One out of every 700 newborn babies is affected by a cleft lip and palate, making it one of the most common birth defects in the United States.
A multidisciplinary team approach is extremely important in caring for children with cleft lip or cleft palate, because these children have a broad range of treatment needs that no one type of specialist can effectively fulfill.
The Craniofacial Anomalies Program at Michigan Medicine is one of the most experienced cleft lip and cleft palate repair programs in the nation, and the largest program of its type in Michigan. Our team of plastic surgeons, oral surgeons, speech pathologists, pediatric dentists, orthodontists, audiologists, neuropsychologists, dietitians, pediatric nurse practitioners and social workers collaborates to provide the highest quality, family centered care for each child. The outlook for these children in terms of appearance, function, and psychosocial well-being is greatly improved by this innovative approach.
What is a cleft lip?
Cleft lip refers to an abnormal separation of the lip. Cleft lips come in many shapes and sizes. A child can have a cleft on one side of the lip (unilateral) or on both sides of the lip (bilateral). The cleft lip can extend all the way to nose (complete cleft lip) or to skin below nose (incomplete cleft lip). A child may also have one type of cleft lip on one side and a different kind of cleft on the other side. Every infant is unique.
What is cleft palate?
Cleft palate refers to an abnormal separation of the roof of the mouth (palate). Clefts of the palate can include just the back part of the roof of the mouth (soft palate), or the hard bony part of the roof of the mouth (hard palate).
Multiple portions of the upper lip come together during fetal development to form one piece during the sixth week of pregnancy. The development of the palate occurs later than the lip, during the last part of the first trimester. Because the lip and palate develop at different times, it is possible for a child to be born with only a cleft lip, only a cleft palate, or with both a cleft of the lip and the palate.
How is cleft lip and palate diagnosed?
Accurate diagnosis is extremely important in the care of a child with a cleft lip and/or cleft palate.
Cleft lip and palate conditions are often diagnosed before a baby is born, during a prenatal ultrasound. A suspected cleft lip and/or cleft palate diagnosis would then be confirmed at birth by a detailed examination.
Michigan Medicine is one of only a few centers nationwide at which the birth center is co-located within a comprehensive children’s hospital. This unique setting allows for seamless integration between our private-room birth center, state-of-the-art newborn intensive care unit (NICU), and access to around-the-clock surgical services in one convenient location.
Rarely, a baby may have a mild instance of cleft palate that only involves their soft palate—the fleshy tissue at the back of her mouth. This type of cleft may not show up on ultrasound, and may not be noticeable until the infant experiences difficulty feeding. At that point, a clinician will perform a comprehensive exam to identify the exact nature of the problem.
Cleft lip and palate treatment
A child with a cleft may undergo four to five operations spanning the years from infancy to young adulthood.
- Cleft lip surgery: The repair of the child's lip generally takes place at age 10 to 12 weeks, although optimum timing of repairs may differ from child to child. There are several methods of repairing a cleft lip, and the surgeon will choose the type of repair that is appropriate depending on the type of cleft lip your baby has. As your child grows older, he may require an additional operation called a lip revision in order to correct any distortions that may occur in the lip over time.
- Cleft palate surgery: The operation to repair the cleft palate involves making several incisions at the margins of the palate and sewing the separated portions of the palate back together in several layers; one layer making up the nasal lining, another middle layer containing the muscles of the palate, and still another layer that makes up the lining of the roof of the mouth.
- Alveolar cleft bone grafting: A cleft defect can also involve the teeth and gums. A child with a cleft palate may need surgery after the initial cleft palate repair to replace missing bone in the gumline. The placement of bone to this area is referred to as "alveolar cleft bone grafting" (ACBG). This bony repair of the cleft gumline enables the teeth which may not have erupted (or come up through the gums) a stable scaffold to erupt through. ACBG also adds support and improved contour to the base of the nose and provides structural support for a dental implant or bridge if needed to fill in missing teeth.
- Pharyngoplasty (Pharyngeal Flap Procedure): Children with a repaired cleft palate may have a resulting condition referred to as "VPI" (Velopharyngeal Incompetence). This means that too much air escapes through the nose during speech, resulting in a nasal sounding speech. This occurs because the repaired soft palate is too short or does not move adequately. Pharyngoplasty improves the function of the soft palate, by repositioning some of the tissue from the palate and the back of the throat to help close off the escape of air through the nose and enable more successful communication for the child.
- Orthognathic surgery: Orthognathic surgery is a procedure performed on the bones of the upper and lower jaw as well as the chin. When the teeth do not fit together properly (malocclusion) and there is an associated facial deformity, such as an imbalance in facial proportions. Orthognathic surgery can be performed to change the position of the upper and/or lower to allow the teeth to fit together properly while restoring normal balance and symmetry to the face.
- Rhinoplasty: Nasal surgery (rhinoplasty) may be necessary to improve the appearance and function of the nose which may have been distorted with growth after a cleft lip, cleft palate or other craniofacial surgery. The nose may appear flattened, or there may be asymmetry of the nose. There may be nasal obstruction due to a small nostril or a deviated septum.
What is the long-term outlook for a child with cleft lip and/or cleft palate?
C.S. Mott Children’s Hospital’s Craniofacial Anomalies Program has deep, specialized experience taking care of children like yours. The outlook for the future in terms of your child's appearance, function, and psychosocial well-being is excellent.
Children who have had cleft lip and/or cleft palate repair often require care beyond just the surgical repair of their lip or palate. Our multidisciplinary team will work with you to meet your family’s needs every step along the way. Common challenges experienced by children with cleft lip and/or cleft palate include:
- Problems with feeding: Often a parent's first concern is, "How will I feed my baby with a cleft lip and palate?" For example, the cleft can make effective sucking difficult and the milk may come back through the baby's nose. A speech and feeding therapist can help you to find the right feeding method for you and your baby. You will be taught ways to feed your baby, such as holding her in an upright position, giving small amounts of milk, and using a syringe or a nipple with a large hole.
- Problems with speech: Difficulties in speech may occur for many reasons. The development of hypernasal speech after a cleft palate repair is not uncommon. The quality of speech is often nasal and certain consonant sounds may be difficult for your baby to make because air may leak through the nose. Fortunately these speech difficulties can often be corrected with speech therapy alone. Therefore, your baby needs to be under close supervision of a speech and language therapist.
- Problems with hearing: Your baby may have many more ear infections than a baby without a cleft. Difficulties in swallowing affect air pressure in the middle ear and spread infection through the nose to the ears. An audiologist and an ear, nose, and throat specialist will need to monitor your child's hearing closely because frequent ear infections that could lead to hearing loss.
Please see our comprehensive patient resources section for a number of patient guides and resources we have prepared for our patients and families.
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