CLEFT LIP AND CLEFT PALATE

PPT
Introduction:
Good morning everyone! Today, we’re going to discuss the second topic which is Cleft lip and
palate. I am Angelica B. Villalon, and my partner is Ms. Riza Barazan. But before we go into the
lesson proper, let us first watch this very short clip regarding the case of a young boy who was born
with Cleft lip.

Objective:
So, at the end of this discussion, hopefully you will be able to gain knowledge and understanding on
the concept of cleft lip and palate, it’s causes, risk factors, the pathophysiology, complications as well
as the appropriate nursing and medical management for the said condition.

Definition:
So, Clefts of the lip and palate are facial malformations that occur during embryonic development.
The word “Cleft” means a split or separation. Thus, with cleft lip, there is an opening or split in the
upper lip that occurs when developing facial structures in an unborn baby don't close completely. This
disorder can range from a small notch in the upper lip to total separation of the lip and facial structure
up into the floor of the nose, with even the upper teeth and gingiva absent. While, with cleft palate,
there is an opening of the palate that is usually on the midline and may involve the anterior hard
palate, the posterior soft palate, or even both.

Statistics:
- The incidence of CLP is estimated at 1 in 1000 live births in the United States. It has been noted
that Incidence is significantly lower in black populations, 1 in 2000, and significantly higher in
Asian populations, 1 in 300.
- About 46% of children have combined cleft lip and palate, while 21% only a cleft lip, and 33% only
a cleft palate. Almost 30% of children with cleft lip and palate deformity have associated birth
defects or the cleft palate occurs as only a portion of a larger syndrome. (Hoffman, 2008)
- In the Philippines, in 1 out of 1,000 Filipino live births, a cleft lip or palate patient is born. (SLMC,
2017)

Causes:
So, the occurrence of cleft lip and palate can be due to different causes.
It can either be because of multifactorial inheritance.
There’s a greater chance of having the condition if a family member such as a sibling maybe, or a
parent or relative has had the problem. If more than one member is affected, the chance of acquiring
the same condition actually increases.
Also, it can be due to environmental factors. Such as exposure to teratogens during the 5 th to 8th
weeks of intrauterine life; such as smoking, alcohol use and viral infections such as rubella or
medicinal drugs specifically anticonvulsant drugs, steroids, and retinoids.

For the predisposing factors, we have maternal deficiency of B vitamins (B6, folic acid, b12)
- As these vitamins lower the chances of infants to have birth defects
And maternal or gestational diabetes mellitus, because…

Risk Factors
Clefts occur more often in children of Asian, Latino, or Native American descent. Compared with girls,
twice as many boys have a cleft lip, both with and without a cleft palate. However, compared with
boys, twice as many girls have cleft palate without a cleft lip.
Several factors may increase the likelihood of a baby developing a cleft lip and cleft palate, including:
- Family history
- Exposure to certain substances during pregnancy
- Having diabetes- there is some evidence that women diagnosed with diabetes before pregnancy
may have an increased risk of having a baby with a cleft lip with or without a cleft palate.
- Being obese during pregnancy

Variations:
So, for the variations or classifications. Cleft lip or cleft palate may be:
 Combined or Isolated
With combined, there is both Cleft Lip and Cleft Palate
For Isolated, it’s either Cleft lip or Cleft palate is present
 Complete or Incomplete
Complete- involves the vermilion (red lip), the skin between the vermilion and the nose, and

the floor of the nose. The alveolus (tooth bearing segment of the palate) is typically clefted, as

well. In addition to the skin and vermilion, the cleft involves the muscle beneath the skin,
 called the orbicularis oris. The nose has deformities on the skin and cartilage. Each of these

structures must be addressed during a cheiloplasty (cleft lip repair).

Incomplete- part of the lip or nasal floor is intact. Incomplete clefts may involve only a small

part of the lip. In some patients, the majority of the lip is affected by the cleft, while there is a

small intact area at the base of the nose. This is called a Simonart band. The least severe

form of a cleft lip is called a forme fruste, or microform cleft lip. This may manifest only as a

small indentation.

 Unilateral or Bilateral
Unilateral- if the defect only occurs on one side.

Bilateral- if it involves both sides

It is possible for both sides to have a complete cleft, or for both sides to be incomplete, or for

one side to be complete and the other incomplete.

CLEFT PALATE (TYPES)

Similar to the lip, clefting of the palate may be complete or incomplete. Complete cleft palates

involve the alveolus, the hard palate, and the soft palate or velum. Incomplete cleft palates

may involve some or all of the soft palate, with or without part of the hard palate. The palatal

cleft may also be either unilateral or bilateral.

