Cleft Lip and palate


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Cleft Lip and palate

Cleft lip and palate are a group of congenital deformities which can either arise sporadically or passed on hereditarily. The parents are anxious about getting a baby affected with this deformity. Fortunately, these deformities can be corrected by surgery and the child can get a chance to lead a near normal life in the society.

Cleft palate refers to the split in the palate which is the normal partition between the oral cavity and the nose. This can either occur along with the cleft lip or as a case of the isolated cleft palate when the lip is normal. This can be either be complete when it extends throughout the length of the palate or incomplete when it involves the more posterior regions only.


Cleft



Before


After


Nasoalveolar moulding



Palate



Before


After


Alveolar bone grafting



Inadequate bone for canine to erupt


During bone grafting


Canine brought into occlusion by orthodontics after bone grafting



  • 1. Why does Cleft lip and palate occur?

  • Cleft lip and palate occur when tissues in the baby's face and mouth don't fuse properly. The reason behind this is mostly unknown. Cleft lip and palate is thought to occur due to multiple factors namely changes in the genes, intake by the mother of some drugs like phenytoin, retinoids, steroids and other reasons like smoking, alcohol consumption by the mother.


  • 2. Is Cleft lip and palate hereditary?

  • Yes. Cleft lip and palate can be hereditary. However, no single gene has been identified as universal culprit. A parent affected with cleft lip/palate has a 3-5% chance of having an affected child.


  • 3. How common is Cleft lip and cleft palate?

  • In India, cleft lip and palate is estimated to be present in 1.4 children for every 1000 live births.There is approximately 35,000 new cleft lip and palate patients added every year to the Indian population.


  • 4. If a parent has a child with cleft lip and palate, what is the chance that the next child will also have a cleft lip and palate?

  • If a child or a parent has a cleft lip/palate, there is a 4% risk to the subsequent children. If 2 children have cleft lip/palate, the risk increases to 9%. If one parent and one child have cleft lip/palate, then the risk increases to 17%.


  • 5. Do children with cleft lips have difficulty in feeding? If so, how should the mothers feed the children?

  • The child is unable to create a negative pressure while sucking as there is a cleft lip. In addition, the child swallows a lot of air while drinking milk. Hence the stomach gets bloated, and they feel full early and don’t drink milk much. They get hungry soon and they cry again. We recommend feeding the child in an upright position or in reclining position with the head up using a “Paladai” or a clean spoon. Soon after feeding the child , we recommend tapping the child’s back gently so as to encourage burping and remove the excessive air in the stomach.


  • 6. What problems do children with cleft lip and palate have?

  • Children with cleft lip and palate face a variety of challenges like difficulty in feeding, speech difficulties, ear infections, dental problems and can look different.


  • 7. Can cleft lip and palate be detected during antenatal scans? If so, is this a reason for termination?

  • Children with cleft lip and palate can be detected by ultrasound from the 13th week of pregnancy. The detection rate varies widely between 16-93%. Usually, the foetus is screened for the presence of abnormalities which are not compatible with living. Even though cleft lip and palate can be detected at pregnancy, this condition is not a good reason for the termination of pregnancy as they can be treated well and it is not a condition that is risky for life.


  • 8. Can children with cleft lip and palate be vaccinated?

  • Yes. Children with cleft lip and palate should be vaccinated just like other children.


  • 9. Can children with cleft lip and palate attend normal schools?

  • Children with cleft lip and palate should attend normal schools just like other children. It's important to remember that many children with cleft lip and palate do very well at school, without any additional support.


  • 10. Do children with cleft lip and palate need any change in diet?

  • As written before, children with cleft lip and palate may need help in giving food. However, they can have the same food that others receive.


  • 11. Can surgeries for cleft lip and palate be done in the same sitting? If not how many surgeries do children with cleft lip and palate need and when?

  • Surgeries for cleft lip and palate are usually done in separate sittings. The timeline is as follows

    Nasoalveolar moulding : Within 1 month after birth
    Cleft lip repair : 4 to 6 months
    Cleft Palate : 9 to 18 months (6 months after cleft lip repair)
    Surgery for speech : 4 to 6 years
    Surgery for closing cleft in the gums : 7 to 11 years(Alveolar bone grafting)
    Jaw Surgery (Orthognathic Surgery) : 18 years
    Definitive Rhinoplasty : 18 years

  • 12. How soon should you bring a child with cleft lip and palate for treatment?

  • We would recommend bringing the child as early as possible within 1 week after birth. We would give advise the parents regarding feeding, vaccination and also discuss with the patient the treatment that the child would need to undergo. The child can also start Nasoalveolar moulding (NAM) by coming early.


  • 13. What is Nasoalveloar moulding (NAM)?

  • In children with cleft lip and palate, the edges of the cleft lip, palate and the alveolus can be wide apart from each other. Besides, the nose can be depressed. Nasoalveolar moulding is a presurgical treatment which consists of an intraoral moulding plate with nasal stents to mould upper jaw bone, nasal cartilages and bring the edges of the cleft together. By bringing the edges of the cleft nearer, subsequent surgeries would be easier and the results of the operation better.


