Cleft lip is formed in the top of the lip as either a small gap or indentation in the lip (partial or incomplete cleft) or continues into the nose (complete cleft). It can be either one sided/unilateral or two sided/bilateral. It occurs due to the failure of fusion of the maxillary and median nasal processes (formation of the primary palate).

Cleft palate is the condition in which the two plates of the skull that form the hard palate are not completely joined. The soft palate also clefts in these cases. In most cases, cleft lip is present as well. Palate cleft can be complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a ‘hole’ in the roof of the mouth, usually as a cleft soft palate). It occurs due to the failure of fusion of the lateral palatine processes, nasal septum and/or the median palatine processes (formation of secondary palate).

Clefts of the lip and palate are generally divided into two groups, isolated cleft palate and cleft lip with or without cleft palate, representing a heterogenous group of disorders affecting the lips and oral cavity. These defects arise in about 1.7 per 1000 liveborn babies, with ethnic and geographic variation. Cleft lip with or without cleft palate is most frequent in males, and the isolated cleft palate is mostly seen in females, across various ethnic groups.

Complications

• Difficulty feeding – a baby with a cleft lip and palate may be unable to breastfeed or feed from a normal bottle because they cannot form a good seal with their mouth
• Hearing problems – some babies with a cleft palate are more vulnerable to ear infections and a build-up of fluid in their ears (glue ear), which may affect their hearing
• Dental problems – a cleft lip and palate can mean a child’s teeth do not develop correctly and they may be at a higher risk of tooth decay
• Speech problems – if a cleft palate is not repaired, it can lead to speech problems such as unclear or nasal-sounding speech when a child is older

Effects on speech, hearing, appearance and psychology can lead to long-lasting adverse outcomes for health and social integration. Typically, children with these disorders need multidisciplinary care from birth to adulthood and have higher mortality and morbidity than unaffected individuals.

The sex ratio varies with severity of the cleft, presence of additional malformations, number of affected siblings in a family, ethnic origin and possibly paternal age. Cleft lip with or without cleft palate and isolated cleft palate are usually seen associated with other major congenital anomalies.

Factors

Epidemiological and experimental data suggest that environmental risk factors might be important in cleft lip and palate, and maternal exposure to tobacco smoke, alcohol, poor nutrition, viral infection, medicinal drugs and teratogens(substances causing malformations of the fetus during development) during early pregnancy all contribute to the risk.

Genetic risk factors also play a very important role in the pathology. Cleft lip with or without cleft palate is listed as a feature of more than 200 specific genetic syndromes, and isolated cleft palate is recorded as a component of more than 400 such disorders. The proportion of orofacial clefts associated with specific syndromes is between 5% and 7%.

Treatment

Children with a cleft lip or palate will need several treatments and assessments as they grow up. A  typical care plan timetable for cleft lip and palate is:

1. Birth to 6 weeks – feeding assistance, support for patients, hearing tests and pediatric assessment
2. 3 to 6 months – surgery to repair a cleft lip
3. 6 to 12 months – surgery to repair a cleft palate
4. 18 months – speech assessment
5. 3 years – speech assessment
6. 5 years – speech assessment
7. 8 to 12 years – bone graft to repair a cleft in the gum area
8. 12 to 15 years – orthodontic treatment (correction of malalignment of teeth using placement of braces) and monitoring jaw growth

The child will also need to visit regular outpatient appointments to monitor their condition.

About the Author

This article has been contributed by the Department of Oral Pathology & Microbiology, Yenepoya Dental College under Yenepoya (Deemed to be University) established in the year 1992, with its robust alumni of 3000 Under graduates and 67 Post graduates students and research scholars has many accolades and achievements to its credit. It strives to provide state of the art Oral diagnostics and Molecular Pathology while excelling in research activities and instilling a holistic approach in dental education among students. The department contributes its expertise in fostering inter-disciplinary collaboration and providing exemplary education and scientific research.