The treatment of cleft lip and palate aims at correction of the problems of speech, dental occlusion, facial appearance and hearing caused by the cleft.
Clefts can also cause psychosocial impairment, especially if the outcome of treatment is not good.
Prevalence
Clefts of the lip and/or palate are the most common congenital malformations in the facial region.
Cleft lip and alveolus (15%) may be unilateral or bilateral, and it may involve only the lip or may extend to the alveolar ridge.
Cleft lip and palate (25%) extends uni- or bilaterally through the lip and alveolar ridge to the hard and soft palate.
Cleft palate (60%) is in the midline, either limited to the soft palate only or more often extending to the hard palate. Occult cleft palate is submucous and difficult to discern.
15-20% of oral clefts are associated with congenital structural anomalies, most often in the extremities or in the heart. Clefts can also be associated with congenital syndromes.
Aetiology
In most cases the aetiology of a cleft remains unknown. It is thought to result from the combined effect of several predisposing genes and extrinsic adverse influences.
Treatment
The treatment of all patients with cleft lip and/or palate is centralized to cleft centres.
The treatment is carried out by a multidisciplinary team. In its core it involves plastic surgery, oral and maxillofacial surgery, otological and orthodontic treatment, speech therapy, paediatric dental care and cleft-specialized nursing. As necessary, the family can be referred to a psychologist for support and counselling.
A cleft lip and/or palate is diagnosed at the maternity hospital or during pregnancy by ultrasonography. The families are then invited to the cleft centre for treatment and information.
The treatment and follow-up includes scheduled follow-up examinations at certain ages and different treatment episodes from infancy until adulthood. Specialist treatment is possible also in adults if required.
With the current methods the treatment of the facial appearance, speech, teeth and occlusion has good results. The prerequisite for successful management is co-operation of the multidisciplinary cleft team.
Primary corrective surgery of the cleft lip is usually undertaken at the age of about 3-4 months and of the cleft palate at the age of 9-12 months.
Due to hypernasal speech which is possibly associated with cleft palate, speech corrective surgery is performed at the age of 4-5 years or later.
Bone grafting of the alveolar ridge is performed around the age of 9-11 years.
Corrective surgery of the upper (and lower) jaw and cosmetic finishing of the nose and lip are usually postponed until the end of the growth period.
Orthodontics
Oral clefts are associated with an increased incidence of malocclusions and dental abnormalities. Orthodontic treatment is carried out in the school-age years according to the individual treatment plan.
In unilateral and bilateral cleft lip and palate and in cleft lip and alveolus, orthodontic treatment is combined with alveolar bone grafting operation.
Severe malocclusions caused by jaw discrepancy require surgical correction and orthodontic treatment.
Dental prosthetic treatment to replace congenitally missing or malformed teeth may be required.
Speech therapy
Verbal skills usually develop as usual. In some children with treated cleft palate, the speech may initially be more slurred and have a more nasal sound than in their peers. The speech is usually corrected spontaneously or with speech therapy. If considered necessary in the scheduled follow-up visits, the child may be referred to speech development monitoring or to speech therapy.
In its mildest form, nasal speech is only manifested as a sound produced by the air escaping through the nose when pronouncing pressure-sensitive consonants (k, p, t, s). Surgery and speech therapy are required to correct severe nasal speech.
Hearing
In cleft palate, the muscles opening and closing the Eustachian tube are abnormally inserted and their functioning is therefore poor. As a consequence, the middle ear is not normally ventilated and the mucous membranes start to produce mucus. According to current knowledge, this is not harmful for the ears, but excessive secretion may impair the hearing ability. If a child with cleft palate develops glue ears, tympanostomy tubes (grommets) are inserted if needed to preserve hearing.
The grommets are usually inserted in association with cleft palate surgery. After palatal closure surgery, the tendency to develop glue ears has usually subsided when the child reaches pre-school or school age.
References
Semb G, Enemark H, Friede H et al. A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management. J Plast Surg Hand Surg 2017;51(1):2-13. [PubMed]
Rautio J, Andersen M, Bolund S et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 2. Surgical results. J Plast Surg Hand Surg 2017;51(1):14-20. [PubMed]
Bannister P, Lindberg N, Jeppesen K et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 3. Descriptive study of postoperative nursing care following first stage cleft closure. J Plast Surg Hand Surg 2017;51(1):21-26. [PubMed]
Lohmander A, Persson C, Willadsen E et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 4. Speech outcomes in 5-year-olds - velopharyngeal competency and hypernasality. J Plast Surg Hand Surg 2017;51(1):27-37. [PubMed]
Willadsen E, Lohmander A, Persson C et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 5. Speech outcomes in 5-year-olds - consonant proficiency and errors. J Plast Surg Hand Surg 2017;51(1):38-51. [PubMed]
Heliövaara A, Küseler A, Skaare P et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 6. Dental arch relationships in 5 year-olds. J Plast Surg Hand Surg 2017;51(1):52-57. [PubMed]
Karsten A, Marcusson A, Hurmerinta K et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 7. Occlusion in 5 year-olds according to the Huddart and Bodenham index. J Plast Surg Hand Surg 2017;51(1):58-63. [PubMed]
Mølsted K, Humerinta K, Küseler A et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 8. Assessing naso-labial appearance in 5-year-olds - a preliminary study. J Plast Surg Hand Surg 2017;51(1):64-72. [PubMed]
Feragen KB, Rumsey N, Heliövaara A et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and Palate: 9. Parental report of social and emotional experiences related to their 5-year-old child's cleft diagnosis. J Plast Surg Hand Surg 2017;51(1):73-80. [PubMed]
Feragen KB, Semb G, Heliövaara A et al. Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 10. Parental perceptions of appearance and treatment outcomes in their 5-year-old child. J Plast Surg Hand Surg 2017;51(1):81-87. [PubMed]
Shaw W, Semb G. The Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 11. What next? J Plast Surg Hand Surg 2017;51(1):88-93. [PubMed]