prudent because postponement may produce less-than-optimal functional and aesthetic outcomes. Delayed repair can also result in facial asymmetry due to retarded growth and/or disturbed mid-facial development. Moreover, postponement in correction may contribute to other problems, such as hearing loss due to recurrent auditory canal infections, which are a direct result of palatal clefts. Additionally, it has been observed that significant numbers of infants with cleft lip and/or cleft palate develop maxillary hypoplasia, which may require orthognathic surgical correction; therefore, surgical treatment of the defect should occur when the facial bones are still growing. Treatment should begin as soon as possible and primary surgeries are usually done before a child is 12 months old. Because cleft lip and/or cleft palate defects can occur singly or in combination with varying degrees of complexity, the surgical repair plan is individualized and may consist of a single surgery or a series of surgeries.
Above all, it is mandatory in the state-of-the-art cleft management that treatment is done multidisciplinary and the following professionals are available as team members:
- cleft surgeon
- speech therapist
- ear surgeon
The standard treatment plan at our cleft service is as follows (treatment plan is always individualized according to the cleft type and severity):
Presurgical Nasoalveolar Molding (PNAM): This non-surgical treatment modality starts as early as possible to facilitate palatal shelf alignment and nasal form. It is performed with a palatal device consisting of nasal stents.
Repair Of Cleft Lip (Cheiloplasty): This surgical repair is typically performed in early infancy (6-16 weeks of age). If wide clefting is present, preliminary surgery (nose-lip adhesion) may be necessary to enable anatomical closure and alignment of oral musculature. Lip anatomy and function should be restored before the age of 6 months. Nostril deformities, which are often present with cleft lips, can be improved at the time of the cheiloplasty or at a later surgery.
Repair Of Cleft Palate (Palatoplasty): This surgical repair is typically performed between 9 and 18 months of age, and may require several stages, including:
- closure of the soft palate with modified Furlow plasty and intravelar veloplasty aligning the palatal muscles
- closure of the hard palate with hinge door flaps or palatal island flaps
Maxillary alveolar bone grafting: this procedure restores the bony defect of the alveoalr process and restores the bony nasal base (piriform aperture). It is done in the mixed dentition phase at the age of 9-10. Nowadays, CT scans and 3D virtual planning are useful tools in preoperative planning and are used on a daily basis.
Rhinoplasty: A surgical procedure to reshape the nose, rhinoplasty is sometimes necessary as part of the corrective repair of cleft lip and/or cleft palate. Rhinoplasty may be provided at the time of the original surgery or at a later revisional surgery.
Revisional Surgery: Typically, as part of a reconstructive plan, the defects of cleft lip and/or cleft palate are repaired by the time the child has reached adulthood, but there may be circumstances where revisional surgeries may be required after the individual has reached adulthood. Revisional surgeries consist of serial surgeries as part of the reconstructive plan, and are generally performed to improve function and aesthetics, as well. In revision surgery, the following inetrventions are usually performed: speech enhancement surgery, scar revision, orthognathic surgery, osteodistraction, free tissue transfer.
The information listed above is the opinion of the doctors of the Department of Maxillofacial Surgery, AZ Sint Jan Bruges, Belgium and does not necessarily reflect the opinion of the specialty as a whole.