CLEFT FORMATION. DOUBLE LIP.CASE REPORT.

Vocabulary
cleft/kleft/palate is an oral deformity affecting the hard palate;
cleft lip is a visible facial/oral deformity characterized by the insufficient development of skin or lip
tissue, resulting in a split or opening;
bilateral /ˌbaɪˈlætərəl/- involving two groups of people or two countries;
uvula /ˈjuːvjələ/plural uvulae /ˈjuːvjəli/-a small, soft part of the body that hangs from the top of the
inside of the mouth just above the throat;
velopharynx plural velopharynges- region of the soft palate and the pharynx;
stigma - a strong lack of respect for a person or a group of people or a bad opinion of them because they
have done something society does not approve of;
alienation /ˌeɪliəˈneɪʃn/- the act of making somebody less friendly towards you, the feeling that you do
not belong in a particular group;
regurgitation /rɪˌɡɜːdʒɪˈteɪʃn/- the act of bringing food that has been swallowed back up into the mouth
again;
squeeze /skwiːz/-to press something firmly, especially from
all sides in order to change its shape, reduce its size, or remove liquid from it

READING AND WRITING

Cleft lip and cleft palate, also known as orofacial cleft, is a group of conditions that includes cleft lip, cleft
palate, and both together. A cleft lip contains an opening in the upper lip that may extend into the nose. The
opening may be on one side, both sides, or in the middle. A cleft palate occurs when the roof of the mouth
contains an opening into the nose. These disorders can result in feeding problems, speech problems, hearing
problems, and frequent ear infections. Less than half the time the condition is associated with other
disorders.
Cleft lip and palate are the result of tissues of the face not joining properly during development. As such,
they are a type of birth defect. The cause is unknown in most cases. Risk factors include smoking during
pregnancy, diabetes, obesity, an older mother, and certain medications (such as some used to treat seizures)
Cleft lip and cleft palate can often be diagnosed during pregnancy with an ultrasound exam.
A cleft lip or palate can be successfully treated with surgery. This is often done in the first few months of
life for cleft lip and before eighteen months for cleft palate. Speech therapy and dental care may also be
needed.
Cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed world. Cleft lip is about twice
as common in males as females, while cleft palate without cleft lip is more common in females. If the cleft
does not affect the palate structure of the mouth, it is referred to as cleft lip. Cleft lip is formed in the top of
the lip as either a small gap or an indentation in the lip (partial or incomplete cleft), or it continues into the
nose (complete cleft). Lip cleft can occur as a one-sided (unilateral) or two-sided (bilateral) condition. It is
due to the failure of fusion of the maxillary prominence and medial nasal processes (formation of the
primary palate).

Unilateral incomplete Unilateral complete Bilateral complete

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the
lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and
might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with
a craniofacial team as soon as possible to determine the severity of the cleft.

Six-month-old girl before going into The same girl, 1 month after the surgery The same girl, age 8, the scar almost
surgery to have her unilateral complete gone
cleft lip repaired

Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth)
are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also
present. Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or
incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs,
the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal
septum, or the median palatine processes (formation of the secondary palate). The hole in the roof of the
mouth caused by a cleft connects the mouth directly to the inside of the nose.