  • 14. When is nasoalveolar moulding done?

  • It is usually done as early as possible after birth within the first week an dcan be done upto the end of the first month. It is believed that when done early, the maternal hormones make the tissues more pliable and elastic and can be moulded easily.


  • 15. How frequently do parents need to bring their child for nasoalveolar moulding?

  • The parents need to bring the child frequently for minor adjustments in the nasoalveolar moulding every week for the first 3 months.


  • 16. Is Nasoalveolar moulding very painful for the baby? Do they tolerate it well?

  • No. The nasolaveolar moulding is not very painful for the baby and they adapt to it very well, though it may concern the mother initially while applying NAM.


  • 17. When is surgery done for cleft lip?

  • Surgery for the cleft lip is done when the baby is 4 to 5 months old with an adequate weight of 4.5 to 5 kgs.


  • 18. How is surgery done for the cleft lip?

  • Surgery for cleft lip is done under general anaesthesia. It usually takes about 1-2 hrs. In this the tissues around the cleft of lip are released and brought together to create a near normal lip both in terms of function and appearance.


  • 19. How are patients with cleft lip managed post-operatively?

  • Number of days of stay in hospital : 3 days
    Patient can drink water : usually 3 hrs after surgery
    Suture removal time : we need not remove the sutures as absorbable sutures are used

  • 20. When is surgery done for cleft palate?

  • The surgery for the cleft palate is done between 9 months to 18 months. It is generally done 6 months after the surgery for cleft lip.


  • 21. Why should surgery be done for cleft palate?

  • Repair of the cleft in the palate is essential for good speech and to prevent the food in the mouth regurgitating into the nose.


  • 22. How is the surgery done for cleft palate?

  • Surgery for the cleft palate is done under general anaesthesia. The tissue from the side of cleft is released, tissues in the palate moved around and sutured together in layers to seperate the nose from mouth.


  • 23. How are patients with cleft palate managed post-operatively?

  • Number of days of stay in hospital : 5 days
    Patient can drink water : usually 3 hrs after surgery
    Patient can eat normal food : Child is allowed to have liquid diet upto 3 weeks and then normal diet
    Suture removal time : sutures dissolve on their own

  • 24. What is Palatal fistula?

  • Palatal fistula is an abnormal communication between the nasal and oral cavity after cleft palate repair.


  • 25. How common is palatal fistula?

  • The incidence of palatal fistula ranges between 0-76%.


  • 26. How is the surgery for palatal fistula done?

  • The surgery for palatal fistula is done by mobilising the tissue from the rest of the palate or by using tissue from the tongue to close the defect in the palate.


  • 27. How is surgery for palatal fistula managed post operatively?

  • Number of days of stay in hospital : 5 days
    Patient can drink water : 3 hrs after surgery
    Patient can eat normal food : Semisolid food from next day and normal food in 3 weeks
    Suture removal time : dissolvable sutures are used and hence they need not be removed.

  • 28. How important is speech therapy following cleft palate surgeries?

  • Patients with cleft palate are managed with a multi-disciplinary team approach in which speech Therapy is an integral part. It plays a key role in improving pronunciation and verbal communication in the long term.


  • 29. Is surgery done for better speech if it is not clear?

  • Yes. Surgery can be done for the betterment of speech if indicated.


  • 30. Why is surgery done for better speech?

  • For a good speech, the posterior part of the palate should touch the pharynx behind so that there is no escape of air into the nasal cavity. Else the child speaks with a nasal twang. This is called Velopharyngeal Insufficiency (VPI). When the abnormal speech is because of the structural abnormality in the palate which happens commonly in children with cleft palate, surgery can be done to close the gap between the posterior part of the palate and the pharynx.


  • 31. When is surgery done for better speech?

  • The preferred timing for surgery to correct the Velopharyngeal Insufficiency (VPI) is about 4 to 6 years of age.


  • 32. How is surgery done for better speech?

  • For better speech, the gap between the posterior part of the palate and the pharynx should be obiliterated so that air wouldn’t escape into the nose to produce a nasal twang in speech. This gap can be closed by surgeries which would lengthen the palate or by surgeries which would use part of the flap from the pharynx to close the defect.


  • 33. What is the post operative follow-up for surgery for velopharyngeal insufficiency (VPI)?

  • We would start speech therapy within 3 weeks. Regular speech therapy is the key for improvement and nasal endoscopy for monitoring.
    Facts at a glance

    Number of days of stay in hospital : 5 - 6 days
    Patient can drink water : 2 hours after surgery without introducing any object into the mouth
    Patient can eat normal food : 3 weeks
    Suture removal time : absorbable sutures would be used for surgery and hence removal would not be needed

  • 34. What is an alveolar cleft?

  • Alveolar Cleft is a discontinuity in the upper jaw dental arch due to the lack of fusion of the upper jaw bone.


