Oral-facial clefts are birth defects in which the tissues of the mouth or lip don't form properly during

fetal development. In the United States, clefts occur in 1 in !! to 1,!!! births, ma"ing it one of the most common ma#or birth defects. $lefts occur more often in "ids of %sian, &atino, or 'ative %merican descent. (he good news is that both cleft lip and cleft palate are treatable. )ost "ids born with these can have reconstructive surgery within the first 1* to 1+ months of life to correct the defect and significantly improve facial appearance.

About Oral Clefting

Oral clefting occurs when the tissues of the lip and,or palate of a fetus don't grow together early in pregnancy. $hildren with clefts often don't have enough tissue in their mouths, and the tissue they do have isn't fused together properly to form the roof of their mouths. % cleft lip appears as a narrow opening or gap in the s"in of the upper lip that e-tends all the way to the base of the nose. % cleft palate is an opening between the roof of the mouth and the nasal cavity. Some "ids have clefts that e-tend through both the front and rear part of the palates, while others have only partial clefting. (he three common "inds of clefts are. 1. cleft lip without a cleft palate *. cleft palate without a cleft lip /. cleft lip and cleft palate together In addition, clefts can occur on one side of the mouth 0unilateral clefting1 or on both sides of the mouth 0bilateral clefting1. )ore boys than girls have a cleft lip, while more girls have cleft palate without a cleft lip. 2ecause clefting causes specific visible symptoms, it's easy to diagnose. It can be detected through a prenatal ultrasound. If the clefting has not been detected prior to the baby's birth, it's identified immediately afterward.

Causes
3octors don't "now e-actly why a baby develops cleft lip or cleft palate, but believe it may be a combination of genetic 0inherited1 and environmental factors 0such as certain drugs, illnesses, and the use of alcohol or tobacco while a woman is pregnant1. (he ris" may be higher for "ids whose sibling or parents have a cleft or who have a history of clefting in their families. 2oth mothers and fathers can pass on a gene or genes that can contribute to the development of cleft palate or cleft lip.

Complications
4ids with a cleft lip or palate tend to be more susceptible to middle ear fluid collections, hearing loss, and speech defects. 3ental problems 5 such as missing, e-tra, malformed, or displaced teeth, and cavities 5 also are common in "ids born with cleft palate. )any children with clefts are especially vulnerable to ear infections because their eustachian tubes don't drain fluid properly from the middle ear into the throat. 6luid accumulates, pressure builds in the ears, and infection may set in. 6or this reason, they may have special tubes surgically inserted into their ears at the time of the first reconstructive surgery. 6eeding can be another complication for an infant with a cleft lip or palate. % cleft lip can ma"e it more difficult for a child to suc" on a nipple, while a cleft palate may cause formula or breast mil" to be accidentally ta"en up into the nasal cavity. Special nipples and other devices can help ma"e feeding easier7 you'll get information on how to use the speciali8ed feeding e9uipment and where to buy it before you ta"e your baby home from the hospital. In some cases, a child with a cleft lip or palate may need to wear a prosthetic palate called an obturator to aid in proper eating. If your baby has problems with feeding, your doctor can offer other suggestions or feeding aids.

Treatment
(han"s to medical advancements, reconstructive surgery can repair cleft lips and palates and, in severe cases, plastic surgery can address specific appearance-related concerns. % child with oral clefting will see a variety of specialists who will wor" as a team to treat the condition. (reatment usually begins in the first few months of life, depending on the health of the infant and the e-tent of the cleft. )embers of the cleft lip and palate treatment team usually include.

a geneticist a plastic surgeon an ear, nose, and throat physician 0otolaryngologist1 an oral surgeon an orthodontist a dentist a speech pathologist 0often called a speech therapist1 an audiologist a nurse coordinator a social wor"er and,or psychologist

(he specialists will evaluate your child's progress regularly, and monitor hearing, speech, nutrition, teeth, and emotional state. (hey'll share their recommendations with you, and can forward their evaluation to your child's school and any speech therapists that your child may be wor"ing with. In addition to treating the cleft, the specialists will wor" with your child on any issues related to feeding, social problems, speech, and your approach to the condition. (hey'll provide feedbac" and recommendations to help you through the phases of your child's growth and treatment.

