Cleft Lip and Palate
What are cleft lip and cleft palate?
Cleft lip and cleft palate are malformations (defects) in the face and mouth that occur very early in pregnancy, while the baby is developing inside its mother. A cleft results when the tissues do not join together properly.
- A cleft lip is a physical separation of the two sides of the upper lip, and appears as a narrow or wide opening or gap in all layers of the upper lip. This separation can include the gum line or the palate.
- A cleft palate is a split or opening in the roof of the mouth. A cleft palate can involve the hard palate (the bony front portion of the roof of the mouth) and/or the soft palate (the soft back portion of the roof of the mouth), and can be associated with a cleft lip
Cleft lip and cleft palate can occur on one or both sides of the mouth. Because the lip and the palate develop separately, it is possible to have a cleft lip without a cleft palate, a cleft palate without a cleft lip, or both a cleft lip and cleft palate together (the most frequently occurring defect).
An infant with cleft lip. The same child, age 2, after cleft lip repair.
Who gets cleft lip and/or cleft palate?
Cleft lip and/or cleft palate affects 1 in 1,000 babies every year, and is the fourth most common birth defect in the United States. Clefts occur more often in children of Asian descent.
Twice as many boys as girls have a cleft lip, both with and without a cleft palate. However, twice as many girls as boys have cleft palate without a cleft lip.
Symptoms and Causes
What causes a cleft lip and cleft palate?
In most cases, the causes of cleft lip and cleft palate are not known, and these conditions cannot be prevented. Most scientists believe clefts are caused by a combination of genetic (inherited) and environmental (related to the natural world) factors. There seems to be a greater chance of newborn having a cleft if a sibling, parent or other relative has had the problem.
Another cause of a cleft lip/palate may be related to a medication a mother may have taken during her pregnancy, including antiseizure/anticonvulsant medications, acne treatment medications containing Accutane®, or methotrexate, a drug commonly used for treating cancer, arthritis and psoriasis.
Other factors that can contribute to development of a cleft include:
- Vitamin deficiency (folic acid)
- Smoking during pregnancy
- Substance abuse
The condition may also occur as a result of exposure to viruses or chemicals while the baby is in the womb. In other situations, cleft lip and cleft palate may be part of another medical condition.
Diagnosis and Tests
How are cleft lip and/or cleft palate diagnosed?
Because clefts cause obvious physical changes, they are easy to diagnose. Prenatal ultrasound can diagnose most clefts of the lip. Isolated cleft palate is detected only in 7 percent of the patients during the prenatal ultrasound.
If a cleft has not been detected in an ultrasound before the baby is born, a physical examination of the mouth, nose and palate can diagnose cleft lip or cleft palate after a child’s birth. Sometimes, other tests may be conducted to learn if there are any other abnormalities.
Management and Treatment
What problems are associated with cleft lip and/or cleft palate?
- Eating problems: With a separation or opening in the palate, food and liquids can pass from the mouth back through the nose. Usually, babies quickly learn how to eat and feeding is not a problem.
- Ear infections and hearing loss: Children with cleft palate are at increased risk of ear infections since they are more prone to fluid buildup in the middle ear. If they are not treated, ear infections can cause hearing loss.
- Speech problems: Children with cleft palate may also have trouble speaking. These children’s voices don’t carry well, the voice may take on a nasal sound, and the speech may be difficult to understand after palate repair. Not all children have these problems, and surgery may fix these problems entirely.
- Dental problems: Children with clefts are prone to many dental problems, including:
- A greater number of cavities;
- Missing, extra, malformed or displaced teeth that need to be treated.
- A defect of the alveolar ridge, the bony upper gum that contains the teeth. A defect in the alveolus can: displace, tip, or rotate permanent teeth; prevent permanent teeth from appearing; prevent the alveolar ridge from forming; and, cause premature loss of erupting canine and incisor teeth.
Who treats children who have cleft lip and/or palate?
Because of the number of oral health and medical problems associated with a cleft lip or cleft palate, a team of doctors and other specialists usually works together to develop a plan of care for each patient. Members of a cleft lip and palate team usually include:
- Plastic surgeon to evaluate and perform necessary surgeries on the lip and/or palate.
- Orthodontist to straighten and reposition teeth.