CONCEPT MAP:
Risk factors
So, for the risk factors, we can classify them into two. We have the non-modifiable and the modifiable
ones. For the Non-Modifiable: we have Family history and gender - males have greater risk than
females. While for the Modifiable: we have exposure to teratogens during pregnancy, maternal
deficiency of B vitamins, maternal diabetes mellitus and being obese during pregnancy

Pathophysio
So, normally, the maxillary and median nasal processes fuse between weeks 5 and 8 of intrauterine
life. And the palatal process closes at approximately weeks 9 to 12 of intrauterine life. However, due
to various factors or causes, fusion of this anatomical structures fail to occur which can lead to infants
having cleft lip and or palate.

With cleft lip, it can manifest as Compromised lip seal

With cleft palate, it can result to abnormal tensor veli palatini insertion.

LEFT SIDE:
The tensor veli patini tenses the soft palate and by doing so, it assists the levator veli palatini in
elevating the palate to occlude and prevent entry of food into the nasopharynx during swallowing.

And due to its abnormal insertion, it may lead to Eustachian tube disfunction
- the eustachian tube is a canal that connects the middle ear to the nasopharynx. It controls the
pressure within the middle ear, making it equal with the air pressure outside the body. So with
eustachian tube dysfunction, the mucosal lining of the tube may be swollen or does not open or
close properly which can possibly lead to
- Ear infection- and eventually hearing loss

And with the dysfunction of the eustachian tube, it can result to a

Non-equalized pressure of the outer and inner ear

Which further results to a

Reduced sound transmission via the eardrum
- which can also lead to Hearing loss

additionally, with cleft palate there is an

MIDDLE:
Inadequate closure of velopharyngeal port
The velopharyngeal port is the orifice or gap behind the velum. This is the distance that the velum
and pharyngeal walls must overcome to have complete closure, such as during speech and
swallowing. inadequate closure of this port may result to:
velopharyngeal Incompetence
- this is when the soft palate does not close tightly against the back of the throat leading to air
coming out of the nose during speech (Abnormal resonance & airflow) that causes speech
difficulties, which may also be due to maladaptive articulation behaviors .
(Maladaptive behaviors are those that stop you from adapting to new or difficult circumstances)
(speaking disorders)
Also, with the presence of velopharyngeal incompetence or insufficiency there may be
- Nasal regurgitation
or the regurgitation (bringing up) of food or fluids through the nose. With this,
o Altered bacterial flora and chronic inflammation of the Eustachian tube may occur
(probably due to the backflow of acidic material which can alter the mechanism of the normal bacteria
in the area)
- Aspirating material laden with infectious organisms or even normal mouth flora can cause
bacterial pneumonitis.
Which can also lead to ear infection and eventually hearing loss

Also, with velopharyngeal incompetence, it can lead to a negative oral pressure

↓Oral negative pressure (or weak intraoral air pressure)
wherein the air pressure maintained in the oral cavity that ensures proper production of oral speech
sounds, is reduced thereby impairing speech eligibility. Besides allowing for the correct articulation of
speech sounds, the adequacy of the velopharyngeal function is also crucial for the balance of other
oral functions such as suction and swallowing. So, impairment of this may also lead to Sucking
difficulties which can be manifested with difficulty in feeding and poor weight gain.

Sucking difficulties may lead to poor nipple compression reducing fluid release, due to Compromised
alveolar ridge. The alveolar ridge is an extension of the maxilla and the mandible and is the one that
holds the sockets of the teeth. This is a very critical anatomical structure for healthy teeth and
successful dental implants. So if it’s compromised, there can be dental abnormalities.

By the time of the first ultrasound in which the fetus’ facial structures can be identified, clefting of the
lip or palate will already have occurred.  Development of the facial structures and form occurs
between the 4th and 8th weeks of gestation.  During the 4th week of development, a series of six
paired (right and left) swellings form near the cranial, or head, end of the fetus.  These are
called branchial arches.  The branchial arches develop into important structures in the head and
neck, as well as the major arteries in the chest.  The first branchial arch develops structures called
the maxillary and mandibular prominences, which ultimately form the skeleton, skin, muscles, and
other structures of the upper (maxilla) and lower (mandible) jaws.  In the center of the upper face, a
structure called the frontonasal prominence, which is separate from the branchial arches, forms,
among other things, the nostrils and the philtrum.  The medial maxillary prominences fuse with the
frontonasal prominence during this time. Failure of this process results in a cleft lip.

The palate is also formed by fusion of the frontonasal prominence and the maxillary
prominences. Although the palate appears to be one complete structure, it actually consists of a
primary palate, behind the front teeth, and a secondary palate, which includes the majority of the hard
and soft palate. These are separated by a hole in the palatal bone called the incisive foramen.  The 2
sides of the secondary palate begin to fuse during the 8th week of development.  Failure of fusion
results in a cleft palate.