Cleft Lip and Palate

Overview

Cleft lip and palate occurs in about one in 1,000 births and is one of the most common conditions we see in our office. Clefts occur when parts of the face don’t join together as they should, which causes an abnormal separation of the lip and/or the palate (roof of the mouth).  A baby’s lip typically forms by 6 to 8 weeks gestation. His palate forms a little later, generally by 9 weeks gestation. Because they form at different times, it’s possible to have a cleft only of the lip, only of the palate, or of both. Clefts may be partial or complete and may involve only one side of the mouth or both sides.

Cause of cleft lip and palate

 Although up to one-third of clefts occur where there is a family history of clefts, the majority of cases occur sporadically. Clefts have been associated with a variety of drugs, including alcohol, cigarettes, vitamin A derivatives and some seizure medications. However, none of these medications has been shown to cause clefts. A number of genes has been identified which may make a cleft slightly more likely to occur. No single gene causes clefts.  In fact, a number of genetic and environmental factors must occur simultaneously in order for clefts to occur.

Diagnosis of cleft lip and palate

Since clefts of the lip and palate occur during the first 10 weeks of gestation, it’s possible that a cleft may be diagnosed by prenatal ultrasound. When a diagnosis of clefting is made before the baby is born, we recommend that families meet with a member of our team to help them learn what to expect and prepare for the care of their new baby. If the cleft isn’t seen by prenatal ultrasound, the diagnosis is typically made at the time of birth.

Characteristic findings

Because babies with clefts of the lip and palate are missing some of the normal structures of the lip and mouth, they may have difficulty with feeding. Babies with clefts may have difficulty sucking and need specialized bottles or nipples to be sure they are able to get all of the nutrients they require. As babies grow, they may also have difficulties with speech. Given these potential problems, it is important that babies with clefts be evaluated early following birth so parents can receive the education and support they’ll need to help their baby thrive.

Treatment

Children with clefts may require a number of surgical procedures throughout childhood and adolescence, depending on the type and extent of the cleft. No uniform treatment plan may be applied to all children. Just as each child is unique, the treatment plan for each child with a cleft is tailored to that child's individual needs.  

Common interventions and treatment for clefts:

  • Feeding evaluation: Since children with clefts frequently have difficulty feeding, any newborn with a cleft should be evaluated by a craniofacial team and a feeding specialist in the first 1-2 weeks of life. At that time, parents learn strategies to help their baby feed well and thrive.
  • Hearing evaluation: Babies with clefts of the palate are more likely to develop fluid behind their eardrums. This benign condition, if left untreated, may progress to ear infections and hearing problems that may affect speech development. Consequently, babies with cleft palate should be seen early by a pediatric ear, nose and throat specialist (ENT) to assess whether they may need ear tubes to help drain the fluid and prevent infection.  When ear tubes are needed, they are easily placed at the time of the lip or palate repair.  We encourage coordination of surgical procedures to minimize the number of trips to the operating room.
  • Lip repair: Repair of a cleft lip typically occurs at around 3 months of age. The most commonly performed repairs take lip tissue from the sides to close the cleft and lengthen the lip.  At the time of lip repair, some surgeons also choose to surgically reshape the nose which is often uneven due to the cleft.  
  • Palate repair: The palate is usually repaired when the baby is 9 -12 months of age. Most of the commonly performed repairs lead to good results.
  • Lip and nose revision surgery: Revision surgery refers to smaller procedures aimed at fine-tuning symmetry and balance of the nose and lip. The need for this type of surgery is determined by how the child heals from his or her initial surgery and how growth occurs over time. Typically, lip and nose revision surgery (when needed) is first performed when children are preparing to enter school. Additional revision surgery may be performed at later times to address specific concerns.
  • Alveolar bone grafting: For children who have clefts going through the gum line, bone must be placed in the gap to provide a stable platform for the canine tooth to erupt.  During this procedure, a small amount of bone is taken from the hip and packed into the gap. This surgery is typically performed when the child is 7 to 9 years of age. A pediatric dentist helps with timing by using X-rays to determine when the canine tooth is forming and preparing to descend.
  • Jaw surgery: For some children with clefts, the upper jaw doesn’t grow properly. This can cause the upper and lower teeth to not meet correctly, with the lower jaw growing far forward of the upper jaw (under bite). Surgical correction may be required. This procedure is usually postponed until the child is nearing completion of his or her facial growth, generally in the mid teens. Also, a child may need braces to prepare for the procedure.

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