Cleft Lip and Palate Treatment

4 January 2018
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Cleft Lip and Palate

Cleft lip and palate occurs as a result of a fusion during different phases of development inside the mother’s womb (in the embryological stage). The cleft lip and palate is seen in different races at different rates seen on average in 750-1000 births in Europe. It is mostly common in Japan (1 in about 600 births) and it’s seen the least in black Americans (about 1 in 2200 births). In this illness, which is called rabbit lip among society, 80% of the cases have a lip cleft, on one side and predominantly on the left side. The left / right ratio is 2/1. Use of certain medication, vitamin deficiencies, virus infections, cigarette smoking, genetics (familial) are thought to be the cause.

Embryology

The development of the face in the mother’s womb is between 5th and 8th weeks and completed by the 12-17th week. In this period, according to the significance of the problem of the gemules coming together to form the face, a lip celft anomaly may occur ranging from a small indentation on the lip to a completely single and double sided cleft. In the same way, an anomaly can develop from a small indentation on the palate to a single and double cleft of the upper jaw. Embryologically, lip palate development consists of two parts as primary and secondary. The primary part is the part containing the upper lip and the teeth of the upper jaw, while the secondary part is the hard and soft palate part.

Clinical Forms of the Illness (Types)

Cleft Lip and Palates are classified according to their embryological development. The cleft may be unilateral, bilateral, symmetrical on both sides, or asymmetrically slit. They are generally classified in 3 groups.

1-Cleft Lip; it isthe clefts seen on the upper lip. There are different forms. The upper lip has complete or incomplete clefts. They can be unilateral or bilateral. These clefts may also continue in the teeth part of the palate.
2- Cleft lip and palate; the group which includes the upper lip, the hard palate and the soft palate.
3- Cleft palate; this is the group where the upper lip is fine, but the hard palate or the soft palate are cleft separately or together.

Diagnosis

Facial clefts can be seen in advanced (morphological) examinations performed during ultrasounds in pregnancies. It is very unlikely to confuse it with another condition. The cleft and lip palate is easy to recognize. After the diagnosis, it should be examined to see whether there’s another accompanying syndrome. Skull base clefts affecting the central nervous system can be seen in the rare mid line lip clefts. The rare Trisomie 13, Trisomie 18, Vander Wood syndrome, Treacher Collins syndrome, Stickler syndrome, Shprintzen syndrome, Goldenhar syndrome, Pierre Robin syndromes should be investigated.

Treatment

The treatment of cleft lip and palate is performed by a team and can be completed during a long period of time. The team includes pediatricians, orthodontists, orthophonists (speech specialists), ENT specialists, psychologists, and specialists in the field (in coordination with a plastic – reconstructive surgeon experienced in the facial clefts). Treatment begins with improving the approach of the family to the child. The characteristics of the child’s care, nutrition and psychology are taught to the family. Pediatricians regularly follow-up on the weight and height of the child. Lung infections due to food escaping into the lungs and hearing problems related to fluid collection in the middle ear (KBB specialists) are closely monitored in these children.
Immediately after babies are born, they are evaluated by an experienced orthodontist and if necessary they are given a closing epidermis for the palate (in the palate) to make feeding easier. In cleft lips, the nose and the teeth bones (alveol) are prepared for surgery with prothesis called Mold (specially prepared for each patient) to stop it from slanting towards the cleft or the shape being distorted (due to lack of bone).

The timing of the surgeries can be summarized as follows.

1- During the 1st week of birth, the baby is evaluated in terms of nutrition and nose-to-palate molding (prosthesis for restoring the nose and palate position).
2- Nutrition, lung and hearing problems are evaluated until week 6.
3- If general development is favorable, cutting the lip is carried out in the third month.
4 -Between 6-12 weeks the palate is repaired.
5- From the 18th month to the 5th year, speech therapy is done with an orthophonist followed up and supported by the family. In this period, the small openings called fistula, which is a complication of the alveolar palate, are surgically repaired.
6- Bone deficiencies are repaired (if any) in the palate or teeth bone between the ages of 7 and 11.
7- With the permanent removal of teeth between the ages of 11 and 16, orthodontic treatment starts and the teeth are alined in the best way, jaw development is followed-up on. If there is lagging in the development of the lower or upper jaw, an orthodontic preparation is made for a possible future operation.
8 – After 18 years of age, the necessary corrections are made. A correction will be performed on the lip and the nose, if needed. If there is a biting disorder, corrective jaw surgery is performed, deficiencies in the teeth are completed by an appropriate method and treatment is finalized.
9- At any stage of the treatment, at the request of a family member or a specialist from the team a psychologist can be brought in for support.

