Alveolar Cleft Repair

Cleft Lip

During early pregnancy, separate areas of the face develop individually and then join together, including the left and right sides of the roof of the mouth and lips. However, if some parts do not join properly, sections don’t meet and the result is a cleft. If the separation occurs in the upper lip, the child is said to have a cleft lip.

A completely formed lip is important not only for a normal facial appearance but also for sucking and to form certain sounds made during speech. A cleft lip is a condition that creates an opening in the upper lip between the mouth and nose. It looks as though there is a split in the lip. It can range from a slight notch in the colored portion of the lip to complete separation in one or both sides of the lip extending up and into the nose. A cleft on one side is called a unilateral cleft. If a cleft occurs on both sides, it is called a bilateral cleft.

A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum into separate parts. This is called an alveolar cleft because it is a cleft through the alveolar bone. This is the bone that supports the teeth and gums (gingiva). A similar defect in the roof of the mouth is called a cleft palate.

Cleft Palate

The palate is the roof of your mouth. It is made of bone and muscle and is covered by a thin, wet skin that forms the red covering inside the mouth. You can feel your own palate by running your tongue over the top of your mouth. Its purpose is to separate your nose from your mouth. The palate has an extremely important role during speech because when you talk, it prevents air from blowing out of your nose instead of your mouth. The palate is also very important when eating. It prevents food and liquids from going up into the nose.

As in cleft lip, a cleft palate occurs in early pregnancy when separate areas of the face have developed individually do not join together properly. A cleft palate occurs when there is an opening in the roof of the mouth. The back of the palate is called the soft palate and the front is known as the hard palate. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth (soft and hard palate).

Sometimes a baby with a cleft palate may have a small chin and a few babies with this combination may have difficulties with breathing easily. This condition may be called Pierre Robin sequence.

Since the lip and palate develop separately, it is possible for a child to be born with a cleft lip, palate or both. Cleft defects occur in about one out of every 800 babies.

Children born with either or both of these conditions usually need the skills of several professionals to manage the problems associated with the defect such as feeding, speech, hearing and psychological development. In such cases, surgery is recommended. When surgery is done by an experienced, qualified oral and maxillofacial surgeon such as Dr. Reynolds, the results can be quite positive. Our team limits our part in treating clefts to secondary repairs. These include alveolar cleft bone grafting and replacement of missing or lost teeth into the cleft.

Cleft Lip Treatment

Cleft lip surgery is usually performed when the child is about 10 weeks old. The goal of surgery is to close the separation, restore muscle function and provide a normal shape to the mouth. The nostril deformity may be improved as a result of the procedure or may require a subsequent surgery.

Cleft Palate Treatment

A cleft palate is initially treated with surgery safely when the child is between 10-24 months old. This depends upon the individual child and his/her own situation. For example, if the child has other associated health problems, it is likely that the surgery will be delayed.

The major goals of surgery are to:

  1. Close the gap or hole between the roof of the mouth and the nose.
  2. Reconnect the muscles that make the palate work.
  3. Make the repaired palate long enough so that the palate can perform its function properly.

There are many different techniques that surgeons will use to accomplish these goals. The choice of techniques may vary between surgeons and should be discussed between the parents and the surgeon prior to the surgery.

The hard palate and alveolar clefts are generally repaired between the ages of 7 and 12 years when the cuspid teeth begin to develop. The procedure involves placement of bone from the hip into the bony defect, and closure of the communication from the nose to the gum tissue in three layers. It may also be performed in teenagers and adults as an individual procedure or combined with corrective jaw surgery.

Clefts and their related surgeries can result in midface (upper jaw and nose) deficiencies. This is when the upper jaw and nose don’t grow forward enough and the face can look dished-in or flat. It can also result in a class III mal-occlusion commonly called anunderbite. In these cases the patient may require jaw repositioning (orthognathic) surgery. This is done at 14-17 years of age. Early surgery may be done in anticipation of future final treatment if the growth discrepancy is severe. Often the best type of orthognathic surgery for clefts involves distraction osteogenesis. 

Rhinoplasty, if needed, is done at 15-20 years and sometimes in conjunction with orthognathic surgery

General Timetable for Cleft Management

10 weeks -6 months
 Lip repair
 Rule of 10’s applies: < 10 lbs wt, < 10 wks old, HgB < 10, WBC < 10,000
10 – 24 months
 Palate, primary repair
 
5 – 7 years
 Pharyngeal flap
 
As needed
 Lip, nose revision
 
7 – 12 years
 Alveolar cleft bone graft
 When the canines begin to develop
14 – 17 years
 Orthognathic surgery
 
15 – 20 years