Tuesday, 26 July 2011

Surgery for Cleft Lip & Cleft Palate

Published in City Times

Treating Cleft Lip and Cleft Palate

One in every 700 babies is born with either a cleft lip, a cleft palate or
both of these, annually in the UK. The incidence is likely to be more in
the Middle Eastern region, mainly due to marriages among cousins and
relatives, reveals Dr.(Ms.)Salam Al Khayyat, Orthodontic specialist,
Dr.Nicolas and Asp Dental Centre, Jumeirah, Dubai.

Treatment involves a multidisciplinary approach. The role of the
orthodontist within the cleft team is to take primary responsibility for the
assessment of maxillofacial growth and development.

The incidence of the condition has increased two-fold in the last couple of
decades and the reason for this congenital craniofacial deformity is 40% due
to heredity and 60% due to environmental factors, being quite predominant in
certain races of people including the American Indians and Japanese. For
some unknown resason, while more girl babies are affected by cleft palate,
more male babies are affected by a combination of cleft lip and palate,
reveals Dr.Khayyat.

What are cleft lip and cleft palate and how do the symptoms manifest?
Cleft lip is a gap or split in the upper lip while a cleft palate is a gap
in the roof of the mouth. Children born with cleft lips may show up
features ranging from a small notch in the lip to a complete fissure
extending into the roof of the mouth and nose. These features may occur
separately or together. The affected lip is always the upper one and very,
very rarely, a lower lip may be clefted. The clefts may be unilateral, as
happens mostly, or they may be bilateral in some children
Why is it that some children are born with this condition?
The lip and palate in a foetus form during the first trimester of pregnancy.
They develop from tissues lying on either side of the tongue. Normally,
as the face and skull form, these tissues grow towards each other and fuse
in the middle. But for some reason, these tissues that form the upper lip,
fail to join the middle of the face, giving rise to a gap in the lip. If one
side of the lip is affected (unilateral cleft), a single gap appears below
one of the nostrils; if both sides are affected, (bilateral cleft lip), two
gaps appear in the upper lip, one below each nostril. In the same way, when
the palate fails to fuse, there's a gap formed in the roof of the mouth up
into the nose. While it may be difficult to pinpoint the exact cause,
heredity and genetic factors are certainly involved. Besides, the other
risk factors for cleft formation include exposure of the mother during the
first trimester of pregnancy to x- rays, if she is under undue stress, if
she is taking certain medications for other health conditions or if the she
is a smoker.

Do the cleft lip and cleft palate become apparent in the baby immediately
after birth?
The cleft lip is obviously noticeable at birth in a baby. However, the
cleft palate becomes obvious only to the pediatrician who examines the baby
immediately after birth, since it has no visible symptoms or manifestations
to the lay people.

What are the problems that cleft lip and cleft palate cause to the baby?
Besides being disfiguring, the immediate practical problems that are caused
by the conditions include difficulty in feeding because the baby cannot
suck. Some babies with a cleft lip and palate can breastfeed but most of
them can not. There is difficulty in forming a vacuum to suck properly.
The problem is more apparent in babies with cleft palate and they require
special appliances called orthodontic feeding appliances which are dental
plates made of acrylic to be used to seal the roof of the mouth to help them
suck from a bottle and to decrease the size of the palatal cleft by causing
gradual movement of the clefted segments towards each other and this needs
periodical changes of the plates as in the end of 9th month the clefted
segments will be very close to each other and accordingly a less traumatic
palatal surgery will be achieved allowing a normal growth of the maxilla.

Another common problem with these babies is their susceptibility to
infection, particularly of the upper respiratory tract, breathing
difficulty if the cleft palate is too severe and bilateral. Weight gain is
very slow in these babies if they will not be treated, since they find it
difficult to feed.

Cleft palate in particular can cause speech problems and these children
usually tend to have nasal speech if the cleft is not corrected
appropriately and on time. Hearing may be affected as these children are
susceptible to repeated ear infections and the cleft palate may affect the
growth of the upper jaw and proper development of the teeth which may be
mal-aligned or absent at the cleft region. The speech and audio impairment
may in themselves lead to learning difficulties.

Besides clinical examination of the newborn, are any other tests done to
diagnose cleft lip and palate?
A physical examination of the mouth, nose and palate confirms the presence
of cleft lip or cleft palate. Further diagnosis may be required should the
pediatrician suspect any other abnormalities which require to be ruled out.

How are the conditions treated?
Ideally, treatment of the conditions require a team of specialists including
pediatric, orthodontic, plastic, maxillofacial and ENT surgeons, speech
therapist, audiologists and psychologists. Further care and support of the
child by the parents and family is required right from birth till the child
stops growing at about the age of 18 years, with regular checkups with the
dentist and orthodontist.

Primary Surgery is almost inevitable for the conditions and is performed
under general anesthesia. Cleft lip surgery is best done between the ages
to 0 - 3 months while surgery to rectify the palate is best done between the
ages of 9months to one year. If the baby's weight is normal, if its blood
haemoglobin level is normal and it is otherwise healthy and can tolerate
anesthesia, the ideal time to perform a cleft lip surgery is after 24 hours
of birth. If not, at least before 3 months.

The cleft palate surgery is best done between the ages of 9 months and a
year because infants usually start speaking around the age of 1 year and
hence if their normal speech development has to be built and enhanced,
surgery is best done before the child turns one. Until palatal surgery,
usually the orthopedic feeding plates are used to the palate for feeding and
controlling of the bony clefted segments.

Will these children require further surgeries following the primary surgery?
In most instnaces, as these children grow, they may require orthodontic
treatment because of the malaligned teeth at the region of the cleft.
Surgery may be required to improve the appearance of the facial structures
like the lip and nose and also to enhance the function of the palate. The
secondary surgical intervention is mostly done when the children grow to 9
or 10 years of age. At this time an avular bone graft may be required to
allow the canines to erupt in the area of the cleft. Ortognathic surgery is
mostely required after the age of 16 to correct jaws relationship and this
is done by a co-ordination between the orthodontist and the oromaxillofacial
surgeon. Another plastic surgery may be required at the age of 17 or
thereabout if the person wants to have a different shape to his or her nose.

Apart from further surgery, will these youngsters require any other
The success of surgery in the hands of an expert team is monumental, almost
100%. However, it may take months and even a few years for the oral cavity
and hence the face to acquire its proper shape since secondary surgeries
following the primary one are necessary in most instance where the palate is
involed. When lip and palatalsurgeries are performed the healing process
may take about a week during which time the babies will not be able to
suckle; hence they have to be spoonfed. When the second surgery such as
orthognathic surgery is performed at about 17 years of age, the youngster
will not be able to eat solid food and hence will have to make use of straw
to take in liquids for almost 6 weeks following surgery. Once healing is
complete, he/she can resume normal diet.


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