Cleft Lip and Palate
A cleft palate occurs when the roof of the mouth does not come together and leaves an opening between the mouth and nasal cavity. A cleft palate may occur as part of the cleft lip deformity (cleft lip/cleft palate) or as an isolated mid-line deformity. The cleft palate may only affect the hard palate but can extend to the back of the mouth to affect the soft palate as well.
Etiology of Cleft Lip and Palate
The events that occur in utero and result in clefting are not clear. Cleft deformities can occur without any previous family history. Research has indicated that environmental and genetic chromosomal factors may be responsible for the occurrence of this anomaly with all its variations, but these findings are not proven. In some patients the clefting is indeed caused by an underlying genetic condition. Parents tend to blame themselves or to feel guilty about their baby’s condition, but the cleft lip and/or palate is not their fault. Instead, parents can redirect these emotions toward the care and healing of their newborn.
Timeline of Treatment
3-4 Months of Age – Cleft Lip Repair & ENT Consultation
Our surgeons typically repair the cleft lip between 3-4 months of age. Timing can vary depending on gestational age at birth, pre-surgical orthodontics, and other circumstances which we will discuss with you prior to any surgical intervention at the time of the initial visit. The sutures will need to be removed in one week. The baby should only stay overnight in the hospital and be able to go home the next morning. Read more about our treatment for cleft lip.
Infants with cleft palates are prone to middle ear infections and effusions (fluid build up). If this is ignored, it can lead to hearing loss. We will always have one of our ENT colleagues evaluate the baby and be ready to place tubes if necessary (Myringotomy and Grommets). This is a simple and very effective means of preventing hearing loss and multiple infections that are so common with cleft patients. In fact, this is something we are even incorporating into our international mission work in some of the most underdeveloped countries in the world.
9-11 Months of Age – Cleft Palate Repair
Studies have shown that if the cleft palate is repaired before 1 year of age, a child has the best opportunity of developing normal speech. We generally choose around 11 months as the optimal time to repair the cleft palate. Surgery on the palate younger than that tends to have a more negative effect on facial growth (Scar tissue in the palate can interfere with midfacial growth – see orthognatic section below). Both the hard and soft palate are repaired at this time, and the child will stay in the hospital overnight. The sutures inside the mouth are dissolvable.
After the cleft palate is repaired, it is important to monitor speech development (see “Optimal Speech Therapy in the Cleft Patient” by Dianne Altuna). The soft palate and pharynx (throat tissue) act as a precise valve in speech that is every bit as important as the tongue and lips. Certain sounds, called “plosives” require all air to come out through the mouth. Examples in the English language include “p” and “k”. Other sounds are “nasal” like “m” and “n”. Scar tissue in the palate (or an open palate) can prevent a person from making the oral plosives and thus everything sounds nasal. The brain opens and closes that valve multiple times without conscious realization in normal speech. If the valve cannot close, the brain begins to develop compensatory means of dealing with it, and these, while helpful, do not resolve the problem and can become detrimental to normal speech. This is why we begin our speech monitoring at around 2 years of age and try to make a determination if the scar tissue is impairing normal speech by the age of 4. Some things can be improved by speech therapy, but an anatomical inability to close the posterior valve cannot. This requires precise diagnosis and appropriate surgical treatment.
About 15 % of children with cleft palates will need a surgical procedure to help them speak optimally. The two main surgical procedures are pharyngeal flap and pharyngoplasty. Each of these operations addresses the anatomic deficiency by adding enough tissue to allow closure of the posterior valve when the brain needs it to close to form normal speech. Again, the optimal time to do this procedure, when indicated, is around 4 years of age.
Dental Development and Alveolar Bone Graft
In this day and age, the possibility of a child with a cleft having beautiful teeth is very attainable. If the cleft runs through the gum ridge (alveolus), the surgeon must fill it with bone to allow the teeth in that area to erupt and to be stable once erupted. NAM therapy frequently allows the alveolar ridge to be repaired at the time of the initial cleft lip repair. For 1/3 to 1/2 of patients, this may prevent the need for alveolar bone grafting later. But, even if it doesn’t, it makes the orthodontic treatment more effective and the surgery more straightforward. If surgery is needed, soft bone is taken from the inside of the hip and placed where the gap is, and the tissue separating the mouth and the nose is precisely closed over it. We rely on orthodontists experienced in cleft treatment to participate in this procedure.
Orthognathic Surgery in the Cleft Patient
Despite all attempts to optimize treatment, a small percentage of patients will end up with midface retrusion or midface hypoplasia. Retrusion or hypoplasia happens when scar tissue limits the growth of the upper jaw and prevents the teeth from lining up correctly (malocclusion), causing a severe concavity to the face. Craniofacial orthodontists use a combination of braces and the craniofacial plastic surgeon performs a jaw surgery called “LeFort 1” to address this condition. The surgery is best done when growth is complete – 15 to 17 years in girls and 16 to 18 years in boys. Here is a before and after example of a young lady who underwent LeFort 1 upper jaw surgery and final lip and nasal repair:
And here is Camey now with her husband, Nathan, and three beautiful children.
For a consult with Dr. Hobar & Dr. Cone for your child with a cleft lip & palate, please call us in Austin at 512-600-2888 or in Dallas 972-566-3700