The cleft unit at Amrita Institute of Medical Sciences, Kochi is the first and the only unit in Kerala that provides comprehensive management for children with cleft lip and palate. The team consists of a craniomaxillofacial surgeon, plastic surgeon, ENT specialist, orthodontist and a speech therapist. We are associated with international organizations such as The Smile Train Project, which provides free surgeries for children with cleft lip and palate.
The spectrum of cleft lip and palate ranges from a minor lip deformity or a cleft of the soft palate only, to a major cleft affecting the lip, nose, palate and the midface. Children with cleft lip and/or palate present with issues pertaining to feeding, appearance, speech, hearing, dentition and facial growth.
Infants with cleft palate have a large opening between the mouth and nose, which leads to nasal regurgitation and also interferes with efficient sucking in both breast and bottle-feeding. Babies with more extensive clefts may have feeding difficulties due to the fact that the baby cannot create enough pressure on the nipple or teat to suck. Breast-feeding if unsuccessful, bottle-feeding with expressed milk can be an option. Many cleft babies feed well from a bottle using a normal soft teat with an extra hole or an enlarged hole. Cutting an X in the teat using a sterilized knife or scissors can enlarge the hole. Use of an enlarged hole allows milk to flow more freely. The child should be positioned in a semi-upright position to reduce the risk of coughing.
Articulation (the ability to make speech sounds) is affected by abnormalities of lip, tongue or palatal movement. The cleft palate will cause air to escape from the mouth in to the nose during speech and will therefore give rise to nasal escape and hypernasality (a nasal tone). This problem, however, can be treated with speech and language therapy, and usually by the time the child is going to school, language development is normal. Some children may have difficulty with articulation, i.e. difficulty making speech sounds. Most children develop normal articulation with ongoing speech therapy. However, occasionally, further surgery on the soft palate is required.
Abnormalities of the muscles in the cleft palate affect the eustachian tube, which in turn can cause poor drainage of the middle ear and hearing problems.
A cleft lip by itself does not affect the teeth but if there is a cleft alveolus/ palate, dental abnormalities are expected.
In a severe cleft the mid part of the face may fail to grow satisfactorily and result in a “dished in”/ concave appearance. The lower jaw becomes more prominent compared to the upper jaw. Problems with bite may result. These will be looked after by the orthodontist and the maxillofacial surgeon.
NAM is carried out at the earliest (few weeks after birth). This helps in lengthening the columella of the nose and also gets the palatal shelves closer to each other. The appliance consists of a palatal plate, which enables the child to suck.
The surgical repair of the cleft lip is carried out at about three months of age after a sufficient amount of columellar lengthening and mesialization (getting the palatal segments closer) is achieved following Naso-alveolar Molding.
Lip repair aims to restore the continuity of the lip muscles, which encircle the mouth. The muscles will then help to mold the alveolus (gum) into the correct position in a one-sided cleft, and the premaxilla into position in a double cleft.
The lip stitches will be clearly visible and these are removed under short general anesthesia one week after surgery. At first the scar will be pink and hard and may sometimes pull the lip upwards. This, however, will settle after a few months and the scar will gradually become softer. The use of vitamin E massage is encouraged at this stage.
This is carried out at 1 year of age just before the child develops speech. The child should weigh 10kgs at the time of palatal repair.
The gap in the alveolus (gums) is bridged by a bone graft taken from the iliac crest (hip). This is known as alveolar bone grafting, and is carried out when the permanent canine begin to erupt. Bone grafting is done between 9 and 11. The orthodontist makes the decision on timing and the craniomaxillofacial surgeon carries it out. The bone grafting procedure enables the permanent teeth to erupt. When all the permanent teeth erupt (usually by the age of 13 years), full orthodontic alignment of teeth can start with the use of fixed braces.
All children with a cleft palate undergo full speech assessment. Children with cleft palate should be undergone speech therapy. Children with persistent velopharyngeal incompetence (increased distance between the palate and the pharynx) undergo pharyngoplasty. It is carried out on the advice of the cleft team after several investigations such nasal endoscopy (palatal movement assessment during speech).
Children may have issues related to middle ear drainage, grommets may have to be inserted into the ear drums. An ear, nose and throat surgeon carries this out after examination and consideration of audiometry results.
The orthodontist plays a vital role in the treating the mal-aligned teeth. The orthodontist will keep records and impressions of developing dental arches. Any extra (supernumerary) teeth are removed as they can interfere with eruption of the permanent teeth.
Before the bone grafting is carried out, the teeth are brought into the correct relationship to each other with the use of an appliance to expand the upper dental arch. The optimum age for this procedure is usually between the age of 10 to 11 years depending on the stage of dental development. The aim of orthodontic treatment is to align all the teeth and to close all residual spaces without the use of bridges or dentures.
Major bony surgery to move forward the whole of the upper jaw, or to move the mandible (lower jaw) is required in a minority of those affected by a cleft. In a significant number of patients the underlying jaws remain poorly related to each other and straightforward fixed braces cannot produce the optimum result. A craniomaxillofacial surgeon carries this out after careful planning and can often have dramatic results.
With a flattened nose with tip, it is hoped that the initial lip repair will help its position greatly, but further operations are often required. Rhinoplasty (“nose job”) at 16 to 18 years old is often required.
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