Cleft Lip and Palate: Disabilities & Treatment

• Dr. Mohamed Farouk Abdalla is a professor of prosthodontics at Galala and Cairo University.

Disabilities Associated with Cleft Lip and Palate

• Babies with a cleft lip cannot suckle properly due to a lack of negative pressure in the oral cavity.
• Masticatory function gets impaired by missing teeth and malocclusion, leading to malnutrition and debilitation in cleft patients.
• General health deteriorates due to inefficient feeding, inadequate nutrition, and mouth breathing.
• Cleft lip or palate leads to a distorted facial appearance.
• Children with clefts have incompetent lips or inadequate velopharyngeal closure, resulting in air escaping through the nose instead of the oral cavity, which impacts speech.
• Speech problems are generally more complex in congenital defects.
• Children with clefts often struggle to communicate within society, leading to psychological trauma.

Sequence of Treatment

• Typical sequence includes presurgical phase, surgical phase, orthodontic treatment, and definitive prosthetic phase

Presurgical Phase

• Starts at birth and may continue up to 3 months until surgery.

Early Intervention and Counseling

• When an infant is born with a cleft, early intervention and counseling are necessary
• The cleft palate team should assess the severity of the case.
• Reassuring parents and teaching them how to deal with cleft problems is key.

Feeding

• Maintaining nutrition is necessary for growth and development
• It helps in the infant's preparation for the first surgery.
• Infants with an isolated cleft lip can often feed normally with a broad base nipple.
• Infants with a cleft palate struggle to generate negative pressure during suckling, leading to fatigue and unfinished feeding.

Overcoming Feeding Problems

• Options include bottle feeding, using a specific feeding position, and/or a feeding appliance.
• Use a soft, broad nipple adapted to the palatal defect.
• Cross-cut nipples allow milk to flow more easily, reducing strain on the child.
• Longer nipples are more successful, since they can be placed posterior to the defect.
• A squeezable bottle can be helpful.
• Infants should be in a semi-sitting position during bottle feeding.
• Feeding appliances are a prosthetic management method that helps cleft palate infants feed during the pre-palatal surgery period.
• A custom-made obturator is a feeding device that covers the palatal defect temporarily, either attached to the feeding bottle or with a wire handle for the mother to obliterate the feeding against the cleft

Naso-Alveolar Molding (NAM) Device

• The device realigns alveolar segments to prepare them for surgical closure, sometimes with bone grafting.
• It molds and positions surrounding soft tissues to bring the columella of the nose into a more midline position and helps reshape the nostrils.
• Tissues take about 5-6 months to be optimized before surgery.
• Elastics, fixed to the face with steri-strips and connected to extended appliance rods, apply the realigning forces.

Surgical Phase

• The treatment of choice for congenital defects should be done at the proper time when no contraindications exist.

Lip Repair

• The first surgery for the lip typically occurs around 3 months to facilitate feeding and improve appearance.
• Lip repair without excessive tension establishes a favorable contour in the premaxillary area and narrows the palatal cleft, if present.

The Rule of Ten

• Refers to 10 pounds in weight (4.5-4.6kg), 10 weeks old, and a hemoglobin count of 10 for the infant.

Palatal Repair

• Aims to enhance speech development
• Aims to promote proper swallowing and breathing
• Aims to decrease dento-alveolar deformities
• Aims to maintain proper maxillary growth
• Surgery on the palatal shelves should not be done too early to allow the child to grow
• Palatal shelves continue to grow and narrow the cleft.
• Sufficient tissue growth helps with proper closure.
• The timing for palatal closure varies from 12 months to 4 years, based on the width of the cleft; if it is very wide, sufficient tissues may not be available for closure leading to delays.

Orthodontic Phase: Expansion Type Prosthesis

• Jaw growth and dentoalveolar development do not follow normal patterns in children with clefts due to intrinsic tissue deficiency or early/improper surgery.
• Anterior alveolar process narrowing of the maxillary arch can result from pressure from lip repair or scar tissue after palatal repair.
• Often results in mal-alignment of teeth.
• Maxillary expansion to correct the palatal segment position and cross-bite is carried out using a palatal expansion type prosthesis around 7 years of age, when permanent incisors and first molars have erupted.

Definitive Prosthetic Treatment

• Normal Prosthetic Restoration options include fixed restorations, removable restorations, and dental implants.

Maxillofacial restorations

• Include rehabilitation of a patient who underwent surgical treatment, e.g. failure of surgery to close the defect or movement of the soft palate is inactive.
• Include rehabilitation of an un-operated patient, e.g. with a wide soft or hard palatal defect.