Cleft Lip and Palate

Cleft lip and palate is a common congenital anomaly occurring in 1 in 600 births and presenting in a wide variety of forms and combinations. Cleft lip ranges from notching of the lip to a complete cleft, involving the floor of the nose and may be associated with a cleft of the primary palate (alveolus / pre-maxilla) and with clefts of the secondary palates (hard and soft palate).

Clefts may be unilateral or bilateral, complete, incomplete, or microform. Cleft palate may occur in isolation, may be unilateral or bilateral, and ranges from a bifid uvula to a complete cleft of hard and soft palates. It may also present in a sub-mucous form. Clefts may be part of very many syndromes affecting the first and second branchial arches, including the Pierre Robin anomaly.

The deformity has a potential effect on facial appearance, hearing, speech, feeding and social integration. Indicators of poor outcome, dysfunction and deformity include recurrent otitis media (glue ear), hearing loss, speech anomalies, patent oronasal fistula, problems with eating and swallowing and psycho-social difficulties.

It is, therefore, essential that care is multi-disciplinary involving at least a cleft surgeon, otologist, speech and language therapist, orthodontist, paediatrician, paediatric anaesthetist, specialist paediatric nurses, restorative dentist, clinical psychologist and clinical geneticist.

Primary surgery, however, is central and the choice of technique based on a full understanding of the structures involved, and understanding gained from a training in dentistry, is of paramount importance. The aim of cleft surgery is the restoration of normal anatomy and the promotion of normal growth and development of all structures affected by the cleft. Emphasis must be placed on the restoration of muscle continuity whether of the lip and/or nose, or the soft palate. Techniques in which these concepts are promoted have been shown to produce the most acceptable results in the long-term. In reality, given even the most favourable circumstances, secondary surgery may be required and a return to the basic principles employed in primary surgery rather than modifying the existing state is necessary.

However, there are other surgical procedures that are required as the child grows older. Where problems with speech exist, that cannot be resolved by therapy alone, velopharyngeal surgery may be necessary. Following assessment, this includes revision palatoplasty, palatal lengthening or pharyngoplasty. Later, in clefts involving the alveolus, bone grafting is carried out usually between the ages of 7 and 11 years. When growth is complete orthognathic surgery to correct abnormal facial bone development, in particular an under-developed maxilla, may be needed. Finally, there may be residual deformities of the nose and rhinoplasty will be required. Ultimately, the adherence to an agreed protocol working in a fully equipped and co-ordinated setting with a full complement of concerned professionals and the facility for collection of data such that problems can be identified and corrected at the earliest possible opportunity, will enable the surgeon to ensure the best outcome.

Designated Cleft Lip and Palate Centres have been identified in the UK, where a multidisciplinary team looks after patients from birth.