Craniofacial and Cleft Center

What are cleft lip and cleft palate?

Cleft lip and palate are the result of incomplete formation of the upper lip and roof of the mouth. This causes a gap or defect to occur in the affected area, involving skin, muscle, and the tissue lining the oral cavity. There is often an associated deformity of the nose on the affected side.

Cleft lip can occur on one (unilateral) or both (bilateral) sides of the upper lip. This can occur alone or in association with a cleft palate. Similarly, a cleft palate may occur in isolation, without a corresponding deformity of the upper lip.

In the presence of a cleft palate, the mouth and nasal cavities are not separated. Air may exit the nose upon speaking. In addition, the muscles located in the back of the palate do not form properly, resulting in speech that if often difficult to understand.

Why do clefts occur?

Clefts of the lip and palate are one of the most common congenital anomalies in children. They occur in approximately one in 700 births. Currently, there is no known cause of cleft lip and palate. There are various genetic and environmental factors that may contribute to clefting. However, in the majority of new patients that we see, there is no family history of clefts.

Most infants with cleft lip and/or palate are healthy children who have no other birth anomalies. However, children with clefts may sometimes have other medical problems. A geneticist will examine all infants and discuss with the family the chances of having another infant with a cleft.

What are the types of cleft lip and palate?

There are several types and severities of cleft lip and/or palate. 

Types of cleft lip

• Forme fruste unilateral cleft lip: a subtle cleft on one side of the upper lip, which may appear as a small indentation or line.
• Incomplete unilateral cleft lip: a cleft on one side of the upper lip, which does not extend into the nose. There is often a small bridge of tissue left intact at the baee of the nose.
• Complete unilateral cleft lip: a cleft on one side of the upper lip, which extends into the nose. The nose may be severely distorted.
• Incomplete bilateral cleft lip: clefts on both sides of the upper lip, not extending to the nose.
• Complete bilateral cleft lip: clefts on both sides of the upper lip, extending into the nose. The nose is distorted and may appear wide and flat.

 Types of cleft palate

• Incomplete cleft palate: a cleft in the back of the mouth in the soft palate. 
• Complete cleft palate: a cleft affecting the hard and soft parts of the palate. The oral and nasal cavities are in communication.
• Submucous cleft palate: a cleft involving the hard and/or soft palate, covered by the mucous membrane lining the roof of the mouth. May be difficult to visualize.

What are the problems related to cleft lip and palate?

Feeding
Feeding difficulties may occur in newborns with cleft lip and/or palate. Each baby is different. The normal anatomy of the mouth is disrupted. In the presence of a cleft lip, the child may be unable to form a seal around the nipple of a bottle. Children with cleft palates have difficulty in generating suction because of the aberrant communication with the nasal cavity. On his or her first clinic visit, the baby will have a feeding assessment, with the occupational therapist, who will provide information and demonstrate how to feed the baby.

Tooth Development
A cleft lip and/or palate can affect development of teeth. The type of cleft the child has will have an impact on how the teeth will be affected. Missing teeth, small teeth, extra teeth and crooked teeth are common. Regular dental care is important for healthy teeth and gums. 

Orthodontics
A baby with a cleft lip and palate may have the upper jaw divided into two or three widely separated parts.  Orthodontic treatment for a child with cleft lip and palate could start as early as a few days old depending on the child’s type of cleft. A custom-fitted orthodontic appliance is used to bring the parts of the upper jaw, lips and nose closer together and in a better position. This is called Nasoalveolar Molding (NAM). Not all infants will need this treatment. The orthodontist at Childrens Hospital Los Angeles will direct fitting of the appliance.  Most children with cleft lip and palate will have problems with the alignment of the teeth and jaws. The orthodontist can correct this problem with regular treatments starting at age seven for some children.  

Hearing
Proper hearing is important for normal speech development. In children with clefts involving the soft palate, the middle ear may be affected. This occurs when the eustachian tube, which connects the middle ear with the back of the throat, does not function properly. This structure allows fluid to drain from the middle ear into the back of the throat. When its function is compromised, fluid may build up in the middle ear, interfering with hearing. The child may develop a temporary hearing loss. This fluid can also get infected and ear infections may be frequent. For this reason, many children have tubes inserted into the eardrum to drain the fluid. This results in improved hearing and fewer ear infections. 

Speech
Children with unrepaired cleft palates will have speech difficulties. Normal speech is the goal of surgery. Many children will require speech therapy after the operation, and some may need a second procedure, if speech difficulties persist.  The speech therapist will regularly assess speech development and will arrange for speech therapy in the community, if necessary. (maybe have a speech pathologist discuss this in more detail)

How are children with cleft lip and palate treated?

The goal of surgical repair of cleft lips is to restore the normal appearance and muscular anatomy of the upper lip. At our institution, this is done typically between three and six months of age. Cleft palate repair proceeds at approximately 10 to 12 months of age. The goal is to close the cleft between the mouth and nose, in addition to restoring the muscular function of the soft palate. The initial cleft lip repair is often combined with placement of ear tubes by the otolaryngologist. The child is monitored closely following palatal repair to assess for proper development of speech and hearing.  

Since each child's cleft is unique, different surgical techniques may be used to repair the cleft. Also, secondary procedures may be required to correct speech, fill in the bony gap between the teeth, improve the relationship of the upper jaw to the lower jaw, or refine the appearance of the nose. Your plastic surgeon will discuss with you the surgeries that will be performed on your child at each stage.

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