  • 35. Why should the alveolar cleft be closed?

  • Alveolar cleft is needed to maintain the bony continuity and facilitate tooth eruption. An intact upper jaw should be present if further procedures need to be done to change the position.


  • 36. How and when is the surgery done for closure of the alveolar cleft?

  • The surgery for alveolar cleft is done prior to the eruption of the permanent canine tooth. The approximate age at which the surgery is done would be between 8 to 10years of age. Flaps are raised from the gums in the upper jaw near the cleft. Bone is harvested from the pelvic bone prominence on one side and packed into the cleft area within the flaps raised to recreate the dental arch.


  • 37. How is the surgery for alveolar cleft managed post-operatively?

  • The patient is maintained on liquid diet for 2 days and is then started on semisolid diet. Upto 3 weeks. We encourage the patient to have good oral hygiene by brushing the mouth twice daily and using mouth washes after each meal.
    Facts at a glance

    Number of days of stay in hospital : 3 - 4 days
    Patient can drink water : 2 hours after surgery Started on soft mashed solids after 48 hours and advised not to chew but directly swallow.
    Patient can eat normal food : 3 weeks
    Suture removal time : absorbable sutures

  • 38. How important is a treatment with a dentist after alveolar cleft closure?

  • Follow up treatment with an orthodontist is important in bringing back the erupting tooth to normal alignment of the dental arch.


  • 39. When and why is the underdevelopment of the upper jaw treated?

  • Due to the treatment of the cleft palate, the upper jaw may not develop well corresponding to the lower jaw. Hence there can be a flattening of the midface. Correction of the position of the upper jaw would also mean that the position of the teeth should be adjusted by the dentist so that the teeth would meet each other well after correction of the upper jaw. It is advisable to correct the underdevelopment of upper jaw after the full growth of the upper jaw is completed. Hence correction of the upper jaw is done after 16 years of age.


  • 40. How is the surgery done for correcting the underdevelopment of the upper jaw?

  • Before surgery can be done to advance the upper jaw, the final plan is planned along with the dentist because after the operation, the teeth in both the jaws should meet well. After planning with certain plaster models, the dentist would apply dental appliances to correct the alignment of the teeth so that it would suit the future dental alignment. Surgery is then done whereby the upper jaw is cut within the mouth and is then advanced forward as planned earlier. In some cases, the lower jaw may also be cut within the mouth and then brought back to maintain the right alignment of the face. There will not be any sutures over the face. For further contour deformities on the face, fat can be harvested from the thighs or buttocks and injected into the midface.


  • 41. What is the post operative follow-up for surgery for correction of the underdevelopment of the upper jaw?

  • The upper and lower jaws of the patient will be kept together with rubber bands so that there wont be inadvertent mouth opening. This is done to prevent moving of the jaw bones sothat the jaw bones can settle in the new place. These bands will be removed in 3 weeks an dthen the patient is slowly asked to open and close the mouth. Patient will be on liquid diet for one month followed by mashed soft solid food for another month. In 3 months, the patient can eat normal food.
    Facts at a glance

    Number of days of stay in hospital : 3 - 4 days
    Patient can drink water : after 4 hours of surgery.
    Patient can eat normal food : 3 months after surgery
    Suture removal time : absorbable intra-oral sutures will be used and hence need not be removed.

  • 42. How and when is the nose deformity corrected?

  • Nasal deformity can be corrected initially while operating for cleft lip correction, this is called as primary rhinoplasty. It is advisable to correct the nasal deformity after the full growth of the upper jaw and the nasal complex which takes about 16 years of age. If the correction of the upper jaw is planed, then the correction of the nose is done after that


  • 43. How is the surgery done for correcting the nasal deformity?

  • Each nasal deformity is thoroughly evaluated before surgery by taking photos and analysing the photos. We discuss in detail with the patient and the attenders, on what we would correct after the operation and what one can expect after the operation. The surgery is done under general anaesthesia. The only place where the incision for the nose would be visible is in the undersurface of the nose between the two external nostrils. Alterations in the cartilage and bones of the nose is done. Extra cartilage is usually required to build the nose and this is taken either from the spetum of the nose or from a cartilage near the ribs in the chest. The surgery would take around 2 to 4 hours.


  • 44. How is the surgery for correction of the nasal deformity managed post-operatively?

  • Nasal packs are kept inside both nostrils at the end of the surgery to avoid any nasal bleeding. These nasal packs are removed at the end of 2 days. A splint is applied on the dorsum of the nose to give protection to the nose. This splint is removed in 10 days. The patient is advised to take liquids on the day of surgery. Semisolid diet is started the next day and gradually the patient is asked to take normal diet. Swelling and bruising of the face is expected for the first few weeks after surgery which will resolve within a few weeks.
    Facts at a glance

    Number of days of stay in hospital : 3 - 4 days
    Patient can drink water : 4 hours after surgery.
    Patient can eat normal food : 3 - 4 days after surgery
    Suture removal time : Need removal between 5 to 7 days after surgery.