Incomplete cleft palate Unilateral complete lip and palate Bilateral complete lip and palate
 A result of an open connection between the mouth and inside the nose is called velopharyngeal
insufficiency (VPI). Because of the gap, air leaks into the nasal cavity resulting in
a hypernasal voice resonance and nasal emissions while talking. Secondary effects of VPI include
speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations
and mispronunciations (e.g., glottal stops and posterior nasal fricatives). Possible treatment options
include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the
palate, and surgical procedures.
Submucous cleft palate can also occur, which is a cleft of the soft palate with a split uvula, a furrow along
the midline of the soft palate, and a notch in the back margin of the hard palate. The diagnosis of submucous
cleft palate often occurs late in children as a result of the nature of the cleft. While the muscles of the soft
palate are not joined, the mucosal membranes covering the roof of the mouth appear relatively normal and
intact.
Cleft may cause problems with feeding, ear disease, speech, socialization, and cognition. Due to lack of
suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater
success feeding in a more upright position. Individuals with cleft also face many middle ear infections which
may eventually lead to hearing loss. Hearing is related to learning to speak. Babies with palatal clefts may
have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of
speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at risk for
receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with
cleft usually need the aid of a speech therapist.
Research has shown that during the early preschool years (ages 3–5), children with cleft lip or cleft palate
tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and
their social interactions increase, children with clefts tend to report more dissatisfaction with peer
relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated
stigma of visible deformities and possible speech impediments. Children who are judged as attractive tend to
be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than
children with cleft lip or cleft palate. Children with clefts tend to report feelings of anger, sadness, fear, and
alienation from their peers, but these children were similar to their peers in regard to "how well they liked
themselves."
The relationship between parental attitudes and a child's self-concept is crucial during the preschool years.
It has been reported that elevated stress levels in mothers correlated with reduced social skills in their
children. Strong parent support networks may help to prevent the development of negative self-concept in
children with cleft palate. In the later preschool and early elementary years, the development of social skills
is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip or
cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children
ways to handle negative social situations related to their cleft lip or cleft palate. A child who is entering
school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently
explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative
social experiences.
As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child
relationship change as peer groups are now the focus of attention. An adolescent with cleft lip or cleft palate
will deal with the typical challenges faced by most of their peers including issues related to self-esteem,
dating and social acceptance. Adolescents, however, view appearance as the most important characteristic,
above intelligence and humor. This being the case, adolescents are susceptible to additional problems
because they cannot hide their facial differences from their peers. Adolescent boys typically deal with issues
relating to withdrawal, attention, thought, and internalizing problems, and may possibly develop
anxiousness-depression and aggressive behaviors. Adolescent girls are more likely to develop problems
relating to self-concept and appearance. Individuals with cleft lip or cleft palate often deal with threats to
their quality of life for multiple reasons including unsuccessful social relationships, deviance in social
appearance, and multiple surgeries.
Most clefts are polygenic and multifactorial in origin with many genetic and environmental factors
contributing. Genetic factors cause clefts in 20% to 50% of the cases and the remaining clefts are
attributable to either environmental factors (such as teratogens) or gene-environment interactions. The
polygenic/multifactorial inheritance model predicts that most individuals will be born without clefts;
however with a number of genetic or environmental factors, it can result in cleft formation.
Orofacial clefts may be associated with a syndrome (syndromic) or may not be associated with a syndrome.
Syndromic clefts are part of syndromes that are caused by a variety of factors such as environment and
genetics or an unknown cause. Nonsyndromic clefts, which are not as common as syndromic clefts, also
have a genetic cause. Genetic factors contributing to cleft lip and cleft palate formation have been identified
for some syndromic cases. Many clefts run in families, even though in some cases there does not seem to be
an identifiable syndrome present.
Environmental influences may also cause, or interact with genetics to produce, orofacial clefts. Cleft lip
and other congenital abnormalities have also been linked to maternal hypoxia caused by maternal smoking,
with the estimated attributable fraction of orofacial clefts due to smoking in early pregnancy being 6.1%.
Orofacial clefts occur very early in pregnancy and so smoking cessation right after recognition of pregnancy
is unlikely to reduce the exposure during the critical time period. Maternal alcohol use has also been linked
to cleft lip and palate due to the effects on the cranial neural crest cells. Other environmental factors that
have been studied include seasonal causes (such as pesticide exposure); maternal diet and vitamin
intake; retinoids (members of the vitamin A family); anticonvulsant drugs; nitrate compounds; organic
solvents; parental exposure to lead; alcohol; cigarette use; and a number of other psychoactive drugs
(e.g. cocaine, crack cocaine, heroin).
Cleft lip with is classified as the most common congenital birth defect. It has been noted that the
prevalence of orofacial clefts varies by race. Accurate evaluation of craniofacial malformations is usually
possible with the ultrasound scan performed during pregnancy. The accuracy of ultrasonography for prenatal
diagnosis of cleft lippalate is dependent on the experience of the sonologist, maternal body type, foetal
position, the amount of amniotic fluid and the type of cleft. Prenatal diagnosis enables appropriate and
timely education and discussion with parents by the cleft team. This helps improve the quality of treatment
received by the child and improves quality of life.
Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of
the cleft. Most children with a form of clefting are monitored by a cleft palate team or craniofacial
team through young adulthood. Care can be lifelong and are looked after by craniofacial cleft teams often
consist of: cleft surgeons, orthodontists, speech and language therapists, restorative dentists, Psychologists,
ENT surgeons and audio-logical physicians. Treatment procedures can vary between craniofacial teams. For
example, some teams wait on jaw correction until the child is aged 10 to 12, while other teams correct the
jaw earlier. Within teams, treatment can differ between individual cases depending on the type and severity
of the cleft.

