Celebrating a birth
The birth of a healthy child is a moment of celebration for parents
and all others related alike. But it turns out be a sad experience
to find newborn child with a birth defect of Cleft Lip and Palate.
The immediate relations, particularly parents, and friends fall in
psychological stress and start worrying about future development of
the child. The birth defects could either involve the external parts
or internal organs separately or may be both in varying combinations.
As far as the birth involving internal organs is concerned, they do
not have significant immediate bearing to cause psychological stress.
Today, much advancement has already been made in the surgical techniques.
The deformity of Cleft Lip & Palate is no longer an unfortunate
situation and is easily treatable. The same could be reconstituted
to a near normal appearance and function.
Overview
Cleft lip is a most common genetic birth defect syndrome involving
a split in the upper lip. The centre of the roof of the mouth is called
palate. When there is a split down the palate, it is called Cleft
palate. It is not always that both the defects occur at the same time.
These defects also occur separately. In their isolation they are known
as isolated cleft lip or isolated cleft palate. But when these defects
occur together in a child, a cut in the upper lip and the palate also
failing to grow properly and forming a split, this is termed as cleft
lip with cleft palate
These defects are known to be present together in varying degree in
about 40 percent of the newborn babies. As per the conservative figures,
it occurs with a 2:1 male-to-female ratio. Clefts can occur on one
side of the mouth (unilateral) or on both sides of the mouth
(bilateral). Another aspect with varying degree of inconclusive
reasons to understand is that Cleft lips occur more often on the left
side rather than the right side. The studies in the United States
mention clefts occurring in 1 in 700 to 1,000 births, whereas children
of Asian, Latino, or Native American descent suffer these defects
more often
Going on in the body
Cleft lip and cleft palate develop during the pregnancy. When grooves
in a developing fetus don't smooth out as it grows, the baby is born
with a cleft lip. The tissues on each side of the mouth grow up to
form roof of the mouth. If the tissues do not fuse normally, the baby
is born with a split called cleft palate. The presence of cleft can
be easily detected or diagnosed through a prenatal ultrasound, as
it causes specific visible symptoms. If somehow the clefting has not
been detected prior to the baby's birth, it's identified immediately
afterward. There are generally three different kinds of clefts:
Cleft palate without a cleft lip
Cleft lip without a cleft palate
Cleft lip and cleft palate together
Possible reasons it happens
More often a genetic link is suspected particularly when other family
members also have cleft. The some of other clefts can be attributed
to a cluster of health problems or certain unidentified syndromes.
Most cleft lips with or without cleft palate are isolated clefts (no
other medical conditions). Since clefts are formed so early in pregnancy,
it is often difficult to link them to any particular causes. Some
studies suggest a link between maternal drug use (such as antiseizure
medication), alcohol abuse, or smoking; maternal illness or infection;
or deficiency of folic acid may be related to the development of a
cleft lip or palate. However, a genetic evaluation should be followed
to identify the possible causes.
Plan of treatment of cleft lip/cleft palate
The very first hurdle to overcome is that of feeding the babies born
with a cleft lip and or palate. Such babies may have difficulty breast-feeding
or using regular nipples. A feeding specialist can help establish
a successful feeding program. A Craniofacial team is formed to detect
other syndromes that are commonly associated with cleft lip and palate
should evaluate children born with this type of deformity. A Craniofacial
team may include an oral and maxillofacial surgeon, a plastic surgeon,
a pediatric dentist, an ENT specialist, a pediatrician, a speech pathologist
and as well as a geneticist.
The Plastic Surgeon, who is made a part of the Cleft and Craniofacial
Team, should normally be a specialist in reconstructive surgery. The
team makes a comprehensive and systematic treatment plan. In most
cases, reconstructive surgery is necessary to align and join these
parts. It considers child’s long term developmental needs along
side his immediate requirements for medical, surgical, and dental
care.
Treatment options
Nasal Alveolar Molding
Surgery for Cleft Lip
Surgery for Cleft Palate
Steps of treatment of cleft lip/cleft palate
It is during the first year of their life almost all children born
with clefts will have to undergo surgery. Normally, the repair surgery
for cleft lip is done at 3-4 months of age and for the palate repair
it is done between 9-12 months. The child’s growth is observed
first to arrive at actual timing for surgery as also formulating the
pre-surgical treatment plan.
Pre-surgical treatment plan is referred to as Pre-surgical Nasal Alveolar
Molding (PNAM). In most cases it requires fitting a dental appliance
to the roof of infant’s mouth. The growth of the tissue is influenced
by this pre-surgical molding and also aids in reducing the size of
the opening. This process should normally begin during the first weeks
of life so that the first surgery gets better results.
An observation is necessary to be made if your child is a candidate
for pre-surgical nasal alveolar molding (PNAM). The pediatric dentist
will do this by taking a dental impression on which he will fashion
an obturator with one or two nasal prongs to help reshape the lip,
nose, and palate. Pre-Surgical Nasal Alveolar Molding is a method
of treatment that reshapes the infant’s nose without surgery
through the use of a custom made orthopedic denture plate, which is
a hard piece of plastic that fits to the roof of the mouth. The important
benefit of the dental appliance is that it provides a hard surface
against which infants press the nipple during feeding. This saves
infant from deterioration in the general health.
The child is allowed necessary time to get used to wearing the molding,
as this device is to be worn 24 hours a day. It is removed only for
the purpose of cleaning. As a next step, nasal prongs are added to
lift the nostril(s). In addition to it, tape is used to help move
and reshape the tissue segments. The pediatric dentist will make adjustment
in these devices at each scheduled visit to him. Once the dentist
and plastic surgeon are satisfied with the position achieved by the
tissue and cartilage that the lip is surgically repaired. Pre-surgical
Nasoalveolar Molding can straighten the columella, rotate the pre-maxilla,
lengthen the prolabium, aligns the alveolar ridge (gum), and lift
the alar (nostril).
Since your child is under constant observation, if necessity of the
secondary repair is felt, it is done at approximately 4-6 years. Further,
an Alveolar bone graft may be necessary at 8-10 years to fill/repair
the gap (cleft) in the gum where the teeth come in. In the last leg,
at 14-16 years, lip and/or nose revisions are done if necessary. The
child and parents are under regular counseling to encounter with ease
all psychological barriers. It is important to note that depending
upon the severity of the cleft and healing response, some children
may require more surgeries than others.
Sketches Explaining
Unilateral and Bilateral Cleft Lip
Normal roof of mouth
One-sided cleft lip
Two-sided cleft lip
Sketches Explaining Cleft Palate
Cleft of back of soft palate
Complete cleft of soft palate
Cleft of soft and hard palates
Complete cleft of lip and palate
Necessary feeding guidelines before surgery
All solid food intake to be stopped at midnight, not even formula
or milk after midnight.
Breast milk is an elixir anyway, and can be given up to four
hours before scheduled surgery call.
There is no restriction on any amount of clear liquids, such
as water, white grape juice or apple juice up to two hours before
the scheduled time.
If the child happens to be asleep, and is 2 years old or younger,
you must wake him up for a clear liquid feed.
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Statutory Warning: The information is intended
to help you better understand dental conditions and procedures and should
not be construed as specific medical advice or recommendation. The general
information provided here is not a substitute for a consultation with the
dentists. Only personal discussion of your individual needs with a professionally
qualified doctor / dentist will determine the best method of treatment suitable
for you.
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