- Dentist to perform routine dental care.
- Prosthodontist to make artificial teeth and dental appliances to improve the appearance and to make the changes needed for eating and speaking.
- Speech pathologist to assess speech and feeding problems.
- Otolaryngologist (an ear, nose and throat doctor) to evaluate hearing problems and consider treatment options for hearing problems.
- Audiologist (a specialist in hearing disorders) to check and monitor hearing.
- Nurse coordinator to provide ongoing supervision of the child’s health.
- Social worker/psychologist to support the family and take note of any adjustment problems.
- Geneticist to help parents and adult patients understand the chances of having more children with these conditions.
Treatment usually begins in infancy and often continues through early adulthood.
How are cleft lip and palate treated?
A cleft lip may require 1 or 2 surgeries, depending on the extent (complete or incomplete) and width (narrow or wide) of the cleft. The first surgery is usually performed by the time a baby is 3 months old.
Several techniques can improve the outcomes of cleft lip and palate repairs when used appropriately before surgery. They are non-invasive and dramatically change the shape of the baby’s lip, nose and mouth:
- A lip-taping regimen can narrow the gap in the child’s cleft lip.
- A nasal elevator is used to help form the correct shape of the baby’s nose.
- A nasal-alveolar molding (NAM) device may be used to help mold the lip tissues into a more favorable position in preparation for the lip repair.
The first surgery, to close the lip, usually occurs when the baby is between 3 and 6 months old. The second surgery, if necessary, is usually done when the child is 6 months old.
Repair of a cleft palate is performed at 12 months and creates a working palate and reduces the chances that fluid will develop in the middle ears. To prevent fluid buildup in the middle ear, children with cleft palate usually need special tubes placed in the eardrums to aid fluid drainage, and their hearing needs to be checked once a year. This is often done at the time of palate repair.
About 30-40 percent of children with a cleft palate need further surgeries to help improve their speech. Speech is usually assessed between ages 4 and 5. Often a nasopharyngeal scope is performed to check the movement of the palate and throat. A decision is then made, together with the speech pathologist, if surgery is needed to improve the speech. This surgery is usually performed around age 5.
Children with a cleft involving the gum line may also need a bone graft when they are about 6-10 years old to fill in the upper gum line so that it can support permanent teeth and stabilize the upper jaw. Once the permanent teeth grow in, a child will often need braces to straighten the teeth and a palate expander to widen the palate.
Additional surgeries may be performed to improve the appearance of the lip and nose, close openings between the mouth and nose, help breathing, and stabilize and straighten the jaw.
Outlook / Prognosis
What is the prognosis (outlook) for children who have cleft lip and/or palate?
Although treatment may take many years and require several surgeries, most children affected by these conditions can achieve normal appearance, speech and eating.
How should dental care needs of children with cleft lips or palates be met?
Generally, the dental care needs of children who have clefts are the same as for other children. However, children with cleft lip and/or palate may have special problems related to missing, misshapen, or poorly positioned teeth that should be watched closely.
- Early dental care: Like other children, children born with cleft lip and/or cleft palate require proper cleaning, good nutrition, and fluoride treatment in order to have healthy teeth. Appropriate cleaning with a small, soft-bristled toothbrush should begin as soon as teeth appear. If a soft children’s toothbrush does not adequately clean the teeth because of the different shape of the mouth and teeth, the dentist may recommend a soft, mouthwash-containing sponge on a handle to swab the child’s teeth. Many dentists recommend that the first dental visit be scheduled at about 1 year of age, or earlier if there are special dental problems. Routine dental care can begin around 3 years of age.
- Orthodontic care: A first orthodontic evaluation occurs during the cleft and craniofacial clinic. After teeth appear, an orthodontist can further evaluate a child’s short and long-term dental needs. Most children with a cleft palate will require palatal expansion around age 6-7. After the permanent teeth erupt, an orthodontist can align the teeth. Orthodontic care is required also in preparation for jaw surgery (orthognathic surgery).
- Prosthodontic care: A prosthodontist may make a dental bridge to replace missing teeth, or special appliances called "speech bulbs" or "palatal lifts" to help close the nose from the mouth so that speech sounds more normal. The prosthodontist coordinates treatment with the oral or plastic surgeon and the speech pathologist.