Surgery for Oral Clefting

Surgery is usually performed during the first / to : months to repair cleft lip and between ; and 1< months to repair the cleft palate. 2oth types of surgery are performed in the hospital under general anesthesia. $left lip often re9uires only one reconstructive surgery, especially if the cleft is unilateral. (he surgeon will ma"e an incision on each side of the cleft from the lip to the nostril. (he two sides of the lip are then sutured together. 2ilateral cleft lips may be repaired in two surgeries, about a month apart, which usually re9uires a short hospital stay. $left palate surgery involves drawing tissue from either side of the mouth to rebuild the palate. It re9uires * or / nights in the hospital, with the first night spent in the intensive care unit 0I$U1. (he initial surgery is intended to create a functional palate, reduce the chances that fluid will develop in the middle ears, and help the teeth and facial bones develop properly. In addition, this functional palate will help speech development and feeding abilities. (he need for more operations depends on the s"ill of the surgeon as well as the severity of the cleft, its shape, and the thic"ness of available tissue that can be used to create the palate. Some "ids re9uire more surgeries to help improve their speech. %dditional surgeries may also improve the appearance of the lip and nose, close openings between the mouth and nose, help breathing, and stabili8e and realign the #aw. &ater surgeries are usually scheduled at least : months apart to allow time to heal and to reduce the chances of serious scarring. It's wise to meet regularly with the plastic surgeon to determine what's most appropriate in your child's case. 6inal repairs of the scars left by the initial surgery may not be performed until adolescence, when facial structure is more fully developed. Surgery is designed to aid in normali8ing function and cosmetic appearance so that "ids will have as few difficulties as possible.

Dental Care and Orthodontia

$hildren with oral clefting often undergo dental and orthodontic treatment to help align the teeth and ta"e care of any gaps caused by the cleft. =outine dental care may get lost in the midst of these ma#or procedures, but healthy teeth are critical for "ids with clefting because they're needed for proper speech. 4ids with oral clefting generally need the same dental care as other "ids 5 regular brushing supplemented with flossing once the :-year molars come in. 3epending on the shape of the mouth and teeth, your dentist may recommend a toothette 0a soft sponge that contains mouthwash1 rather than a toothbrush. %s your child grows, you may be able to switch to a soft children's toothbrush. (he "ey is to ma"e sure that your child brushes regularly and well. $hildren with cleft palate often have an alveolar ridge defect. (he alveolar ridge is the bony upper gum that contains teeth, and defects can.

displace, tip, or rotate permanent teeth prevent permanent teeth from appearing prevent the alveolar ridge from forming

(hese problems can be fi-ed by grafting bone matter onto the alveolus, which allows the placement of the teeth to be corrected orthodontically. Orthodontic treatment usually involves a number of phases. (he first phase, which starts as the permanent teeth come in, is called an orthopalatal e-pansion. (he upper dental arch is rounded out and the width of the upper #aw is increased. % device called an e-pander is placed inside the mouth. (he widening of the #aw may be followed by a bone graft in the alveolus. >our orthodontist may wait until all the permanent teeth come in before starting the second phase, which may involve removing e-tra teeth, adding dental implants if teeth are missing, or applying braces to straighten teeth. In about *?@ of "ids with a unilateral cleft lip and palate, the upper #aw growth does not "eep up with the lower #aw growth. If this occurs, these "ids 0as teenagers or young adults1 may need orthognathic surgery to align the teeth and help the upper #aw develop. 6or these "ids, phase-two orthodontics may include an operation called an osteotomy on the upper #aw that moves the upper #aw both forward and down. (his usually re9uires another bone graft for stability.

Speech Therapy
4ids with oral clefting may have trouble spea"ing 5 the clefting can ma"e the voice nasal and difficult to understand. Some will find that surgery fi-es the problem completely.

$atching speech problems early can be a "ey part of solving them. % child with a cleft should see a speech therapist between the ages of 1+ months and * years. )any speech therapists li"e to tal" with parents at least once during the child's first : months to provide an overview of the treatment and suggest specific language- and speechstimulation games to play with the baby. %fter the initial surgery is completed, the speech pathologist will see the child for a complete assessment. (he therapist will evaluate developing communication s"ills by assessing the number of sounds the child ma"es and the actual words he or she tries to use, and by observing interaction and play behavior. (his analysis helps determine what, if any, speech e-ercises a child needs and if further surgery is needed. (he speech pathologist often will continue to wor" with the child through additional surgeries. )any "ids will wor" with a speech therapist throughout their grade-school years.

Dealing With Emotional and Social Issues

Society often focuses on appearances, and this can ma"e childhood 5 and, especially, the teen years 5 hard for someone with a physical difference. 2ecause "ids with oral clefting have a prominent facial difference, they might e-perience painful teasing that can damage self-esteem. Aart of the cleft palate and lip treatment team includes psychiatric and emotional support personnel. Bays that you can support your child include.

