Cleft Lip and Cleft Palate - Causes, Symptoms, Diagnosis, and Treatments

What Is a Cleft Lip and Cleft Palate?

A cleft lip is an abnormal opening in the lips and roof of the mouth. It is a common birth defect in children. It can occur on one or both sides depending on the severity. Orofacial clefts include both cleft lip and cleft palate. This condition is often accompanied by other disorders. In cleft palate cases, cleft palate surgery is done to close the separation in the palate, promoting improved function and reducing the potential for associated complications. Recent advances have made both cleft lip and palate completely treatable.

Classification:

1. Unilateral Complete - The slit or the gap extends from the lips to the nose only on one side.

2. Unilateral Incomplete - The slit or the gap extends only up to the lip region only on one side.

3. Bilateral Complete - The slit or gap extends from the lip up to the nose on both sides.

What Are the Causes of Cleft Lip and Palate?

• Genetics.

• Environmental factors.

• Consumption of alcohol and smoking in pregnant mothers.

• When the mother had taken certain toxic medications during pregnancy. Drugs such as anticonvulsants and steroids are included in this.

• Fetal exposure to chemicals and toxins in the womb.

• Gestational diabetes (mother with diabetes during pregnancy).

• When the tissue is not sufficient in the lip area.

• Mother being obese during pregnancy.

• Folic acid and vitamin B deficiency in pregnant mothers.

What Are the Risk Factors?

1. Consanguineous marriage.

2. Risk increases if one of the family members is diagnosed with this condition.

3. Women who conceive in their later years tend to have more risk.

4. Exposure to radiation.

5. It is common in Asian and American children.

6. Mongoloids have high reported cases of this condition.

7. Boys are more frequently affected than girls.

What Does It Look Like?

Every two minutes, a child is born with a cleft somewhere in the world.

What Are the Problems Faced by the Baby?

• Swallowing problems.

• Breathing problems.

• Difficulty in speech.

• Difficulty in hearing.

• Ear infections.

• Dental problems.

  • Gum and bones surrounding the teeth may be affected.

  • Higher risk of tooth decay.

  • A missing or displaced tooth which might require orthodontic treatment (braces).

• Imbalance in social and emotional states.

• Malnutrition (deficient nutrient supply).

• Memory problems.

• Attention deficit.

At What Point During Pregnancy Can an Ultrasound Reveal a Cleft Lip and Cleft Palate?

Healthcare providers can identify a cleft lip during the 20-week ultrasound, also known as the anatomy scan, conducted between 18 and 22 weeks of pregnancy. In some cases, it may be detected as early as 12 weeks. As the fetus progresses in development, the diagnosis of a cleft lip becomes more accurate. However, identifying a cleft palate alone through ultrasound is generally more challenging.

What Is the Management and Treatment for Cleft Lip and Cleft Palate?

The treatment for cleft lip and palate requires a multidisciplinary approach.

1) Surgical Treatment:

For Cleft Lip -

A rule of 10 has to be followed for the surgery to be more successful. The child who is undergoing surgery:

• Should be at least 10 weeks of age.

• Should be at least 10 pounds of weight.

• Should have a hemoglobin (Hb) value of about 10 gm/dL.

Repairing a cleft lip may involve one or two surgeries. The first surgery typically happens when the baby is 3 to 6 months old, closing the infant's lip. If needed, the second surgery is usually performed around the age of 6 months. With proper surgical techniques, the lip, nose, and facial structures can be restored. This will thereby promote normal functioning. The repair of cleft lip is done by a surgical procedure called cheiloplasty.

Before surgery, various non-invasive techniques can significantly enhance the outcomes of cleft lip and palate repairs, positively affecting the shape of the baby's lip, nose, and mouth:

• Lip-Taping Regimen: This technique helps narrow the gap in the child's cleft lip.

• Nasal Elevator: This tool assists in forming the correct shape of the baby's nose.

