Cleft lip and palate (also known as orofacial cleft) are the inborn defects caused by unattached nasal tissues to the upper jaw (cleft lip) and the opening of the roof of the mouth reaching the nose (cleft palate) during the fetal period. The typical feature of the defect is a cleft lip. In general, those defects lead to problems with appearance, speech formation, and nutrition. However, the psychosomatic development of a child is not violated. The fact of the presence of these defects may be diagnosed with the help of the ultrasound diagnostics during the fetal period. A cleft lip may be removed with the help of surgery (cheiloplasty). In cases when both defects (cleft lip and palate) are observed the cheiloplasty; cleft rhinoplasty, palatoplasty and tip rhinoplasty may be performed.
Cleft lip is a malformation in the development of the maxillofacial area. The lip is split into parts. About 0,04% of all children (among them are mostly boys) are born with such a defect. The formation of cleft lip and palate happens before the 8th week of pregnancy when the maxillofacial organs are developing. Facial cleft defects rarely appear to be isolated, in every 5th case, they serve as a component of severe inborn syndromes. Specialists in maxillofacial surgeries, dentists, speech therapists, pediatrics-deal with correction of the cleft lip and restoration of all the functions.
Cleft palate may present together or without a cleft lip and expresses in a gap of the roof or the mouth. Cleft palate disturbs eating and may cause ear infections and hearing violations.
Causes of cleft lip and palate development
The formation of both cleft lip and cleft palate is performed at the genetic level. Mutations of the TBX22-gene causing the cleft lip may be caused by toxicity, stress, antibiotics, radiation, infections, drugs, smoking and drinking alcohol. Those factors are especially dangerous during the first 2 months of pregnancy. Another factor causing the cleft lip is a late child-birth (35-40 years). A certain role in the development of these defects is performed by gynecological and somatic pathologies of the pregnant. The factors, influencing the formation of the cleft lip and palate are ranged in the following the order: chemical (22.8%), psychiatric (9%) mechanical injuries (6%), biological (5%), physical (2%), and so forth. Determining the child with cleft lip or palate is possible during the ultrasound diagnostics. Parents who already have the child with cleft lip should undergo medical-genetic screening.
Classification of the cleft lip
As a rule, the cleft is formed on the upper lip on one side of the central line. It is less frequently observed on both sides or on the lower lip. Usually, the cleft lip is placed on the left side. In case it affected both sides the presence of the protruding forward rostral bone of the upper jaw is admitted. There are full and partial forms of cleft lip. The partial cleft usually appears on one side in the formed recess in the lip. Full cleft of the lip is characterized by deep crack (cleavage) rising from the lip to nose from one or both of the sides. This process is caused by nasal nonunion with left and right maxillary. The defect may vary in depth and extension. In less severe cases splitting affects only the soft tissues of the lip. In severe cases, a defect is associated with the palatine bone and the bone of the upper jaw. Cleft lip can occur in isolation, but often is accompanied by other anatomical defects of the maxilla: Cleft hard and soft palate, nose deformities, etc. The establishment of the defect shape, severity, combination with other oral and maxillofacial pathology allows determining the tactics of treatment and methods of correction of the defect.
Appearances of cleft lip
Cleft lip is determined during the external examination of the child right after the childbirth. The characteristic feature of cleft lip is a deformation of the face accompanied with a cleft on one or both sides of upper or lower lip. If the cleft lip is not eliminated it may lead to the decline of self-esteem of the child. Infants with cleft lip appear to have difficulties with sucking and swallowing. If the cleft lip is deep and big the feeding through a nasal tube may be necessary. In future due to the teeth deformation and bite disrupt the process of chewing food may be violated. The violation of dentition is characterized by teeth skipping or presence of extra ones, incorrect growth angle of teeth, tooth decay. In the case of those violations the orthodontic treatment and bite correction might be required. Sometimes the implantation or extraction of teeth could be necessary. Children with cleft lip have violations with the formation of the sounds which is manifested by speech function disorder (nasality) Those patients have unclear speech with a pronounced nasal sound ( snuffles) and problems with pronouncing consonants.
