What is a cleft?
In simple terms, a cleft is a separation of the parts of the lip or roof of the mouth which usually come together during the early weeks in the development of an unborn child. A cleft lip is a separation of the two sides of the lip and often includes the bones of the maxilla (upper jaw) and the upper gum (alveolar ridge). It looks as though there is a split in the lip and upper gum.
Figure 1 illustrates a normal lip and labels the parts of the lip and base of the nose. A cleft lip can range from a slight notch in the vermilion (red portion of the lips) to a complete separation of the lip extending into and distorting the tip and side (ala) of the nose. When there is a cleft lip, frequently the alveolar ridge (upper gum) is also separated. As seen in figure 2, clefts of the lip may may occur on one or both sides, with varying degrees of severity. If the cleft occurs on one side, it is called a unilateral cleft lip (Fig 2 left). If the cleft occurs on both sides of the lip, it is called a bilateral cleft lip (Fig 2 right).
The palate is the roof of the mouth. The front part contains bone and is hard (hard palate); the back part does not contain bone and is soft (soft palate). Figure 3 (left) illustrates a normal palate and labels parts of the palate that you may hear discussed. A cleft palate (figure 3 right) is an opening in the roof of the mouth. A cleft palate does not mean that the palate is “missing” although it may sometimes look that way.
It means that the two sides of the palate did not join together (fuse) as the unborn baby was developing. Cleft palates can vary in extent; an incomplete cleft palate involves just the back of the soft palate, while a complete cleft palate extends the length of the palate to just behind the gums (Figure 3 right).
Because the lip and palate develop separately, it is possible for a child to have only a cleft lip, only a cleft palate, or both a cleft lip and cleft palate. When clefts of the lip and palate occur together they can involve one side (unilateral) or both sides (bilateral) of the palate (Figure 4).
Thanks is given to the Cleft Palate Foundation for allowing us to share the above information.
Why is a Cleft Palate Team Necessary?
Over the years, it has become apparent that no one individual is able to take care of all the specialized needs of a child with a cleft lip and/or palate. Not only would this hold true for children in this country, but ideally in all countries in which there would be an interface with FACES Foundation. The following is a list of specialists involved with a cleft palate team and the services they provide.
Social Services: Social workers help people deal with the emotional, social, and environmental impact of a medical problem. For the cleft palate patient and family, the social worker offers assistance in identifying the emotional issues involved in learning to cope with a cleft lip or palate. He/she can help in the assessment of the family’s support system and, if needed, explore community resources that are available.
Nursing: Both the outpatient nurse and the Home Health nurse contribute to the care of the cleft palate patient. The Home Health nurse provides skilled nursing care and teaching in the home while the outpatient nurse coordinator organizes the care given amongst the different specialties. Both nurses provide emotional and educational support prior to and following surgery, any special testing, and ongoing medical treatment as well as promote general preventive health care.
Genetics: The clinical geneticist makes an assessment about whether or not a genetic syndrome is associated with the cleft lip or palate condition. The geneticist will discuss with the family the prevalent patterns of clefting and the potential of having future family members with similar problems.
Audiology: The audiologist evaluates a person’s hearing. Since hearing loss due to middle ear problems is frequent in children with cleft palates, it is important to check hearing periodically. Good hearing is necessary for proper speech and language development. Hearing tests performed will help the otolaryngologist (ear, nose, and throat physician) to determine whether medical or surgical treatment is required.
Speech Pathology: The speech and language pathologist evaluates the voice of the cleft palate patient for normal nasal quality. He/she also tests articulation in relation to the patient’s age, dental irregularities, and degree of palatal clefting in order to make recommendations about surgical, orthodontic, and speech treatment. Other screenings include language development, swallowing-feeding functions, the ears, and hearing.
Otolaryngology (Ear, nose, and throat): The otolaryngologist diagnoses and treats conditions related to the ears, nose, and throat. A majority of children with a cleft palate have diminished hearing due to fluid which builds up behind the ear drums. To alleviate this condition, he/she may insert ear tubes and conduct ongoing observations to prevent chronic disease. He/she also treats conditions of the head and neck, including tonsils and adenoids, that may develop.
Dentistry: The pediatric dentist is involved with the dental health of the teeth to include cleaning, fluoridation, and a program of home oral hygiene. He/she coordinates care with the orthodontist and oral surgeon.
Orthodontics: An orthodontist straightens teeth, evaluates the position of individual teeth and their relationship to the upper and lower jaws, and assesses the balance between the jaws and the head. Any required orthodontic adjustments are timed for the overall benefit of the patient’s care.
Oral Surgery: The oral and maxillofacial surgeon is primarily involved in evaluating the bony components of the face. This often involves coordinating treatment with the dentist and orthodontist in order to obtain good function of the jaws.
Timing of bone grafting, necessary dental extractions, and jaw bone distraction (bone lengthening) are all coordinated through the oral/maxillofacial surgeon.
Facial Plastics: The facial plastic and reconstructive surgeon repairs the clefts of the lip and palate. The surgeon performs operations on the palate to correct speech, if necessary, as well as secondary operations on the nose, face, lips, and palate. These secondary procedures are often necessary in older patients who have been treated for cleft lip and palate. The plastic surgeon may be a general surgeon who has had specialty training or an otolaryngolgist who has had specialty training in facial plastics and reconstructive surgery.