Cleft Lip and Palate

Dr Aishwaraya Gupta
The lip forms between the fourth and seventh week of pregnancy. As a baby develops during pregnancy, tissues from each side grow toward the center of the face and join together to make the face. This joining of tissue forms the facial features, like the lips and the mouth.If these tissues fail to meet, a gap appears where the tissues should have joined. A cleft lip happens if the tissue that makes up the lip does not join completely before birth. This results in an opening in the upper lip. It is due to the failure of fusion of the maxillary prominence and medial nasal processes. Cleft lip appear as a small notch or an indentation in the lip (partial or incomplete cleft), or it continues into the nose (complete cleft).A cleft lip can be on one (unilateral) or both sides (bilateral) of the lip or in the middle of the lip, which occurs very rarely. Children with a cleft lip also can have a cleft palate.
What is cleft palate?
The roof of the mouth (palate) is formed between the sixth and ninth weeks of pregnancy. A cleft palate happens if the tissue that makes up the roof of the mouth does not join together completely during pregnancy. For some babies, both the front (hard palate) and back part (soft palate) of the palate do not fuse. For other babies, only a part of palate is involved.
Causes and risk factors?
The causes of orofacial clefts among most infants are unknown. Researchers believe that most cases of cleft lip and cleft palate are caused by an interaction of genetic and environmental factors.
The mother or the father can pass on genes that cause cleft, either alone or as part of a genetic syndrome that includes a cleft lip or cleft palate as one of its manifestation. In some cases, babies inherit a gene that makes them more likely to develop a cleft, and then an environmental trigger actually causes the cleft to occur.
According to the Centers for Disease Control, factors that could increase a baby’s risk of developing a cleft lip or cleft palate, include:
* Family history. Parents with a family history of cleft lip or cleft palate have a higher risk of having a baby with a cleft.
* Exposure to certain substances during pregnancy. Cleft lip and cleft palate may be more likely to occur in pregnant women who smoke cigarettes, drink alcohol or take certain medications during pregnancy like anti-seizure medicines.
* Having diabetes. There are evidences that women diagnosed with diabetes before pregnancy may have an increased risk of having a baby with a cleft lip with or without a cleft palate.
* Being obese during pregnancy. There are some evidence that babies born to obese mothers may have increased risk of cleft lip and palate.
* Not getting enough nutrients, like folic acid, before and during pregnancy
* Consanguineous Marriages,marriage amongst the blood relations.
Children with cleft lip with or without cleft palate face a variety of challenges, depending on the type and severity of the cleft.
* Difficulty in feeding. One of the most immediate concerns after birth is feeding. Due to lack of suction, an infant with a cleft may have trouble feeding. While most babies with isolated cleft lip may breast-feed, a cleft palate makessucking difficult.Usually long nipple bottle, haberman feeder, obturator or feeding plate etc. are advised.
* Ear infections and hearing loss. Babies with cleft palate are especially at risk of developing middle ear infections and hearing loss.
* Dental problems. If the cleft extends through the upper gum, tooth development may be affected.Other problems may include fused teeth, missing teeth, and extra teeth, hypo mineralized teeth etc.In addition, abnormal positioning of individual teeth may affect occlusion, which can create an open bite or cross bite. This in turn can then affect the patient’s speech.
* Speech difficulties. Because the palate is used in forming sounds, the development of normal speech can be affected by a cleft palate. Also, because of an open connection between the mouth and inside the nose, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions while talking.
* Challenges of coping with a medical condition. Children with clefts may face social, emotional and behavioral problems due to differences in appearance and the stress of intensive medical care.
* Psychosocial issues. Social anxiety amongst parents and children, poorself-esteem and self-confidence amongst children is observed.
Orofacial clefts, especially cleft lip with or without cleft palate, can be diagnosed during pregnancy by a routine ultrasound. Usually, cleft in the lip or palate is immediately identifiable at birth. However, sometimes certain types of cleft palate (for example, submucous cleft palate and bifid uvula) might not be diagnosed until later in life.
After a baby is born with a cleft, parents are understandably concerned about the possibility of having another child with the same condition. While many cases of cleft lip and cleft palate can’t be prevented, consider these steps to lower the risk:
* Consider genetic counseling. If you have a family history of cleft lip and cleft palate, tell your doctor before you become pregnant. Your doctor may refer you to a genetic counselor who can help determine your risk of having children with cleft lip and cleft palate.
* Don’t use tobacco or alcohol. Use of alcohol or tobacco during pregnancy increases the risk of having a baby with a birth defect.
* Take prenatal vitamins.
Who Treats Children With Cleft Lip and/or Palate?
Due to the number of oral health and medical problems associated with a cleft lip or cleft palate, a team of doctors and other specialists is usually involved in the care of these children. Members of a cleft lip and palate team typically includes Pediatrician, Pedodontist, Plastic Surgeon, Otolaryngologist, Oral Surgeon, Orthodontist , Prosthodontist, Speech Pathologist ,Speech Therapist, Audiologist, Psychologist, Geneticist etc. The health care team works together to develop a plan of care to meet the individual needs of each patient.
(The author is Post graduate student Department of Pedodontics and preventive dentistry Indira Gandhi Government Dental College, Jammu.)