| Cleft Lip and Palate
An oral cleft is a gap in the lip, palate or dental arch. Oral clefts occur when parts of the face and mouth don't fuse together as they develop during pregnancy.
A baby can be born with any of the following clefts:
- Lip
- Hard palate (roof of the mouth)
- Soft palate (tissue in the back of the mouth, near the throat)
- A combination
Oral clefts most often occur as a baby's only birth defect. However, they can also be linked to other problems. In fact, more than 400 medical syndromes are known to include a cleft lip or palate and at least one other developmental problem.
Clefts occur when parts of the mouth that normally start as separate pieces fail to fuse together as the fetus develops. For example, the upper lip forms during the fifth to sixth week of pregnancy. It forms from three separate parts that advance toward one another. If they fail to meet and fuse, a cleft lip results. A similar process forms the palate by 10 weeks of pregnancy. If these parts don't meet and fuse, a cleft palate occurs.
A mother's health and habits affect the fetus as it grows in the womb. Some of these conditions increase the risk of cleft lip and/or palate. They include:
- Infections and illnesses
- Smoking
- Alcohol use
- Folic acid deficiency
- Use of some anti-seizure drugs
For most oral clefts, however, there is no known cause. A pediatric geneticist or genetics counselor can provide more information.
In general, clefts of the lip and palate occur in 1 or 2 of every 1,000 babies born. They are among the more common birth defects.
Oral clefts are more common in Asian and American Indian children than in Caucasian children. They are less common among African-American children. Clefts of the palate alone are about half as common as clefts of the lip. Clefts of the palate vary less across groups.
Most oral clefts are diagnosed when the newborn is examined thoroughly at birth. However, some clefts of the soft palate in the back of the mouth may not be diagnosed until speech begins. These are submucous clefts, in which the lining of the palate is intact but the underlying muscles failed to fuse.
Unlike cleft palates, cleft lips are all readily visible at the time of birth. This defect appears as a distinct split in the lip. The cleft causes an opening from the mouth to the nose on the affected side. If both sides of the lip are cleft, the lip will appear to have three pieces — one on the outer side of each nostril and a third connected to the base of the nose. This is known as a bilateral cleft lip.
Cleft lips are more dramatic-looking, but clefts of the palate are of more urgent concern in newborns. Clefts of the palate can range from a small to a wide opening. Babies with large clefts of the palate cannot suck well. Nursing by breast or bottle may be difficult or impossible. Feeding the baby may require special techniques and baby bottles such as the Haberman nipple, dental appliances or both.
Clefts of the palate sometimes affect the Eustachian tubes, which connect the middle ear with the throat. Such problems can affect hearing.
A child with an unrepaired cleft palate will have speech problems. In some children who have had a repair, speech may also be abnormal. These children may have leakage of air from the mouth to the nose because the muscles of the palate and throat don't function normally.
If a child's cleft involves the bony dental ridge that supports teeth, a variety of dental problems can result. These can include missing, unusually shaped or crooked teeth. In addition, teeth that form on either side of the cleft may not have enough bone support. This problem can lead to periodontal (gum) disease.
Diagnosis of cleft lip and/or cleft palate is sometimes made by an ultrasound test before birth. Clefts usually are diagnosed by appearance at the time of delivery. Mild clefts of the palate are sometimes not diagnosed until later. Usually this occurs after a child starts to talk. Someone with a cleft palate usually will have problems saying certain sounds.
Cleft lip and cleft palate are lifelong conditions. However, they can be treated with surgery, speech therapy and other methods.
Most clefts can't be predicted or prevented. Women should get good prenatal care and follow good health practices during pregnancy. But even these precautions won't prevent most oral clefts. Research suggests that taking folic acid before conception and during the first two months of pregnancy may reduce the odds of having an oral cleft. Women should also avoid alcohol during pregnancy.
Treatment begins right at birth, with counseling and feeding instructions.
Parents are often surprised and disturbed and wonder what they could have done to prevent the problem. Not surprisingly, many feel anxious or guilty. They worry about how their baby will be accepted by others and what lies ahead for them and their child. They soon learn, however, that oral clefts are common and have a clear path of treatment.
Because clefts cause a variety of problems and require lengthy treatment, they are best managed by "cleft palate teams" in regional medical centers. These teams typically provide "one-stop-shopping" for the services a child needs. These teams typically include the following:
- Pediatric dentist
- Oral and maxillofacial surgeon
- Plastic and reconstructive surgeon
- Otolaryngologist (ear, nose and throat doctor)
- Pediatrician
- Pediatric geneticist
- Orthodontist
- Nurse
- Feeding or lactation counselor
- Audiologist
- Speech pathologist
- Psychologist
- Social worker
- Dental laboratory technician
If a team approach is not used, the surgeon usually treats the child first and manages his or her overall needs.
Cleft palate teams first see children at birth and coordinate care throughout the years of growth and development.
Teams all address the same concerns. They may have different philosophies and protocols for providing care. Parents who have more than one team available in their area may want to interview the teams. Then they can decide where they are most comfortable receiving care.
Surgery to close clefts of the lip is usually done at about 2 to 3 months of age. The palate is frequently repaired by 1 year of age. The exact timing and surgical techniques will vary according to each child's needs. In children with cleft palate, an ear, nose and throat doctor often will place ear tubes at the time of the palate repair to improve hearing. These tubes are temporary. Other surgeries are performed to improve appearance and to fill in missing bone. Repeat surgeries are common. The final procedures often happen late in the teen years.
The child typically will need both regular dental treatment and orthodontic treatment. Many children with clefts need lengthy orthodontic treatment to help the teeth erupt into the mouth and to improve the shape of the dental arches. Some children need jaw surgery to improve function and appearance if the upper jaw does not grow large enough.
A small number of newborns require an oral appliance to assist feeding. Some children with cleft lip and palate also receive an orthodontic-type appliance to align the two parts of the hard palate before the lip repair. As the child grows, other caregivers on the team will provide or arrange for whatever services are needed.
Most babies born with oral clefts will have quick attention from a cleft palate team. However, very minor clefts of the palate may not become evident until the child begins to talk or even later. Sometimes very mild clefts are not noticed until a child begins to speak. If you have concerns about your child’s speech, contact your pediatrician or pediatric dentist. They can refer you to a speech therapist.
Cleft lip and cleft palate are lifelong conditions. They usually are sorted out and well managed before adulthood. They don't typically require any care after childhood.
March of Dimes Birth Defects Foundation
1275 Mamaroneck Avenue
White Plains, NY 10605
Toll-Free: (888) 663-4637
http://www.modimes.org/
The Cleft Palate Foundation
1829 E. Franklin Street
Suite 1022
Chapel Hill, NC 27514
Phone: (919) 933-9044
http://www.cleftline.org/
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