Cleft lip and palate

Cleft lip and palate 

A cleft lip and palate may be of variable extent across the lip, gums and palate. It may be bilateral (on both sides) or unilateral (on one side). 
 
A unilateral cleft lip and palate (pictured above) often presents with significant asymmetry in the area of the nose, lip and upper dental arch. 

With a bilateral cleft lip and palate (pictured below), the central part of the upper jaw and upper dental arch is twisted up and forward. The tip of the nose is flat and broad.
 

Cleft lip, and cleft lip and alveolus 

We perform corrective surgery on a cleft lip when the child is 3 to 6 months old. Alveolar bone graft surgery to correct the bone structure malformation under the gums (cleft alveolus) will be performed much later, at the age of 9 to 11 years. 

Cleft palate 

We perform corrective surgery to close up a cleft palate when the child is about 12 months old. We close the cleft by separating folds of mucous membrane on the soft and hard palates and by stitching the cleft shut. 
 
Cleft lip and palate 

Currently, we generally correct a cleft lip and palate in two separate surgical procedures. First, we close the cleft in the lip and the hard palate at the age of 4 months. We close the cleft in the soft palate at the age of 10 months. Bone graft surgery for a cleft alveolus is performed at the age of 9 to 11 years. 

Correcting the nose and/or lip  

In cases with an extensive cleft, whether unilateral or bilateral, shaping the nose is difficult and often requires further corrective surgery. In bilateral cases, it is almost always necessary to perform further corrective surgery on the nose to adjust the broad, flat profile of the nose. We correct the structure of the nose with cartilage grafts at the age of 6 years or later. The final corrections to the nose and lip are not possible until the child has stopped growing. 

Surgery to improve speech 

Children who have had a cleft palate may initially have less clear and more nasal speech than their peers. This generally corrects itself or can be remedied with speech therapy. However, about one in five of these children must later have surgery to narrow the velic passage to improve the quality of the speaking voice. 

In cases of unilateral and bilateral cleft lip and palate and cleft lip and alveolus, we usually perform bone graft surgery to repair the structure of the alveolus at the age of 9 to 11 years. The purpose of this is to correct the bone deficiency in the alveolar ridge and the nasal floor and to ensure that the permanent teeth will erupt properly. We usually use spongy bone taken from the iliac crest as the graft. Orthodontic treatment is almost always required in connection with a bone graft operation. 

Surgical treatment of jaw growth defects 

Nearly half of the patients who have a unilateral or bilateral cleft lip and palate will develop a growth anomaly in the upper jaw and midface in adolescence. The related severe crossbite may significantly impede the function of the jaw and affect the appearance of the face. 

Growth anomalies in the upper jaw cannot be corrected by orthodontic treatment alone; surgery is required to correct the bone imbalance between the mandibles. 

Growth anomalies in the upper jaw are usually treated with a surgical procedure known as a Le Fort I osteotomy. We usually perform this operation once the child’s growth has ended. In the most severe cases, two operations may be required: one during growth and one towards the end of the growth period. 

Sometimes surgery to the lower jaw is necessary for correcting the facial structure. In addition to correcting the bite, we focus particular attention on the appearance of the face and its proportions. The nose shape typical for cleft patients may be enhanced by a Le Fort I osteotomy. We usually perform corrective rhinoplasty (nose surgery) at the same time.

Cases of cleft lip and/or palate involve a higher than normal rate of dental anomalies, bite anomalies, and jaw growth anomalies. Nearly everyone born with a cleft lip/palate require orthodontic treatment at school age because of this. They may also require dental prosthetics and corrective surgery of the jaw to correct growth anomalies. Orthodontic treatment is also almost always required in connection with a bone graft operation. 

Dental anomalies typical for cleft lip/palate cases include an abnormal number of teeth, and anomalies in tooth structure, formation, and eruption. These anomalies are more common for permanent teeth than for baby teeth. 

The more extensive the cleft was, the more probable it is that there are anomalies in the permanent teeth. We can correct dental anomalies either by closing the space of missing teeth with orthodontic treatment or by installing prosthetics to fill in for the missing teeth. 

Bite defects are also usually the more difficult the more extensive the cleft originally was. Typical bite defects include misalignment of teeth at the cleft site, crowding, and maxillary deficiency, which may lead to a crossbite. 

The patients with the greatest need for prosthetics are those who have had a cleft lip and alveolus or a cleft lip and palate, because these conditions usually cause the greatest changes in the bone structure and the teeth at the site of the cleft. The majority of these patients are adolescents and young adults, but ageing patients also require new prosthetics and prosthetic repairs. Dental prosthetics form part of the comprehensive treatment of cleft lip/palate.