Introduction to Cleft Lip & Palate
Children born with a facial cleft require a team of highly experienced physicians, surgeons, and health care providers to properly manage the issues associated with this condition. A thorough understanding of the causes, treatment options, variations, and surgical procedures is necessary to provide comprehensive treatment. Surgical execution of the required procedures should be performed by facial reconstructive surgeons experienced in cleft surgery in order to achieve the best possible outcome. All of the surgeons at our center have an extensive knowledge of facial clefting and are integral members of The New Jersey Institute for Craniofacial Surgery. Our tem of Craniofacial Surgeons, Plastic & Reconstructive Surgeons, and Oral & Maxillofacial Surgeons provide the majority of care for the Institute. Members of our team have lead the Institute for more than 35 years.
Facial clefts occur in approximately one in 700 to 800 births in the United States, making them one of the most common birth disorders. During early pregnancy, the upper lip, upper jaw, and the roof of the mouth develop as individual segments. These segments eventually merge together to form a unified upper lip, jaw, and palate. However, if the segments fail to merge properly, a cleft will result between the unmerged segments. A cleft may occur in the lip (cleft lip), upper jaw (cleft of alveolus), palate (cleft palate), or any combination of these areas. Clefts in each of these areas may be complete or incomplete. A cleft that occurs on only one side of the face is referred to as unilateral, and one that occurs on both sides of the face is referred to as bilateral.
If the separation occurs in the upper lip, the child is said to have a cleft lip. The separation of the upper lip is usually slightly to the left or right of the midline in the area underneath the nostril. It can range from a slight notch in the colored portion of the lip to a complete separation of the lip extending into the nose. An intact upper lip is important not only for facial appearance but also for feeding and speaking.
Cleft of the Upper Jaw (Alveolar Cleft)
A cleft in the upper jaw may occur in association with a cleft lip. This cleft may range from a small notch in the gum to a complete division of the upper jaw into separate segments. Typically, it is in the area where the canine tooth needs to erupt. Without correction of this cleft, the canine tooth either will not erupt or will erupt into an incorrect position, usually with minimal bone support. In addition, the lateral incisor in the area is typically hypoplastic (small) or missing.
The palate is made of bone and muscle and is covered by pink mucosal. The front of the palate is known as the hard palate, and the back of the palate is referred to as the soft palate because of the lack of bone in the area. A cleft palate can range from just a notch in the back of the soft palate (bifid uvula) to a complete separation of the soft and hard palate (complete cleft palate). When formed correctly, the palate separates the nose from the mouth. The palate plays an important role in eating, speaking, and maintaining proper ear function.
An intact palate normally keeps food and liquids out of the nose during feeding. In children with a cleft palate, feeding issues may present because of the opening between the mouth and nose. These issues are usually easily overcome with some guidance from a feeding specialist and the use of special feeding bottles.
When speaking, the palate prevents air from escaping through the nose. The palate is typically repaired before the child begins to speak (around 1 year of age), as this provides the best chance of avoiding significant speech issues. Commonly, speech therapy during childhood is recommended to achieve the best speech possible. Occasionally additional surgical procedures may be recommended to improve speech.
The Eustachian tube is a structure that connects the middle ear to the back of the throat behind the nose. The tube equalizes pressure between the middle ear and the atmosphere, and allows drainage of small amounts of fluid. An intact palate is necessary for proper Eustachian tube functioning because the muscles of the palate help to control the function of the tube. As a result of poor Eustachian tube function, children born with a cleft palate frequently develop middle ear effusions (fluid behind the ear drum), which commonly leads to recurrent ear infections. Often “T-tubes” must be placed in the ears to help drain the fluid.
Procedures for the Correction of a Cleft Lip and Palate
The procedures necessary for each child vary and are dependent on several factors including:
The area of the clefting (lip, palate, or both)
The severity of the clefting (incomplete or complete)
Whether the cleft is on one side (unilateral) or both sides (bilateral)
Possible Procedures and Estimated Timeline
(Procedures and timelines may vary with each individual.)
Repair of cleft lip: 3 months of age
Repair of cleft palate: 1 year of age
Procedures to improve speech production: After 5 years of age (only if necessary)
Repair of alveolar cleft with bone graft: 8‒12 years of age
Corrective jaw surgery: 15‒18 years of age
Rhinoplasty: 14‒18 years of age