The blue lines indicate Movement of the flaps;
incisions. flap A is moved between
B and C. C is rotated
slightly while B is pushed
down.
Pre-operation Post-operation, the lip is
swollen from surgery and
will look more natural
within weeks. See photos
in the section above.

Velopharyngeal insufficiency (VPI) can occur as a result of an unrepaired or repaired cleft lip and palate.
VPI is the inability of the soft palate to close tightly against the back of the throat during speech, resulting in
incomplete velopharyngeal closure. In turn, this results in speech abnormalities. Velopharyngeal closure is
necessary during speech because it forms a seal between the nose and mouth, allowing the production of
normal speech sounds. VPI can cause hypernasality (excessive nasal resonance), hyponasality (reduced
nasal resonance), or a mixed nasal resonance, which is when hypernasality and hyponasality occur
simultaneously.
Children with cleft palate have a very high risk of developing a middle ear infection, specifically otitis
media. This is due to the immature development of the different bones and muscles in the ear. Otitis media
is caused by the obstruction of the Eustachian tube, negative middle ear pressure and fluid build-up in the
normally air-filled space of the middle ear. This is associated with hearing impairment or loss. The insertion
of a ventilation tube into the eardrum is a surgical treatment option commonly used to improve hearing in
children with otitis media. In addition, breast milk has been proven to decrease the incidence of otitis media
in infants with clefts.

GAP FILL

feeding, cavity, swallowing, regurgitation, nutrition, monitored, successfully, fatigue,

problem, weight, discomfort, effectiveness, studies, gain, allow, location, hydration

There are different options on how to feed a baby with cleft lip or cleft palate which include: breast-
feeding, bottle________, spoon feeding and syringe feeding. Although breast-feeding is challenging, it
improves weight-gain compared to spoon-feeding. Nasal _________is common due to the open space
between the oral cavity and the nasal_______. Bottle feeding can help (with squeezable bottles being easier
to use than rigid bottles). Whatever feeding method is established, it is important to keep the baby's weight
gain and hydration_________. Infants with cleft lip or palate may require supplemental feeds for adequate
growth and_________. Breast feeding position as suggested by specialists can also improve success rate.
Babies with cleft lip are more likely to breastfeed ____________than those with cleft palate and cleft lip and
palate. Larger clefts of the soft or hard palate may not be able to generate suction as the oral cavity cannot be
separated from the nasal cavity when feeding which leads to_________, prolonged feeding time, impaired
growth and nutrition. Changes in ___________mechanics may result in coughing, choking, gagging and
nasal regurgitation. Even after cleft repair, the _________may still persist as significant motor learning of
swallowing and sucking was absent for many months before repair. These difficulties in feeding may result
in secondary problems such as poor ________gain, excessive energy expenditure during feeding, lengthy
feeding times, discomfort during feeding, and stressful feeding interactions between the infant and the
mother. A potential source of _________for the baby during or after feeding is bloating or frequent "spit up"
which is due to the excessive air intake through the nose and mouth in the open cleft. Babies with cleft lip
and or palate should be evaluated individually taking into account the size and ________of the cleft and the
mother's previous experience with breastfeeding. Another option is feeding breast milk via bottle or syringe.
Since babies with clip lip and cleft palate generate less section when breastfeeding, their nutrition,
_________and weight gain may be affected. This may result in the need for supplemental feeds. Modifying
the position of holding the baby may increase the __________and efficiency of breastfeeding. Preoperative
feeding – using a squeezable bottle instead of a rigid bottle can ________a higher volume of food intake and
less effort to extract food. Using a syringe is practical, easy to perform and allows greater administered
volume of food. It also means there will be weight ________and less time spent feeding. Post-operative
feeding (isolated lip repair, or lip repair associated or not with palatoplasty) - post palatoplasty, some
________believe that inappropriate negative pressure on the suture line may affect results.

References:
https://www.aapd.org/globalassets/media/publications/archives/meadows-14-06.pdf
https://www.aapd.org/globalassets/media/publications/archives/meadows-14-06.pdf
https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html
https://www.nhs.uk/conditions/cleft-lip-and-palate/
https://youtu.be/IUr-5Rwy8VY
https://www.youtube.com/watch?v=TTZI7x_IQq8
https://youtu.be/ini6hwyXDQo
https://youtu.be/Vl7pnaf36Kg