Cleft Lip and Palate

Question 1

How to describe cleft lip?

Answer 1

LAHSAL = lip alveolus hard soft palate alveolus lip
Upper case denotes complete (all across hard palate)

Iahsal - lower case denotes incomplete

Question 2

Incidence of cleft palate?

What does it affect?

Answer 2

1 in 2000 births
Affects hard/soft/both
Associated with syndromes

Question 3

Sub mucus cleft palate features?

Answer 3

1 in 12000 births
Not obvious, may not be suspected until child is older
Usually a previous history of problems with feeding/failing to thrive

Question 4

Diagnostic features of sub mucous cleft palate?

Answer 4

Notch on palatal shelf
Bifid uvula
‘Blue translucent zone’ or diagnosis made at surgery

Question 5

Cleft lip and palate incidence?

Answer 5

Affects 1 in 600/700 babies
1000 births per year in UK
2 distinct presentations - cleft lip +/- cleft palate, isolated cleft palate

Question 6

Aetiology of cleft lip and palate?

Answer 6

Genetic - FH in 40% of cases 
Environmental:
- Anti convulsant drugs
- Nutritional deficiency
- Anaemia
- Alcohol
- Low socio-economic status 

Probably a genetic predisposition triggered by environmental factors

Question 7

How to diagnose cleft lip/palate?

Answer 7

Ante natal scan, around 20/40 weeks

Question 8

Percentage of cleft lip, cleft lip and palate, cleft palate and associated anomalies?

Answer 8

20% Cleft lip (uni or bi lateral)
50% CLP (uni or bilateral)
30% Cleft Palate
IN ADDITION
15 – 40% of cleft children have 
associated anomalies

Question 9

Syndromes associated with cleft lip and palate?

Features of these syndromes?

Answer 9

Van der woude syndrome

• AD
• Lip pits
• Clef palate
• Linked with cardiac anomalies
• Hypodontia

Pierre Robin Sequence:

• Clef palate, glossoptosis
• Mandibular retrognathia
• Around 1/3 of cases are liked to stickler syndrome = a CT disorder

Foetal alcohol spectrum disorder

• Small head size
• Low body weight
• Learning difficulties
• Coordination issues = lifelong care

Question 10

When can cleft lip and palate be repaired?

Answer 10

When baby is thriving
Lip from 3 months
Posterior palate from 6 months

Question 11

What orthodontic intervention can be done for cleft lip and palate?

Answer 11

When neo natal = lip strapping

Question 12

What is done throughout someone’s childhood if they have cleft lip/palate?

Answer 12

Monitor speech development
ENT assessment/hearing tests
NB: Glue ear
Dental health education
Phayngoplasty or revision surgery to assist speech where indicated

Question 13

Incidence of speech problems with cleft lip/palate?

Answer 13

2/3 of all children with cleft palate repairs receive speech therapy
Half of children with cleft palate = persistent speech difficulties
Speech can be nasal or produced too far back in the mouth

Question 14

Dental abnormalities/problems that may occur with cleft lip/palate?

Answer 14

Hypodontia - missing upper lateral incisons = 30-50% of cleft cases
Supernumeraries
Microdontia in cleft site
54% of cleft cases have dental anomalies

Dental disease, poor oH (cleft children have twice as bad teeth as their peers)
Missing/malformed/extra teeth
Delayed dental development
Unusual paths of eruption / intra oral appearance
Skeletal factors - adverse effects of facial growth and previous surgery
Dental occlusion and alignment

Question 15

How should a dentist manage a cleft palate pt 6-10 yrs old?

Answer 15

Monitor dental development and provide regular dental care
Ortho assessment
Alveolar bone graft as necessary 
Speech and language therapy 
ENT monitoring

Question 16

Why are cleft lip and palate pts high caries risk?

Answer 16

Diet: Highly cariogenic
Oral health: Limited intraoral access, reluctance to brush in areas close to previous surgery, unable to tolerate strong taste (mint)
Reduced salivary flow

Access to dental care: attendance often difficult - multiple hospital appointments
Social deprivation: Higher prevalence of CP in deprived areas

Question 17

Adverse effects of CP surgery and facial growth?

Answer 17

Scarring of soft tissues
Restriction of maxillary development = class III
Mandibular development

Question 18

Ortho treatment for CP?

Answer 18

Preparation for alveolar bone graft age 9-11 yrs
Definitive ortho age 13 yrs plus
Ortho/orthagnathic surgery when growth complete

Pre-surgical ortho alignment:

• Ortho arch expansion
• Open cleft site to facilitate placement of bone graft
• Align rotated incisors if bone support adequate

13-15 yrs: Ortho tx options depend on quality of primary and secondary cleft surgery

Question 19

Treatment provided for 1-20yr olds with CLP?

Answer 19

Support for transition to 2ndry school
Definitive ortho tx
OR
Combined ortho/orthagnathic surgery
Rhinoplasty as appropriate
Referral to clinical geneticist if appropriate

Question 20

Orthagnathic surgery in cleft patients?

Answer 20

Full speech assessment essential to estimate risk of speech deterioration

• Video fluoroscopy (2d)
• Nasendoscopy (3d)

Psychological assessmment
Any other procedures e.g. rhinoplasty, deferred until orthognathic phase complete