What is a cleft?

A cleft is an elongated opening, resulting from the failure of tissues to merge early in prenatal development. Openings in the lip, the hard palate (roof of the mouth), and the soft palate (back of the roof of the mouth) denote the failure of structures to fuse as they normally do between the 6th and the 12th week of pregnancy. This failure may occur on one side or both sides of the face. It may involve only the lip, only the palate or both. The cleft may be present in the entire part ( that is entire lip or palate) or a part of it. Different types of clefts affect children in different ways. Sometimes clefts are also associated with various craniofacial abnormalities or syndromes of the head face and neck.

What are the types of clefts?

There are different types of clefts, affecting the lip and or palate and vary in degree of severity and the affected side.

Unilateral Cleft Lip – Simple cleft of the lip extending through the dental arch on one side. This is usually on the left side.

Unilateral Total cleft of lip and palate – Cleft of the lip extending up to the palate on one side. Most common type of cleft.

Bilateral Complete – Both sides of the lip and the nostrils are affected.

Isolated Palatal Cleft – Cleft of the palate without involvement of the lip

Submucous Cleft palate – This is a covert or hidden type of cleft which is rare. Here in the cleft is present under the mucous lining of the palate.

Signs of the presence of a sub mucous cleft – Bifid Uvula, forward notching of the back edge of the hard palate and a translucent whitish or bluish line in the midline of the palate.

Congenital Palatopharyngeal Incompetence – CPI or Congenital Palatopharyngeal Incompetence is a condition  in which there is inadequate velopharyngeal closure in the absence of any cleft. CPI may go undiagnosed at birth. The problem might get noticed after an adenoidectomy when the child develops persistent hyper nasal speech. These children have normal functioning but exceptionally short palates. Sometimes the muscles that lift the soft palate mighty be misaligned. When the adenoids are present they act like cushions and against which the soft palate makes adequate contact. But when adenoids are removed, the resulting gap between the palate and the back of the throat causes the air to escape through the nose, hence making the speech hypernasal.

What are the causes of Cleft Palate?

A cleft palate happens when the structures that form the upper lip or palate fail to fuse together properly when a baby is developing in the womb.

In most cases the exact cause is unknown, but it’s thought to be a combination of genetic (internal) and environmental (external) factors.

Genetic Inheritance

Research indicates that the genes a child inherits from their parents occasionally makes them more vulnerable to developing a cleft palate. A number of genes have been identified that may be responsible.

In some cases there is a family history of clefts, although most children of parents with clefts will not develop them.

Environmental risk factors

A number of things have been identified that may increase a child’s chance of being born with a cleft palate. These are outlined below.

Lack of folic acid during pregnancy

All pregnant women are advised to take a daily supplement of folic acid during the first four months of pregnancy. Folic acid helps reduce the possibility of birth defects.

While it is known that folic acid deficiency during pregnancy increases the risk of a cleft developing, there is no firm evidence yet to suggest an intake of higher doses of folic acid prevents clefts. However, mothers from families with a history of clefting are often advised to take higher doses of folic acid during pregnancy. This should be discussed with your doctor.

Smoking

A mother who smokes during pregnancy increases her baby’s chance of being born with a cleft. The risks from passive smoking are not fully known, but it is a good idea to avoid breathing in high levels of second hand smoke.

Alcohol consumption

Some studies have shown a link between a mother’s alcohol consumption during pregnancy and the development of a cleft palate in her baby.

Obesity and nutrition

Mothers who are obese have a higher chance of their child being born with a cleft. Poor nutrition during pregnancy can also increase the risk.

Medications during pregnancy

It has been suggested that some medications taken during pregnancy may increase the risk of cleft lip and palate. These include:

  • methotrexate, a medicine used to treat cancer, arthritis and psoriasis.
  • Isotretinoin, a medicine to treat acne
  • anti-seizure medicine

What are the treatment options for children with cleft palate?

A child who is born with cleft palate has to be referred to the Oral Cleft team.The success story of any child with a cleft can be written only by excellent interdisciplinary team system. The core members of an Oral cleft team are plastic surgeon, a speech pathologist, an orthodontist. Other important participants that are directly and indirectly involved are anaesthesiologist, audiologist, coordinator, educator, endodontist, geneticist, genetic counsellor, nurse practitioner, oral surgeon, otolaryngologist, parents, paediatrician, periodontist, prosthodontist, psychiatrist, psychologist, radiologist and social worker.

Plastic Surgeon– The plastic surgeon repairs the cleft by modifying the soft tissue. He is the first specialist that the parents meet.

Otolaryngolosit – Also known as Ear Nose Throat (ENT) specialist, evaluates and treats tonsils, adenoids and middle ear diseases. He might also be involved in nasendoscopic studies of velopharyngeal closure.

Orthodontist – This professional is responsible for positioning of teeth. He or she may use devices to straighten teeth and to ensure as normal an occlusion as possible.

Prosthodontist/ Prosthetic dentist – He or she designs and builds prostheses (devices to replace dental and oral structures). These may include dentures, speech bulbs, palatal lifts, and obturators.

Radiologist – He or she makes and interprets makes and interprets x ray studies of the oral and nasopharyngeal strucures, including still x rays and videotaped motion x rays.

Pediatrician – Takes care of the overall medical condition and the physical development of the child.

Psychologist – Oversees the emotional problems associated with the cleft.

Audiologist – Helps in detecting and testing of middle ear problems in children with clefts.

Speech Pathologist – This professional is responsible for providing help in the areas of feeding, swallowing, and speech and language therapy of the child

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