Cleft is one of the most common birth defect. The incidence of cleft depend on the ethnic groups, highest being the Asians 1 in every 500 births and least the Africans with 1 in every 1200 births. Cleft lip is more common in male and cleft palate is more common in females. Unilateral cases occur in 80% cases and bilateral occurs in only 20% cases.
A cleft occurs when certain parts of the body fails to fuse during fetal development and can occur in the lip or palate (roof of the mouth). Cleft lip is formed at 7-9 weeks of gestation and cleft palate is formed at 9-11 weeks of gestation. They are also associated with various other defects like clubfoot (talipes), etc.
In patient with cleft palate, there is a wide gap present between the mouth and the nose and find it difficult in sucking milk as the gap created fails to form suction. So, feeding is done with special feeding devices help in sucking of the child. Most of the children with cleft, live in isolation making it hard to find friends at school or in neighborhoods.
CAUSES OF CLEFT LIP AND CLEFT PALATE
The exact etiology of cleft is unknown but studies show that cleft is multi-factorial in origin. Also, poor health of the mother during pregnancy has some effect on the child.
1. Genetic factor
Mutation in one or more genes which are located on more than several chromosomes causing cleft.
2.Family history
Parents with cleft lip and palate are more likely to have children with such defects, if one parent have cleft lip than 20% chances of developing cleft, if their one child is born with cleft lip then 14% chances to the next child and if a non cleft parent born with cleft lip then 4% chances of developing cleft lip to the next child.
3.Environmental factors
Insecticides and pesticides containing hexachlorobenzene, cynizine, thiram, etc are known to cause cleft.
4.Nutritional factors
Excessive vitamins A and deficiency of folic acid during pregnancy increases the chances of baby born with cleft.
5.Medications
Drugs like tetracycline, metronidazole, trimethoprime, sulphonamides, phenytoin, warfarin, ethanol, etc taken during pregnancy increases the chances of cleft and other various anomalies.
6.Smoking and drinking during pregnancy doubles the risk of developing cleft in new born.
CLASSIFICATION OF CLEFT
1. Cleft lip
Complete or incomplete cleft
Unilateral or bilateral cleft
2. Cleft palate
Both hard and soft palate
Soft palate only
Bifid uvula
3. Combine cleft lip and cleft palate
Unilateral or bilateral incomplete or complete cleft lip and cleft palate
SYNDROMES ASSOCIATED WITH CLEFT
Crouzon syndrome
Treacher Collins syndrome
Apert syndrome
Gorlin syndrome,
Edward syndrome
Marfan syndrome, etc.
TREATMENT
1. NONSURGICAL TREATMENT
Dental obturator
For severe cleft patients or those who refuse for surgery High rate of closure but the prosthesis need to modify as the child grows.
Pre Surgical Appliances They are custom made acrylic plate for anchorage and molding of the lip, nasal and alveolar structures during the pre surgical phase.
2. SURGICAL MANAGEMENT
The timing and specific techniques used during each stages of cleft reconstruction of cleft lip and cleft palate are still controversial.
THE STAGES OF CLEFT REPAIR IN PATIENT WITH CLEFT LIP AND CLEFT PALATE
CLEFT LIP
Rule of 10’s
Hemoglobin = 10g
Weight = 10 lbs
Age = 10 weeks
Timing = 6-8 weeks
CLEFT PALATE
Timing = 9-12 months
PHARYNGEAL FLAP OR PHARYNGOPLASTY
3-5 years or later based on speech development
ALVEOLAR RECONSTRUCTION WITH BONE GRAFTING
6-9 years based on dental development
ORTHOGNATHIC SURGERY
14-16 years in girls and 16-18 years in boys
RHINOPLASTY
After orthognathic surgery
LIP REVISION
Best performed after 5 years after initial remodeling and scar formation is complete.
CONCLUSION
The treatment of cleft lip and palate requires a multidisciplinary approach by dedicated team of dental and medical professionals. The teams need to perform various surgeries over several years. Give a smile and get a smile by changing the world one smile at a time and make them realize that cleft is no longer a life sentence misery but can be treated effectively by providing free cleft surgeries to those in needs.