Cleft lip and palate

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Cleft lip and/or palate are the most common birth defects of the mouth. A cleft lip occurs when the two structures or processes that make up the lip do not completely fuse before birth.

According to a study conducted by the National Institute of Dental and Craniofacial Research, 7 in 1000 children are born with a cleft lip and palate deformity. This indicates that there are millions who need help but cannot access or afford it. While it is still unclear what causes children to develop deformities, some believe it is caused because of poor Vitamin B and folic acid levels in the mother. Experts believe these deformities could be wiped out if mothers take these vitamins before conception but that seems unlikely where nutrition for women is not really a priority.

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Types

Cleft lip is of the following types.


  • Forme fruste unilateral cleft lip: This type of cleft lip occurs only on one side of your upper lip as a subtle cleft. It may appear as a tiny depression.

  • Incomplete unilateral cleft lip: In this type of cleft lip, the cleft occurs only on one side of your upper limb. It does not extend to the nose.

  • Complete unilateral cleft lip: This type of cleft lip occurs only on one side of the upper lip; however, it extends into your nose.

  • Incomplete bilateral cleft lip: Here, the cleft lip occurs on both sides of your upper lip; it does not extend to your nose.

  • Complete bilateral cleft lip: Here, clefts occur on both sides of your upper lip and extend into your nose.


Cleft palate is of the following types:

  • Incomplete cleft palate: Here, a cleft occurs at the back of your mouth. This cleft occurs in the soft palate.

  • Complete cleft palate: This cleft palate affects both your hard and soft palate. Here, there is communication between your mouth and nose.

  • Submucous cleft palate: This type of cleft palate involves either or both the hard and soft palate. It may be covered by a mucous membrane coating the upper aspect of your mouth, making it difficult to visualize.[1]

Symptoms

Usually, a cleft lip and palate are identifiable at birth and may affect one or both sides of the face. It might appear as a small notch in the lip that extends via the upper gum into the bottom of the nasal septum. However, in some cases, cleft occurs at the back of the mouth (which in turn is covered by the mouth lining). In this type of cleft lip and palate, you might experience signs such as difficulty in swallowing, speaking (nasal voice) and a high risk of ear infections.

Causes And Risk Factors

Causes


Dr Shishir Aggarwal, Senior Consultant, Plastic Surgery, Sri Balaji Action Medical Institute says, ‘Cleft Palate is a form of facial malformations that occur in a baby during the pregnancy stages. It is caused when an opening in the roof of the mouth fails to fuse during the first few months of pregnancy when the embryo starts to develop. Generally, this opening in the palate allows communication between the nasal passages and the mouth. The majority of cleft palate cases are believed to be caused by an interface of genetic and environmental factors. Although a definite cause has not been discovered yet, genes inherited from both the parents cause this condition. In some cases, although babies inherit a gene that increases their risk of developing a cleft defect, the condition will be manifested only when a gene is activated by an environmental trigger. Moreover, exposure to certain substances during pregnancy such as smoking cigarettes, drinking alcohol and taking certain drugs can result in their babies developing a cleft palate. Moreover, the lack of proper nutrition and deficiency of folic acid and vitamin B-complex in pregnant women causes birth defects in their children.

Risk Factors


There are several factors that are likely to increase the baby’s chances of developing a cleft palate:

  • Family history: Parents with a family history of cleft lip and palate have a high risk of having a baby with this birth defect.

  • Race: Cleft lip and palate is most common in American, Indian and Asian children, whereas African children hardly acquire this problem.

  • Sex: Males are twice likely to develop a cleft lip with or without a cleft palate, whereas a cleft palate without a cleft lip is common in females.

  • Obese mothers: Babies born to obese mothers may have an increased risk of acquiring a cleft palate.’

  • Vitamin deficiency: Especially in folic acid

  • Smoking: Mothers who smoke during pregnancy

  • Substance abuse: Drug use when pregnant

  • Exposure: If the pregnant mother is exposed to chemicals or viruses while the baby is in the womb, there are increased chances of the baby developing a cleft.

  • Other medical conditions: In some cases, other medical conditions may increase the chances of the baby getting a cleft.[2]

Prevention

Although it is not possible to prevent the cases of a cleft palate, parents should follow some of the key steps to lower the risk of their kids suffering this condition. Here are a few tips you need to consider:


  • Opting for genetic counselling before pregnancy if your family has a history of cleft lip and cleft palate

  • Take prenatal multi-vitamins before conceiving and during pregnancy to reduce the risk of birth defects (only through proper consultation with a gynaecologist)

  • Avoid tobacco or alcohol during pregnancy to lower the chances of birth defects in your child.

  • Try to attain a normal weight prior to your pregnancy

  • Consult your doctor before taking any medications when pregnant

  • Regular prenatal care is essential to identify and avoid complications

  • Vaccinate yourself to protect against any infections, especially rubella.[3]

Diagnosis

A cleft palate is normally diagnosed by an ultrasound performed during pregnancy (before the baby is born) to detect whether the unborn child suffers from any birth defects. In this way, doctors are able to detect an abnormality in the facial structures by analyzing the pictures.

In some cases, if the cleft lip or palate is not identified on the ultrasound, your doctor may perform a comprehensive examination of your child to identify whether your child has a cleft lip or cleft palate. A fetal MRI may be able to identify the cleft palate. In some cases, when the child has a minor cleft palate, then it may be diagnosed only when you face difficulty in feeding your child.[4]

Treatment

Cleft lip or cleft palate requires treatment from a number of medical specialists from various specialities. This cleft team will include the following members.


