Cleft lip and cleft palate malformations arise when the developing face fails to fuse early in pregnancy. Cleft lip with or without cleft palate is one of the most common congenital abnormalities. The formation of the fetal face occurs in the first trimester of pregnancy. Cleft lip is a defect of normal continuity of the upper lip and jaw and can be complete or incomplete depending on severity and structures involved. In addition to the obvious external deformity, a multitude of functional problems exist including difficulty feeding, communication between the mouth and nose, and normal speech development.
Cleft lip and cleft palate can occur on one or both sides of the mouth. Because the lip and the palate develop separately, it is possible to have a cleft lip without a cleft palate, a cleft palate without a cleft lip, or both together.
Who Gets Cleft Lip and Cleft Palate?
Cleft lip, with or without cleft palate, affects one in 700 babies annually, and is the fourth most common birth defect in the U.S. Clefts occur more often in children of Asian, Latino, or Native American descent. Compared with girls, twice as many boys have a cleft lip, both with and without a cleft palate. However, compared with boys, twice as many girls have cleft palate without a cleft lip.
What Causes a Cleft Lip and Cleft Palate?
In most cases, the cause of cleft lip and cleft palate is unknown. These conditions cannot be prevented. Most scientists believe clefts are due to a combination of genetic and environmental factors. There appears to be a greater chance of clefting in a newborn if a sibling, parent, or relative has had the problem.
Another potential cause may be related to a medication a mother may have taken during her pregnancy. Some drugs may cause cleft lip and cleft palate. Among them: anti-seizure/anticonvulsant drugs, acne drugs containing Accutane, and methotrexate, a drug commonly used for treating cancer, arthritis, and psoriasis.
Cleft lip and cleft palate may also occur as a result of exposure to viruses or chemicals while the fetus is developing in the womb.
In other situations, cleft lip and cleft palate may be part of another medical condition.
How Are Cleft Lip and Cleft Palate Diagnosed?
Because clefting causes very obvious physical changes, a cleft lip or cleft palate is easy to diagnose. Prenatal ultrasound can sometimes determine if a cleft exists in an unborn child. If the clefting has not been detected in an ultrasound prior to the baby’s birth, a physical exam of the mouth, nose, and palate confirms the presence of cleft lip or cleft palate after a child’s birth. Sometimes diagnostic testing may be conducted to determine or rule out the presence of other abnormalities.
What Problems Are Associated With Cleft Lip and/or Palate?
- Eating problems. With a separation or opening in the palate, food and liquids can pass from the mouth back through the nose. Fortunately, specially designed baby bottles and nipples that help keep fluids flowing downward toward the stomach are available. Children with a cleft palate may need to wear a man-made palate to help them eat properly and ensure that they are receiving adequate nutrition until surgical treatment is provided.
- Ear infections/hearing loss. Children with cleft palate are at increased risk of ear infections since they are more prone to fluid build-up in the middle ear. If left untreated, ear infections can cause hearing loss. To prevent this from happening, children with cleft palate usually need special tubes placed in the eardrums to aid fluid drainage, and their hearing needs to be checked once a year.
- Speech problems. Children with cleft lip or cleft palate may also have trouble speaking. These children’s voices don’t carry well, the voice may take on a nasal sound, and the speech may be difficult to understand. Not all children have these problems and surgery may fix these problems entirely for some. For others, a special doctor, called speech pathologist, will work with the child to resolve speech difficulties.
- Dental Problems. Children with clefts are more prone to a larger than average number of cavities and often have missing, extra, malformed, or displaced teeth requiring dental and orthodontic treatments. In addition, children with cleft palate often have an alveolar ridge defect. The alveolus is the bony upper gum that contains teeth. A defect in the alveolus can (1) displace, tip, or rotate permanent teeth, (2) prevent permanent teeth from appearing, and (3) prevent the alveolar ridge from forming. These problems can usually be repaired through oral surgery.
What’s the Treatment for Cleft Lip and Cleft Palate?
A cleft lip may require one or two surgeries depending on the extent of the repair needed. The initial surgery is usually performed by the time a baby is 3 months old.
Repair of a cleft palate often requires multiple surgeries over the course of 18 years. The first surgery to repair the palate usually occurs when the baby is between 6 and 12 months old. The initial surgery creates a functional palate, reduces the chances that fluid will develop in the middle ears, and aids in the proper development of the teeth and facial bones.
Children with a cleft palate may also need a bone graft when they are about 8 years old to fill in the upper gum line so that it can support permanent teeth and stabilize the upper jaw. About 20% of children with a cleft palate require further surgeries to help improve their speech.
Once the permanent teeth grow in, braces are often needed to straighten the teeth.
Additional surgeries may be performed to improve the appearance of the lip and nose, close openings between the mouth and nose, help breathing, and stabilize and realign the jaw. Final repairs of the scars left by the initial surgery will probably not be performed until adolescence, when the facial structure is more fully developed.