Cleft is one of the most common birth defect. The incidence of cleft depend on the ethnic groups, highest being the Asians 1 in every 500 births, Caucasians 1 in every 700 births and least the Africans with 1 in every 1200 births. Cleft lip is more common in male and cleft palate is more common in females. Unilateral cases occur in 80% cases and bilateral occurs in only 20% cases and left sided cleft is more common than right sided cleft.
A cleft occurs when certain parts of the body fails to fuse during fetal development and may occur in the lip or the palate (roof of the mouth). Cleft lip and cleft palate are formed at different time period. Cleft lip is formed at 7-9 weeks of gestation and cleft palate is formed at 9-11 weeks of gestation. Cleft lip can occur with or without cleft palate. They are associated with various other anatomic defects like clubfoot (talipes), etc.
In patient with cleft palate, there is a wide gap present between the mouth and the nose and find it difficult in sucking of the milk as the gap created fails to form suction. So, feeding is done with special feeding devices like a spoon, dropper or an obturator, a device which closes the gap present thereby creating suction and help in sucking of the child. As the child grows, they face difficulty in eating, swallowing, breathing, etc. Most of the child with cleft, live in isolation making it hard to find friends at school or in neighborhoods’.
Causes of Cleft Lip and Cleft Palate
The exact etiology of cleft is unknown but studies show that cleft is multifactorial in origin which is mainly caused due to genetic factors, environmental factors and nutritional factors. Also, poor health of the mother during pregnancy has some effect on the child.
1. Genetic factor
Mutation occurs in one or more genes and these genes are located on more than several chromosomes including 1, 2, 4, 6, 19, etc causing cleft.
2. Family history
Parents born with cleft lip and palate are more likely to have children with such defects, if one parent have cleft lip than 20% chances of developing cleft, if their one child is born with cleft lip then 14% chances to the next child and if a non cleft parent born with cleft lip then 4% chances of developing cleft lip to the next child.
3. Environmental factors
Insecticides and pesticides containing hexachlorobenzene, cynizine, thiram, etc are known to cause cleft.
4. Nutritional factors
Excessive vitamins A and deficiency of folic acid during pregnancy increases the chances of baby born with cleft.
5. Medications
Drugs like tetracycline, metronidazole, trimethoprime, sulphonamides, phenytoin, warfarin, ethanol, etc taken during pregnancy increases the chances of cleft and other various anomalies.
6. Smoking and drinking
During pregnancy doubles the risk of developing cleft in new born.
Classification of Cleft
1. Cleft lip
- Complete or incomplete cleft
- Unilateral or bilateral cleft
2. Cleft palate
- Both hard and soft palate
- Soft palate only
- Bifid uvula
3. Combine cleft lip and cleft palate
- Unilateral, incomplete or complete cleft lip and cleft palate
- Bilateral, incomplete or complete cleft lip and cleft palate
Deformities in Cleft
1. Feeding problems
Weak sucking, weak swallowing reflex, nasal regurgitation.
2. Dental problems
Number, shape, eruption, mineralization.
3. Nasal problems
Flare ala, deviated nasal septum and columella to the non cleft site.
4. Skeletal problems
Maxillary deficiency, mandibular prognathism, class III malocclusion
5. Speech problems
pronouncing consonants like g, b, f, etc are distorted (as they are formed by pressure exerted against the roof of the mouth), nasal resonance and problems with clarity of speech
6. Ear problems
Middle ear infection, hearing problems, possible deafness
7. Associated anomalies
Congenital heart defects, mental retardation
Syndromes Associated with Cleft
- Crouzon syndrome
- Treacher Collins syndrome
- Apert syndrome
- Gorlin syndrome,
- Edward syndrome
- Marfan syndrome, etc
Treatment
1. Non Surgical Treatment
- Dental Obturator
For severe cleft patients or those who refuse for surgery
High rate of closure but the prosthesis need to modify as the child grows.
- Pre Surgical Appliances
They are custom made acrylic plate for anchorage and molding of the lip, nasal and alveolar structures during the pre surgical phase.
2. Surgical Management
The timing and specific techniques used during each stages of cleft reconstruction of cleft lip and cleft palate are still controversial.
The Stages of Cleft Repair in Patient with Cleft Lip and Cleft Palate
CLEFT LIP
Rule of 10’s
Hemoglobin = 10g
Weight = 10lbs
Age = 10 weeks
Timing = 6-8 weeks
CLEFT PALATE
Timing = 9-12 months
PHARYNGEAL FLAP OR PHARYNGOPLASTY
3-5 years or later based on speech development
ALVEOLAR RECONSTRUCTION WITH BONE GRAFTING
6-9 years based on dental development
ORTHOGNATHIC SURGERY
14-16 years in girls and 16-18 years in boys
RHINOPLASTY
After orthognathic surgery
LIP REVISION
Best performed after 5 years after initial remodeling and scar formation is complete.
The treatment of cleft lip and palate requires a multidisciplinary approach by by best dentist in Ashok Vihar. The teams need to perform various surgeries over several years to ensure comprehensive care and treatment of the patient.
Give a smile and get a smile by changing the world one smile at a time along with organizations like smile train, cleft children international, smile angel foundation, operation smile, facing the world, thousand smiles foundation, etc and make them realize that cleft is no longer a life sentence misery but can be treated effectively by providing free cleft surgeries to those in needs.