  • Paediatrician

  • Plastic surgeon to perform surgeries

  • Pediatric speech pathologist

  • Audiologist to monitor hearing

  • Dental specialist for routine dental care

  • Prosthodontists make necessary changes required to eat and speak by making artificial teeth or dental appliances

  • Orthodontist to reposition teeth

  • Ear, nose, and throat surgeon to help with hearing problems

  • Clinical nurse consultant to supervise your child’s health

  • Speech pathologist to help with speech and feeding issues

  • Social worker or psychologist to provide support to the family

  • Geneticists to understand whether the future progeny will be affected by this condition


The primary aims of cleft palate surgery (palatoplasty) are to prevent food and liquid from leaking out of the nose by closing the opening between the mouth and nose and creating a palate to help in speech.[2,5,6]

In the recent past, there have been numerous advancements in the field of cleft palate surgery. Currently, cleft palate surgery is performed with better, soft palate lengthening techniques such as the velopharyngeal space (which creates space behind the palate and aid in proper speaking and swallowing of food) is narrowed with better soft palate movement. With advanced diagnostic video-endoscopy techniques, it is easy to assess velopharyngeal incompetency (caused because of improper closing of the soft palate muscle present in the mouth thereby interfering with speech).’ Moreover, post-surgical operation, patients are recommended to undergo speech training with a speech therapist such that nasal twang is corrected. Furthermore, advancements in maxillofacial surgery (used to treat defects in the mouth, jaws, neck and face) and orthodontics aid in better and more effective treatment of cleft lip and palate.

The primary aim of cleft lip surgery (cheiloplasty) is to close the cleft and improve the form and proportion of the nose and lip.
In maxillofacial surgery, maxillary segments are improved by osteotomy (a surgical operation that involves cutting a bone to fix an injury or facial appearance) to correct midface retrusion, whereas other dental implants such as secondary bone grafting and orthodontic treatment help to bring the teeth in proper alignment. Cleft palate will require multiple surgeries for speech improvement, improvement in appearance, help in breathing, and stabilizing and straightening the jaw. A bone graft may be performed as they grow older to stabilize the upper jaw and support permanent teeth. Braces may be required in future to straighten the teeth and a palate expander to expand the palate.
Other treatment measures are as follows.

  • Feeding support: Support may be required to help breastfeed your baby. In some cases, a special type of feeding bottle may be used.

  • Monitor hearing: Children who are born with cleft palate are at more risk of developing a glue ear (filling of the middle ear with a glue-like substance instead of air). Monitor your child’s hearing such that treatment can be accordingly initiated. Treatment for glued ears will include a hearing aid or tube placement called grommets to drain the excess fluid from the ear.

  • Speech and language therapy: Your child’s speech and language development will be monitored by a speech and language therapist to identify issues and rectify the same.

  • Dental hygiene and orthodontic treatment: Taking care of your child’s teeth is important to prevent dental complications. They may require braces if their adult teeth do not appropriately erupt.[2,5,6]

Prognosis And Complications

Prognosis


The treatment for cleft lip and cleft palate is prolonged, involving multiple surgeries. However, despite this, children affected by cleft lip and cleft palate can lead normal lives. They can achieve normal appearance, speech, and eating.[2]

Complications


Cleft lip and palate cause various problems along with interfering with your day-to-day activities such as:

  • Cleft lip and cleft palate can cause problems with sucking, swallowing, speech and socialization.

  • There could be a risk of aspiration (food going from the mouth to the nose and/or respiratory tract).

  • Teeth may be missing, deformed or displaced. This could cause adjoining teeth to move into the space causing improper bite, irregular gaps between teeth and difficulty in chewing.

  • Soft tissue folds and irregularities in the palate or roof of the mouth can increase the risk of gum disease.


References.

1. Cleft lip and Palate. Children’s Hospital Los Angeles. Available at: https://www.chla.org/cleft-lip-and-palate. (https://www.chla.org/cleft-lip-and-palate)
2. Cleft lip and Palate. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/10947-cleft-lip-and-palate. (https://my.clevelandclinic.org/health/diseases/10947-cleft-lip-and-palate)
3. Cleft lip and Palate. March of Dimes. Available at: https://www.marchofdimes.org/complications/cleft-lip-and-cleft-palate.aspx. (https://www.marchofdimes.org/complications/cleft-lip-and-cleft-palate.aspx)
4. Cleft lip and Palate. Boston’s Children’s Hospital. Available at: https://www.childrenshospital.org/conditions-and-treatments/conditions/c/cleft-lip-and-cleft-palate/diagnosis-and-treatments. (https://www.childrenshospital.org/conditions-and-treatments/conditions/c/cleft-lip-and-cleft-palate/diagnosis-and-treatments) 5. Cleft lip and Palate. NHS. Available at: https://www.nhs.uk/conditions/cleft-lip-and-palate/. (https://www.nhs.uk/conditions/cleft-lip-and-palate)
6. Cleft palate with cleft lip. Kids Health. Available at: https://kidshealth.org/en/parents/cleft-palate-cleft-lip.html. (https://kidshealth.org/en/parents/cleft-palate-cleft-lip.html)

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