Principles of cleft lip treatment
Cleft lip correction is performed during one or several plastic surgeries taking into account the features of each case of defect. Plastic correction of inborn cleft lip is prescribed for children that were born in time and do not have any contradictions (combined defects of vital organs, birth injuries, acquired diseases, physiological jaundice etc.) Surgery removal of the cleft lip should be performed at the age of 3-6 months. In the case of the severe form, it may be done during the first days or the first month of child life. But it should be done in cases if the child gained enough weight, there are no signs of anemia, intestinal pathologies. There are shouldn’t be any violations of cardiovascular, nervous and endocrine systems. If the surgery is performed during first two weeks after the childbirth it will positively affect the lip and nose development. Also, it will reduce the psychological stress for parents. However the anatomical size of the lips is too small at that age, some physiological functions are not completely developed and the tendency to the hemorrhage is increased. The restoration of the anatomical structure of the lip, as well as elimination of nasal and palatal deformations, are achieved due to surgery. Also, the proper development of the maxillofacial system in childhood is possible after surgery. Cleft lip correction should be finished before the child turns three years old ( when the formation of speech takes place). Later the speech therapy aimed at eliminating the speech defects and removal of the postoperative scar is performed. Taking into an account the existing defects of lip, nose, palate and of the alveolar bone cheiloplasty and rhino-cheiloplasty.
However the anatomical size of the lips is too small at that age, some physiological functions are not completely developed and the tendency to the hemorrhage is increased. The restoration of the anatomical structure of the lip, as well as elimination of nasal and palatal deformations, are achieved due to surgery. Also, the proper development of the maxillofacial system in childhood is possible after surgery. Cleft lip correction should be finished before the child turns three years old ( when the formation of speech takes place). Later the speech therapy aimed at eliminating the speech defects and removal of the postoperative scar is performed. Taking into an account the existing defects of lip, nose, palate and of the alveolar bone cheiloplasty, rhino-cheiloplasty and rhino-cheilo-gnathoplasty are held as reconstructive surgeries.
Ways of cleft lip correction
Due to the primary cheiloplasty, the anatomic, esthetic and functional features of the lip are restored. It is performed during first days of child life. Various methods of cheiloplasty are offered. The choice depends on the type of defect and the surgeon’s decision. Primary rhino-cheiloplasty is held for correcting the cleft lip, nose cartilage and abnormal placement of muscles in the mouth cavity. It is technically more complicated surgery and it is prescribed in cases of severe lip defects, nose deformations, and defects of the facial skeleton. Variations of performing rhino-cheiloplasty depend on individual features of the inborn defect. To solve the problems of the restoration of anatomic usefulness lips, elimination of the nasal cartilage deformation , the formation of the high-grade muscular frame in the mouth, as well as the elimination of defects of the alveolar bone and the underdevelopment of maxilla on the side of the splitting the rhino-cheilo-gnathoplasty is performed. It allows creating conditions for the proper development of the upper jaw, nose and lip.
Plastic Reconstructive Maxillofacial Surgery able to help children born with a cleft lip nowadays, to achieve good aesthetic and functional long-term results of operations in 85-90% of cases and to adapt them to a full life in society. Surgeries are performed after a comprehensive examination of the child, confirming its functional readiness for the surgical treatment. After the reposition the sewing of split nasal and labial tissues takes place. Nostril swab is installed to protect the tissues from the food and slime and to prevent the narrowing of the nasal orifice. After the swab is removed a plastic tube is installed for 3 months into the nasal passage. It is done to prevent its narrowing and deformation of the nose wing. After 7-10 days the stitches are removed. The incision on the lip is visible but it may become less expressed due to cosmetic procedures. In 70% of cases, additional surgeries may be required in older age. The functional and aesthetical achievements of cheiloplasty are the visible only year after the surgery took place. In some cases, the scar deformation of lips may develop and it may require plastic surgery of the mouth cavity.