(ry not to focus on the cleft and don't allow it to define who your child is. $reate a warm, supportive, ands accepting home environment, where each person's individual worth is openly celebrated. Cncourage your child to develop friendships with people from diverse bac"grounds. (he best way to do this is to lead by e-ample and to be open to all people yourself. Aoint out positive attributes in others that do not involve physical appearance. Cncourage autonomy by giving your child the freedom to ma"e decisions and ta"e appropriate ris"s, letting his or her accomplishments lead to a sense of personal value. Daving opportunities to ma"e decisions early on 5 li"e pic"ing out what clothes to wear 5 lets "ids gain confidence and the ability to ma"e bigger decisions down the road.

$onsider encouraging your child to present information about clefting to his or her class with a special presentation that you arrange with the teacher. Or perhaps your child would li"e you to tal" to the class. (his can be especially effective with young children. If your child does e-perience teasing, encourage discussions about it and be a patient listener. Arovide tools to confront the teasers by as"ing what your child would li"e to say and then practicing those statements. %nd it's important to "eep the lines of

communication open as your child approaches adolescence so that you can address his or her concerns about appearance. If your child seems to have ongoing self-esteem problems, contact a child psychologist or social wor"er for support and information. (ogether with the members of the treatment team, you can help your child through tough times. =eviewed by. &ouis C. 2artoshes"y, )3, )AD 3ate reviewed. October *!!+

The Speech-Language athologist

(he Speech-&anguage Aathologist is also an essential member of the cleft palate team. $hildren with cleft palate, while having no trouble with normal language development, can often have delayed speech development due to their mouth's unusual anatomy. (he speech-language pathologist will be involved in parent education, newborn feeding instruction, and evaluation and treatment of speech, language, voice and resonance disorders. (he evaluation and treatment of a child with cleft lip E,- palate re9uires ongoing services from a team of various professionals in a coordinated timely manner. Successful rehabilitation of the child is dependent on continued care by these professionals. 'ote that not all children with orofacial anomalies will re9uire the care of a cleft palate team. 6or e-ample, some children with submucous, or occult clefts of the palate, who do not have an impairment of speech,hearing may not need this service.

Team members
6acial deformities re9uire various specialist treatments. (hese range from surgery to psychology. % typical team.

Craniofacial Surgeon. Cither an Oral,)a-illofacial surgeon or Alastic surgeon who has completed a subspecialty fellowship in $raniofacial surgery. De,She has specific training and e-perience in corrective,reconstructive surgery of the craniofacial comple- 0S"ull, face, #aws, etc.1 Otolaryngologist !E"T#. Car, 'ose and (hroat Specialist. )any malformations involve defects in the airway passage, inflammation of the middle ear and,or hearing and speech defects. Such complaints are treated by the C'(-Specialist. De,she is also responsible for the hearing tests and e-amination of the speech defect. Audiologist. ediatrician. ediatric dentist. Orthodontist. %s member of the craniofacial team the orthodontist ta"es care of the non-surgical treatment of the malposition of the #aws. De,she is responsible

for the pre and post operative treatment of #aw surgery and monitors growth by means of F-rays and plaster casts. Orthodontic technician. =esponsible for the design and fabrication of fi-ed and removable orthopaedic and orthodontic appliances for the cleft patient from birth through to adulthood. De,she also fabricates dental study models that are used to monitor growth. rosthodontist. Alans and fabricates an obturator to close defects that surgery is not capable of closing. )any patients with congenital deformities are missing teeth or have poorly shaped teeth and re9uire a denture prosthesis. Speech pathologist. Cvaluate and monitor speech development to help determine if speech therapy, prosthetic devices, or surgery are needed to improve speech s"ills. sychologist. De,she monitors the child's development and teaches the child how to deal with the social aspects of a facial deformity. (he psychologist also aids the parents when needed. Clinical $enetist. %fter thorough family research he,she will advise on heredity with regard to a syndrome. Sometimes a final diagnosis can be defined only after genetic e-amination 0see also Genetic lin"age1. Social Wor%er. De,she is counsellor of the parents and family when there are problems resulting from the syndrome, treatment and,or hospitalisation. She,he acts as an advisor and is able to contact various official authorities, in and outside the hospital. "ursing Officer. 6rom hospitalisation till discharge the nursing officer is responsible for the daily health care and nurture of the child. (he nursing officer also advised the parents with feeding difficulties due to cleft.

%ll team members have deputies in order to guarantee continuity.

[edit] Duties of the Team

$raniofacial (eam 0$6(1 evaluates at least *! individuals with congenital anomalies or syndromes aside from $left. Arior to surgery, $6( assures that the patient has been scheduled or seen for a health evaluation by a primary care physician. $raniofacial surgery is provided in a facility with a pediatric intensive care unit. 6acility has $( and )=I capability. )embers must participate in continuing education programs for craniofacial evaluations and treatment.