In a previous post, we introduced some procedures required for repair of a cleft lip and/or palate. Those surgeries reconstructed the groove between the nostrils and upper lips; the border between reddish lips and normal skin; the nostril area and the muscles of the mouth and lips. Sometimes, further surgical corrections are required. They may include the following.
Alveolar Bone Grafts
When a child’s cleft affects the dental ridge of the upper jaw, bone grafting is often necessary. Bone grafting is a procedure involving the transference of bone material from one area of the body to another. For example, cancellous bone, which is light and porous, can be harvested from the hip area and placed in the area of the cleft near the teeth. The bone tissue will then begin to regenerate and build new bone in the area.
Bone grafting is most successful in patients under 10 years old and is performed on patients as young as 5 or 6 years old as the front incisor teeth are erupting. (Dental x-rays show the development of the permanent teeth.) Although older patients may also benefit from a bone graft, the results are not as good, especially if the patient is a smoker, has a systemic disease such as diabetes or has poor oral hygiene.
Once the bone graft has been placed, one of three options will be implemented to replace missing teeth. Teeth positioned adjacent to the bone graft will be moved into the graft area; a prosthetic replacement called a dental bridge may be used; or dental implants will be inserted. The dental specialists on the cleft palate team will advise which option is best for the patient.
A bone graft to the dental ridge serves several different purposes. It supports teeth that have not yet grown in and those that are next to the cleft. It provides symmetry to the face and supports the lip and nose. It creates a more natural appearance by forming a contiguous upper gum line. The front part of the roof of the mouth becomes stabilized, especially when a bilateral cleft is present. Even when the bone graft is placed after the permanent teeth have erupted, between the ages of 10 and 12 in most cases, it may still be useful for support purposes.
The Centers for Disease Control estimate that approximately 7000 babies are born with cleft lip and/or cleft palate (CLP) each year in the U.S. Clefts occur more often than most other types of birth defects. Along with disfigurement, the structural differences of the mouth, lips and face caused by clefts can lead to myriad complications for the patient. In infancy, the ability to nurse may be impaired because the opening in the palate interferes with suction. As the child develops, difficulties with breathing, hearing, seeing and speaking may develop. Teeth may be crooked and jaws may misalign.
On the bright side, options exist to help alleviate each of these problems. The process of repairing CLP is not an easy one, but with surgical and therapeutic intervention challenges can be overcome allowing the patient to lead a normal life. The evolution and improvement of plastic surgery techniques, medical and dental care, and speech and audiology treatments have all contributed to the successful treating of CLP. Awareness of the psychosocial impact clefts pose for a person has led to the development of strategies to help patients cope with their condition.
The American Cleft Palate-Craniofacial Association advocates for patients’ care to be managed by a team of cleft-craniofacial specialists that support coordination of surgical, medical and dental professionals as they plan treatment. This is designed to make the process less disruptive for the patient and her family while avoiding overlap of services.
In the U.S., the Centers for Disease Control and Prevention (CDC) perform myriad health related services including identifying and tracking birth defects. Because orofacial clefts occur relatively frequently, The CDC’s National Center on Birth Defects and Developmental Disabilities (NCBDDD) conducts research to learn more about cleft lip with or without cleft palate and how to prevent their occurrence.
The CDC seeks to discover correlations between particular circumstances and an increase in the risk of a mother giving birth to a child with a cleft lip or palate. The studies may examine mothers’ use of drugs including nicotine and alcohol, for example. They also explore the many ways orofacial clefts impact the children who are personally affected and their families. Health care expenses and obstacles to obtaining care are considered, as are quality of life issues. The cost in dollars and time, and the inconvenience of long, complex treatment plans are often a burden to families. Through ongoing research, the CDC and its partners mission is to improve the lives of children and families affected by craniofacial conditions present at birth.