Feeding characteristics in cleft lip and palate

Babies with cleft lip and palates are fed in different ways as they have difficulty breastfeeding. The priority is to try to get the baby to breastfeed. When it’s not adequate, with isolated cleft palates the baby can breastfeed with the help of epithesis closures. Mother’s milk can be given in a bottle. The best tip can be found by testing bottle tips of different lengths. Baby’s feeding position is very important. The baby should be in a position higher than 45 degrees that is, it should be in a half-sitting position so that the food can enter the lungs. Otherwise the baby will constantly cough and will have lung infections due to escaping of the food into the lungs.

Cleft Lip Surgery

When the baby is 3 months old, it can have cleft lip surgery. Firstly, the baby’s condition is evaluated in terms of general anesthesia. Babies with appropriate development and weight (hemoglobin 10 mg / dl, weight 4.5-5 kg) are operated on for lip correction. There are many surgical techniques, the Plastic and Reconstructive surgeon can choose one according to his personal experiences. The most commonly used is Millard’s repair technique. Corrections are made in three plans. Mucosal repair, muscle repair and skin repair. In Millard’s technique, the skin muscle and the mucosa on the cleft edges are repaired as a whole by reciprocal rotation and advancement methods. The operation lasts about 1-2 hours and the hospital stay is 1 day. Recovery takes an average of 10 days. The most important thing to know is that the scars on the lips will never go away and it will always be a little visible.

Cleft Palate Surgery

After the baby is 6 to 12 months old, repair operation is done by evaluating the general condition and the width of the ward. Generally, the existing palate tissues are sufficient for repair. Von Langenbeck (simple palatoplasty) is the most commonly used repair technique and is a method of palate repair and puch back palatoplasty. In these surgeries, the palate tissues on both sides of the palate are repaired 3 planes (repair of nasal mucosa, repair of soft palate muscles and repair of oral mucosa). The surgery takes 1-2 hours on average, and the hospital stay is 1 day. Recovery time is about 2 weeks. During this time, the baby is careful not to damage the baby during feeding.

Possible problems and solutions
Problems are minimized when the treatment of infants with cleft lip palate is performed by an experienced team. When we look at details of common problems, the following problems are encountered in each region.

There may not be enough muscle unity in the after cleft lip repair. In this case, the lip may look thinner in the area repaired and may not be able to fully pucker up the lips by making whistling movements, resulting in indentations and irregularity of the scars. The M shape of the mouth may not be fully formed. The solution is to perform a revision surgery and repairing the muscles and improving the scars.
Nasal deformities; in cleft lip palates, there are deformaties in shape and function in different sizes. Due to the deficiencies of the bones, cartilage and soft tissues on the side of the cleft, the nose lies to one side which may lead to abnormal (formal and functional) developments causing impairments in the septum and conchaes. The axe of the nose deviates and the tip droops down. The solution is to resolve these problems with cosmetic nose surgery after 18 years of age. Even if the surgery is performed in the best way, it is important to remember that slight differences from a normal nose will remain due to structural tissue disorders.

Dental and dental bone (alveolar) problems are common problems. Between the lip, palate and nose may be holes (fistulas) that develop due to soft tissue and bone healing problems. They cause the liquids to come out of here. Fusion of the alveolar bone and developmental retardation can lead to loss of teeth and impairment in biting. The solution is to close the fistulas with surgery and, if necessary, bone grafts from the hip region, ie repair of the alveolar bone, followed by removal of missing teeth with implants if possible.

The most common problems in palate patients are voice and speech disorders (pharyngeal nausea), which are caused by the fact that the soft palate of the throat area (pharynx) can not close the throat adequately because of unfilled holes (fistulas) in the palate area. The solution depends on the problem. If there is a fistula, closure of the fistula with surgery is sometimes difficult. If there is midfacial growth retardation, the upper jaw can be brought forward after 18 years of age following orthodontic treatment. Speech disorders can be improved by reducing the soft palate or by eliminating the escape of the soft palate (inadequacies) using various techniques after performing an endoscopic speech examination.

Cavities and misalignments that may occur in teeth are followed-up by dentists and they are treated at every age. Finally, lip and cheek implants are put in to make the cheek bone more distinctive for aesthetic purposes.

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