Cleft Lip, Palate, & Alveolus (Gum)

During early pregnancy, separate areas of the face develop individually and then join together, including the left and right sides of the roof of the mouth and lips. However, if some parts do not join properly, sections don’t meet and the result is a cleft. If the separation occurs in the upper lip, the child is said to have a cleft lip.

A completely formed lip is important not only for a normal facial appearance but also for sucking and to form certain sounds made during speech. A cleft lip is a condition that creates an opening in the upper lip between the mouth and nose. It looks as though there is a split in the lip. It can range from a slight notch in the colored portion of the lip to complete separation in one or both sides of the lip extending up and into the nose. A cleft on one side is called a unilateral cleft. If a cleft occurs on both sides, it is called a bilateral cleft.

A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum into separate parts. A similar defect in the roof of the mouth is called a cleft palate.

Cleft Palate

The palate is the roof of your mouth. It is made of bone and muscle and is covered by a thin, wet skin that forms the red covering inside the mouth. You can feel your own palate by running your tongue over the top of your mouth. Its purpose is to separate your nose from your mouth. The palate has an extremely important role during speech because when you talk, it prevents air from blowing out of your nose instead of your mouth. The palate is also very important when eating. It prevents food and liquids from going up into the nose.

As in cleft lip, a cleft palate occurs in early pregnancy when separate areas of the face have developed individually do not join together properly. A cleft palate occurs when there is an opening in the roof of the mouth. The back of the palate is called the soft palate and the front is known as the hard palate. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth (soft and hard palate).

Sometimes a baby with a cleft palate may have a small chin and a few babies with this combination may have difficulties with breathing easily. This condition may be called Pierre Robin sequence.

Since the lip and palate develop separately, it is possible for a child to be born with a cleft lip, palate or both. Cleft defects occur in about one out of every 800 babies.

Children born with either or both of these conditions usually need the skills of several professionals to manage the problems associated with the defect such as feeding, speech, hearing and psychological development. In most cases, surgery is recommended. When surgery is done by an experienced surgeon, the results can be quite positive. It is important to understand that a series of procedures may be necessary–spread out over several years–to achieve optimal results.

Cleft Lip Treatment

Cleft lip surgery is usually performed when the child is about ten weeks old. The goal of surgery is to close the separation, restore muscle function, and provide a normal shape to the mouth. The nostril deformity may be improved as a result of the procedure or may require a subsequent surgery.

Cleft Palate Treatment

A cleft palate is initially treated with surgery safely when the child is between 7 to 18 months old. This depends upon the individual child and his/her own situation. For example, if the child has other associated health problems, it is likely that the surgery will be delayed.

Cleft Alveolus Treatment

Patients who have a complete cleft on one or both sides will also have a cleft of the alveolus (the jawbone & teeth) and a residual hole (oral-nasal fistula) which allows fluid (and sometimes solid food) to leak into the nose. While the lip and palatal clefts are repaired during infancy, the defect in the jawbone and nose is not usually repaired until at least 5-6 years of age. By that time, the upper jaw has grown to ~85% of its final size and surgical correction of the remaining gaps can be safely performed. Early correction of the cleft alveolus and nasal fistula is preferred rather than waiting until age 10-14 because healing is better, surgical success rates are higher, the permanent teeth can erupt into normalized bone tissue and the gums tissue regrowth is also more favorable. In many cases, the repair can be performed before the start of kindergarten or 1st grade. Depending on the width of the upper jaw, orthodontic treatment may be required–BEFORE and AFTER cleft surgery– to align the segments of the jaw in an ideal configuration, to provide proper space for bone graft placement, and to hold the segments in the desired position while the bone graft heals. IN almost all cases, there is enough gum tissue to repair the cleft areas with local tissue. However, in severe cases, or in cases where previous surgery has been unsuccessful, a graft of tissue from the tongue may be required to close the hole in the roof of the mouth and nose.

The major goals of surgery to repair the cleft alveolus and oral-nasal fistula are to:

1. Close the gap or hole between the jaw and the nose.
2. Graft bone to reunite the segments of the jaw into one piece.
3. Allow the permanent teeth to erupt into normal bone and gum tissue.

Cleft Orthognathic Treatment

Despite proper sequencing and healing after cleft lip, palate, and alveolar surgery, the patient has a 25-30% chance that the upper jaw will be too short horizontally or vertically. The risk is actually higher in patients with one-sided clefts as compared to those with a cleft on both sides. To the patient and family it may appear that the lower jaw is too long but this is an illusion in almost all cases. Repair of the upper jaw is usually performed around age 16-17 and is performed in conjunction with a second stage of orthodontics. The exact timing will depend on many factors including stage of tooth eruption, physical maturity, and orthodontic requirements. Depending on the size of the gap between the upper and lower front teeth, simultaneous surgery of the lower jaw may be required. If there are residual gaps in the alveolus or a residual nasal fistula with persistent leak of fluid into the nose, it is repaired at this time. In adults

Cleft Nasal Treatment

Once the lip, palate, alveolus, and jaw are repaired, any refinement to the nose (and/or lip) can be performed. Typically it is necessary to wait a minimum of 9-12 months AFTER upper jaw surgery–to allow for resolution of the associated swelling in the nose and lip– before correcting any residual nasal problems. The reason is that swelling from upper jaw surgery can alter the position of the nose. Unfavorable results can occur if revision nasal surgery is done too soon., the final nasal result The cleft hard palate is generally repaired between the ages of 8 and 12 when the cuspid teeth begin to develop. The procedure involves placement of bone from the hip into the bony defect, and closure of . It may also be performed in teenagers and adults as an individual procedure or combined with corrective jaw surgery.

What Can Be Expected After The Surgery?

After the palate has been fixed, children will have an easier time in swallowing food and liquids. However, in about one out of every five children following cleft palate repair, a portion of the repair will split, causing a new hole to form between the nose and mouth. If small, this hole may result in only an occasional minor leakage of fluids into the nose. If large however, it can cause significant eating problems, and most importantly, can even affect how the child speaks. This hole is referred to as a “fistula,” and may need further surgery to correct.

After the cleft alveolus is repaired, the leak into the nose is resolved. The patient usually stays overnight for a 23 hour recovery in the hospital and goes home with liquid antibiotic and liquid pain medication. It is important NOT to blow the nose or test the mouth for “leaks” during the 1st few weeks after surgery. All suture dissolve spontaneously. About 4-5 weeks after grafting, the patient returns to the orthodontist to complete orthodontic treatment.

The patient usually stays in the hospital for 2 days following repair of the upper jaw. The jaws are wired together for 4-8 days to assist with proper healing and then rubber bands are used to help guide the jaws and teeth into proper alignment. A blenderized diet is required while the jaws are wired. Soft foods such as fish and pasta can be resumed as soon as the wires are released. About 4-5 weeks after surgery, the patient returns to the orthodontist to complete orthodontic treatment.