More specifically, the CDC supports states in the tracking and causes of birth defects, including cleft and craniofacial conditions, and works to find out what causes them. Partners like the National Foundation for Facial Reconstruction (NFFR) and Operation Smile provide parents, health care providers and school personnel with educational resources on how to care for children with cleft and craniofacial defects. http://www.nffr.org/Parent_Guides_U3FC.html.
July is National Cleft & Craniofacial Awareness & Prevention Month (NCCAPM) in the United States. Ameriface and Cleft Advocate established the campaign to promote public awareness and prevention of cleft and craniofacial conditions.
When a parent of a newborn with cleft lip, cleft palate, or another craniofacial condition has questions about what lays ahead, AmeriFace http://www.ameriface.org has answers. The organization is dedicated to educating and supporting those affected by facial differences. It also seeks to educate the public about the conditions by creating awareness programs such as NCCAPM. Facial differences include those present at birth as mentioned above, or acquired via illness, disease or trauma. Stroke, cancer, accidents, animal bites and burns are some causes of acquired facial differences.
Reviewers of AmeriFace, a non-profit organization, describe their association with the online support group as life- changing. The process of healing craniofacial deformities is long and complex. Emotions run rampant and questions abound as parents seek information about what the future holds. Ameriface provides a place where they can connect and communicate with others who have traveled a similar path and those that are also beginning the journey.
Cleft lip and/or cleft palate can occur in a developing fetus for several reasons. One cause is genetic; the gene can be passed down from one or both parents. Drugs, viruses and toxins are some other causes of the birth defects. Sometimes the deformity is detected during pregnancy. High-tech ultrasonography allows doctors to view well-defined, two-dimensional images of a developing fetus. These high-resolution sonograms can reveal abnormalities of the face, including cleft lip. Although cleft palate is most often diagnosed after birth, in some cases ultra-precise three-dimensional ultrasonography and prenatal magnetic resonance imaging (MRI) may aid an in utero diagnosis.
By the fourth to sixth week of fetal development, the nose, lip, and part of the hard palate are formed. However, the facial features are not generally detectable with imaging equipment until 16-18 weeks. It is possible to diagnose a baby with cleft lip during a routine fetal check-up at approximately 18 weeks gestation. A second-trimester sonogram can show whether a baby has a normally shaped skull. Doctors look for signs that the skull has fused prematurely or if either side of the head is smaller than expected. Slight differences in facial structures are not always evident with prenatal ultrasonography. Many irregularities cannot be detected until after the baby is born.
Cleft lips and cleft palates are craniofacial anomalies that occur in the early phases of fetal development. In medical terms, an anomaly is something irregular or different from normal. A ‘cleft’ is a separation. We all begin life with a separated palate and lips. Sometime between the fourth and seventh weeks of pregnancy, the two sides of a baby’s upper lip begin to fuse together. When the fusing doesn’t happen in the right way, the upper lip remains split, or cleft. The size of the separation can range from a small hole to a more significant opening extending from the base of the nose to the top jaw and gums.
The roof of a baby’s mouth, called the palate, forms sometime between the sixth and twelfth week of pregnancy. There are two parts of the palate. The hard palate is firm and bony. It follows the curve of the top teeth. The tissue of the soft palate is fleshier and more flexible. It covers the area in the back of the mouth. When one or both of these parts forms incompletely, the baby is born with a cleft palate.
A child can be born with a cleft lip, a cleft palate or both. Cleft lips and/or cleft palates are one of the most common birth defects in the U.S., occurring once in every 700 births. Cleft lip is more common than cleft palate. The Center for Disease Control (CDC) estimates that about 2600 babies are born with cleft palate and about 4500 are born with a cleft lip, with or without a cleft palate. A cleft may affect only one side of the mouth and face (unilateral), or both sides (bilateral). Statistically, clefts are more common in boys than girls, and affect more children of Asian, Latino and Native American descent. The incidence of clefts in children of African-American descent is lower than that for children of other ethnicities.