• Nasal-Alveolar Molding (NAM) Device: This device may be used to mold the lip tissues into a more favorable position in preparation for lip repair.

For Cleft Palate- Cleft palate repair or cleft palate surgery often performed around the age of 12 months, focuses on creating a functional palate and reducing the likelihood of fluid buildup in the middle ears. To address fluid accumulation, children with a cleft palate often require special tubes in their eardrums for drainage, with regular hearing check-ups recommended.

• Approximately 40 percent of children with a cleft palate may undergo additional surgeries along with cleft plate surgery to enhance speech. Speech evaluation by a pathologist is typically conducted between ages 4 and 5, utilizing tools like a nasopharyngeal scope to assess palate and throat movement.

• If surgical intervention is necessary for improved speech, the cleft palate surgery is usually performed around age 5.

• For those with a cleft involving the gum line, a bone graft may be needed between the ages of 6 and 10 to support permanent teeth and stabilize the upper jaw.

• Subsequent orthodontic interventions, such as braces and a palate expander, are often required as permanent teeth emerge.

In addition to cleft palate surgery, other procedures may be considered to enhance the appearance of the lip and nose, close openings between the mouth and nose, facilitate breathing, and stabilize the jaw. Cleft lip surgery typically results in a small pink scar that tends to fade over time and becomes less noticeable as the child grows. While surgical risks such as bleeding, infection, and damage to nerves or tissues exist, the overall success rate is high, and risks are generally low.

2) Non-Surgical Treatment:

For patients who have high risk involved in surgery and those who are not willing for surgery, dental obturator is the treatment of choice. It can be used in the sites of deficient tissues. The main advantage of an obturator is the high degree of closure. One of its notable disadvantages is the irritation of oral mucosa.

1. Rehabilitation:

• Hearing - Most of the children with cleft lip and palate suffer from hearing disabilities. Children can be given appropriate hearing aids. An audiologist will help to assess and monitor hearing. Otolaryngologists also play a vital role.

• Speaking - Children will need help from speech-language pathologists and occupational therapists to conduct speech therapies. It is highly effective and will help the children to speak normally.

• Eating - Feeding and growth of the child will be a primary concern for the parents. Infants will not be able to breastfeed like others. Feeding tubes and specialized bottles will be required to feed the infant. Draining of oral fluids in the nasal cavity should be done to enable better feeding.

• Nasality - Velopharyngeal insufficiency is the inability of the soft palate to close while speaking. It can cause hypernasality (increased nasal resonance), hyponasality (reduced nasal resonance), or both, which is known as mixed nasal resonance.

• Psychological Factors - Having a kid with this condition is a great psychological disturbance for the parents. As these parents are generally under constant stress, they are given psychological counseling. In case the child is suffering from an inferiority complex, it is advisable for the child to undergo psychotherapy.

2. Dental Problems -This might require the help of a pediatric dentist, prosthodontist, and orthodontist.

• Prosthodontic Care - Prosthodontists help in designing a feeding obturator. It is also known as a speech bulb. This prosthesis will help the patient to close the separation between the oral and nasal cavities. It helps in the proper development of jaws. It helps to reduce nasal regurgitation (food and liquids coming out through the nose). It reduces choking. In case of a missing tooth, it can be replaced with fixed partial dentures, complete dentures, or dental implants in the later stages. The prosthodontist formulates the treatment plan with plastic surgeons.

• Orthodontic Care - Orthodontists help to regulate the growth of facial structures and monitor jaw development.

Conclusion:

Cleft lip and cleft palate are conditions that some people are born with and can affect how their face looks and their overall health. Luckily, doctors can do surgeries to help fix these issues when the person is still a baby. Finding the problem early and getting the right medical care can make things better for those who have these conditions. There is no exact way to prevent cleft lip and palate. However, the intake of folic acid by the mother during pregnancy might help. Carrying mothers should strictly avoid cigarettes and alcohol. They should also take vitamin supplements.