Cleft lip and palate treatment

Cleft lip, and cleft lip and alveolus

We perform corrective surgery on a cleft lip when the child is 3 to 6 months old. The corrective surgery for a bone transplant 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 9 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. The corrective 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, but ultimately the nose and lips cannot be finally corrected 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.

Bone graft

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 (Figure 1). The purpose of this is to correct the bone deficiency in the structure of 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 functioning 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 (Figure 1). 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 (Figure 2). In addition to correcting the bite, we focus particular attention on the appearance of the face and its proportions when performing an osteotomy on a cleft patient. The nose shape typical for cleft patients may be enhanced by a Le Fort I osteotomy. Because of this, we usually perform corrective rhinoplasty (nose surgery) at the same time.

Almost all children born with a cleft palate develop otitis media with effusion (inner ear infection, or ‘glue ear’). Located behind the eardrum, the inner ear is connected to the pharynx by the Eustachian tube.

In a cleft palate condition, the muscles that open and close the Eustachian tube are abnormally attached and do not function properly. Therefore, the inner ear is not ventilated normally, and its mucous membranes begin to secrete mucus. According to current knowledge, this effusion does not harm the ear in any way, but if there is a lot of mucus, the patient’s hearing may be impaired.

Children with a cleft palate will be fitted with tympanostomy tubes to ensure good hearing. What this means is that small tubes are inserted through the eardrum to ventilate the inner ear through the ear canal.

If tympanostomy tubes are required, we generally insert them during the cleft palate surgery. If, however, the child has very poor hearing, the tube procedure can be performed earlier. The tubes remain in the eardrum for anything between 6 months and 2 years and generally fall out by themselves. Once that has happened, we monitor the situation to see whether mucus begins accumulating again. We will insert new tubes if ‘glue ear’ recurs.

Once the cleft palate has been surgically corrected, as the child grows and his/her anatomy changes, the ‘glue ear’ tendency generally passes by the time the child is at preschool or school age, but there is a great deal of individual variation.

Children with a tendency to ‘glue ear’ are easily prescribed antibiotics for common virus infections. ‘Glue ear’ detected while the child has a flu can easily be misinterpreted as acute otitis, or an inner ear infection.

The physician examining the child should be told that the child was born with a cleft palate. Because of this, it is more than likely that the child will accumulate mucus in the inner ear if the tympanostomy tubes are not functioning.

Mucus impedes the movement of the eardrum, and tympanometry will show readings consistent with acute otitis. The physician should take into account whether the eardrum is bulging outwards. A course of antibiotics for acute otitis is only indicated if the eardrum is bulging outwards.

Cases of cleft lip and/or palate involve a higher than normal rate of dental anomalies, bite anomalies and jaw growth anomalies. Nearly all children born with a cleft lip/palate require orthodontic treatment at school age because of this. They may also require dental prosthetics (replacing their own teeth with synthetic ones) 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 in the front or at the side.

Only some cleft patients require dental prosthetics. The majority of these are adolescents and young adults, but ageing patients also require new prosthetics and prosthetic repairs.

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 of the dental arch and in the teeth. Dental prosthetics form part of the comprehensive treatment of cleft lip/palate.

Children with a cleft lip/palate usually have normal speech development. Some children who have had a cleft palate may initially have less clear and more nasal speech than their peers (hypernasality). This generally corrects itself or can be remedied with speech therapy.

A mild case of hypernasality presents as a buzzing or hissing of air flow through the nose when pronouncing plosive consonants (k, p, t, s). Severe cases of hypernasality require surgery and speech therapy.

About one in five children who have had a cleft palate must later have surgery to narrow their velic passage to reduce the nasal timbre in their voice.