Cleft Lip and Palate

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cleft-lipNo one knows why a child is born with a cleft deformity.  There are important predisposing factors such as family inheritance and certain drugs, but most of the time there is no scientific explanation.

In New York City, the good news is that surgical treatment combined with a Craniofacial Cleft Team (comprised of a Plastic Surgeon, Pediatric Dentist, Orthodontist, Speech Pathologist, Otolaryngologist (ENT) and Oral Surgeon) offer a holistic answer to the multiple problems a child with a cleft deformity has.

When a child is born with a cleft palate, the most important problem to address first is feeding.  Because the cleft palate creates a communication of the mouth with the nose, a newborn is unable to generate enough suction to extract milk from a mother’s breast or from a feeding bottle.  If a newborn baby takes longer than 20 or 30 minutes to feed 3 ounces, the baby is expending more energy trying to eat than the baby is receiving from the feeding.  It is important to learn how to feed a newborn with a cleft palate by an experienced cleft nurse, feeding specialist, or doctor.

The first operation is to correct the cleft lip and nose deformity.  Sometimes, naso-alveolar molding may help to improve the nose shape and align the gap in the gum line prior to the operation.  The cleft lip and nose reconstruction is usually performed at 3 to 4 months of age.  I believe the following is very important for the first operation: 1) create good length and symmetry of the upper lip; 2) create a lip scar that is a fine line without any curve to match the shape of the philtral column on the normal side of the lip; 3) create a nose that lifts the nose base to the proper position and create symmetry of the nasal tip.

The second operation is to correct the cleft palate at 10 months of age or older.  Correcting the cleft palate is very important for speech development.  The technique I always use is the Furlow technique, which not only closes the cleft gap but realigns the important palate muscles and lengthens the palate.  A soft diet for six weeks is required for the palate to heal properly.  An overnight stay at the hospital is needed and the child is able to go home when he or she is  drinking fluids adequately.  Arm restraints are not necessary.

From birth through the teenage years, a Craniofacial Team will provide comprehensive evaluation and treatment plans.  This may include dental care and orthodontic treatment or extraction of a primary (baby) tooth or placement of myringotomy ear tubes.  A speech pathologist will determine a child’s progress in language and speech development and interact with speech therapists in the community to ensure appropriate services are given with Early Intervention and at school.

If a child is unable to make sounds that require power, such as ‘s’ (fricative) and ‘p’ (plosive), then an assessment of the velopharyngeal mechanism (the area where the palate seals the mouth from the nose) is needed.  With a nasal endoscope, we can determine if the palate does not create a seal with the back of the throat.  Usually a child needs to be 5 years of age or older to participate with this examination.  First, the nasal lining will be anesthetized topically with a spray.  Then, we pass the nasal endoscope through one nostril.  Once we see the back of the palate from the nasal side, we ask the child to speak in phrases with fricative and plosive sounds.  We can determine if air is escaping through the velopharyngeal space or or the palate is making a good seal.  If there is air escaping, an operation called a sphincter pharyngoplasty may be recommended to correct the velopharyngeal insufficiency (VPI), which is the air escaping through the nose while speaking.

At 7 to 8 years of age, a child with an alveolar cleft (gap through the gum line of the upper jaw) will begin orthodontic treatment with a palate expander, if needed.  The palate expander will align the upper jaw gum line in preparation for bone grafting to the cleft in the upper jaw (alveolar cleft).  I have been using Bone Morphogenetic Protein (BMP)and Demineralized Bone Matrix or powder with equal success to autologous bone grafting.  Because a bone graft is not needed, this spares the child from having severe discomfort and pain from the hip, from where the bone graft is usually harvested.  A revision of any residual problems of the cleft lip and nose can be treated along with this operation.

As the secondary (adult) teeth migrate out, braces and movement of misaligned teeth will be needed. Orthodontic treatment may take a few years. Any underbite or overbite will be treated if movements are relatively small.

As a child becomes a teenager, we assess upper and lower jaw growth and determine whether or not an operation will be needed to correct any significant malocclusion (when the upper jaw and lower jaw are not properly aligned).  When skeletal growth of the jaw is complete (usually at 15 to 16 years of age) and surgical correction is needed for malocclusion, orthodontic preparation will be required prior to orthognathic surgery.  Once the orthodontic treatment is completed and dental models have been made, an orthognathic operation of the maxilla (upper jaw) and/or mandible (lower jaw) is performed, based on the models.

As you may have learned by now, the holistic treatment requires an experienced plastic surgeon and a team of specialists.  The best thing to do at any age of your child with a cleft deformity is to come in as soon as possible for an overall evaluation and learn about the important treatment options available.  Visit Dr. Kim for an expert evaluation.  He is proud to serve the Manhattan communities of West Village, Greenwich Village, Soho, East Village, Lower East Side, Tribeca, Bronx, Brooklyn, Queens and Staten Island.