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Cleft & Craniofacial

About Cleft Lips & Cleft Palates

The word "cleft" means opening or gap, so a cleft lip is an opening in the mouth, and a cleft palate is an opening in the roof of the mouth. Clefts of the lip and palate can occur separately or together: this means that a child can have a cleft lip, a cleft palate, or both a cleft lip and cleft palate. When a cleft is only on one side of the lip, it's called a unilateral cleft lip. When a cleft is on both sides of the lip, it's called a bilateral cleft lip.

   
 Unilateral Cleft Lip - Before  Unilateral Cleft Lip - After


Bilateral Cleft Lip - Before Bilateral Cleft Lip - After

Causes of Cleft Lips & Cleft Palates

Clefts occur when the left and right sides of the lip and palate don't join together during the first few months of pregnancy. Cleft lips and palates, which are often caused by a combination of genetic and environmental factors, affect 1 in 700 newborns each year.

Issues Caused by Cleft Lips & Cleft Palates

Ear disease and dental problems occur frequently, as do problems with proper speech development. Children who suffer from a cleft lip and/or palate may have difficulty eating. To address these issues, a child and family may work with a team of specialists – a pediatrician, a plastic surgeon, dental specialists, an ear, nose and throat specialist (otolaryngologist), a speech-language pathologist and audiologist, a geneticist and a psychologist/social worker.

Treating Cleft Lips and Cleft Palates

A cleft lip or palate can be successfully corrected with surgery and orthodontic treatment. A pediatrician and a plastic surgeon work with a child's parents to choose the best timing for surgery. Most surgeons agree that a baby cleft lip should be repaired by 3 months old. To repair the partition of mouth and nose as early as possible, a cleft palate generally is repaired between the ages of 12 and 18 months. Any surgical procedure is dependent upon a child's general health and the nature of the cleft lip or cleft palate.

Children with clefts usually continue to receive treatment after surgery, including dental care and speech therapy.

 

Presurgical Orthopedics for Babies with Cleft Lip & Palate

Your plastic surgeon has requested that your baby wear a small plastic plate and lip tape. This is also known as “Presurgical Orthopedics” and is designed to prepare your baby for the best surgical result. Presurgical orthopedics narrows the gap between the lips and gums, improves the symmetry of the nose and minimizes the size of the lip scar from the surgery. In addition, the plate keeps the tongue out of the gap in the roof of the mouth (palate), and allows the gap in the palate to narrow naturally minimizing future palate surgery.

For babies with “bilateral cleft” that is, a gap on both sides of the lip, presurgical orthopedics also brings back the small central portion of the lip and gum in a controlled fashion. This greatly simplifies the surgical repair of the lips and gums, as well as, reduces the occurrence of postsurgical “fistulae” or small holes after surgery.

The cleft condition leads to obvious problems with the soft tissues of a baby’s face and palate. Less obvious is the effect on the bones that house a baby’s teeth, formation of the palate, as well as the effect on the cartilages that shape and support a baby’s nose.

During the first 3 months of your baby’s life, the levels of estrogen (a hormone) is relatively high in your baby’s blood stream. High levels of estrogen allow cartilage in the nose, which is usually resistant to being reshaped, to be quite mouldable. Once your baby is past this stage, the cartilage is set in an asymmetric shape that is difficult to correct surgically. However, if the cartilage forming the nose is reshapen within the mouldable period, a more esthetic shape may be established.

 

How Is All This Treatment Going to Be Carried Out and Where?

Your baby will come into the British Columbia's Children's Hospital Day Care Surgery to have an "impression" or mould taken of the upper gums by Dr. Loo. This procedure is usually done when your baby is 7-14 days old, and most frequently performed in the hospital OR with an anesthetist "standing by" (your baby is not anesthetized). The anesthetist is present to monitor your baby and help with breathing if there is a concern; this however, is very unlikely, but we want to be as careful as possible. Our nurse practitioner or anesthetist will advise you of when your baby's last feed must be before the procedure is to occur.


A plaster cast is made from the impression and then our lab technician will fabricate the appliance. It will be custom-made and specially designed for your baby.

Once your baby is returned to you after 15 to 20 minutes, you may feed him. At this stage, you will be given an appointment at our orthodontic office for the fitting of the plate. This is usually within a couple of days. The rest of the adjustment appointments will occur at our office.

Fitting the Plate

At the plate-fitting appointment, Dr. Loo will show you how to place and remove the plate. To obtain the best result, the plate should be worn 24 hours per day until the roof of the mouth is surgically repaired at 9 to 12 months. Most babies are able to wear the plate 24 hours a day right from the start and within a day or two are actually unhappy when you remove it. You will also be given instructions on how to fit the various tapes (stretchy and steristrips) and elastics.

The image on the right shows the Duoderm (plastic skin) or base tape that is fitted to the cheeks. The image on the left shows the lip tape, which must be placed very tightly, enough to see the lip blanch (looks white).

   
 Duoderm  Lip Tape

At first, you may find that the plate appears loose. You can use denture adhesive to help your baby hold the plate in with the tongue. Also, do not be surprised if your baby has a slight gag reflex at first. This is perfectly normal and goes away soon after placement. Soothe your baby and hold the appliance in with the top of your thumb while rubbing the lower front gums with the bottom of your thumb.

Associating food with the plate in the first few days helps your baby get used to the plate as well. Soak the plate in formula, insert the plate and feed your baby. This provides positive reinforcement for wearing the plate.

 

The Plates

This is a picture of the plate and the design can vary depending on whether the cleft is isolated to the palate, or involves one side (unilateral) or both sides (bilateral) of the lip.


Once your baby is used to the plate and is wearing the plate full time, Dr. Loo will add the nasal “stent” to the plate. The objectives of the stent are to improve the profile and symmetry of the nose on the cleft side. Weekly or bimonthly visits to Dr. Loo’s office would be necessary for incremental adjustments to the stent.

Taping

Once your baby is used to the plate, you can start taping the upper lip. Please note, it is not wise to wear the tape without the plate in place as the tape will move the lip, nose and gums in the wrong direction if the plate is not controlling the movement. You will also find that if you leave the tape on for a long time without the plate in, the plate will no longer fit. The plate is very important to obtain the best surgical result for your baby and should be worn full time. Taping begins by placing a piece of DuoDerm (plastic skin) on both cheeks; this base tape may be left unchanged for one week. Tape is applied onto the DuoDerm in 2 techniques:

  • Stretchy tape alone (about 4.5 to 5 inches in length); or
  • Steristrips and orthodontic elastics.

Dr. Loo will decide which is best and will demonstrate the technique for you. With either technique, you will attach the tape to one side high on the cheek about ½” past the eye and stretch the elastic or stretchy tape across the upper lip. Gently squeeze the sides of the lip together until they blanche white and the gap is as narrow as possible. Attach the other side of the tape high on the opposite cheek about ½“ past the eye.

Sometimes the cheeks react to the taping and a rash appears. We suggest you change the tape once a day and remember to keep the cheeks clean and thoroughly dry to minimize irritation from taping. If the skin irritation is persistent, contact our office. If you find the tape or elastic bothers the nose, cut a small U out of the tape or elastic below the nose. Usually this is only necessary for the first week while the nose gets used to the tape or elastic.

Care Instructions

Babies get used to these appliances very quickly and it will surprise you to see how adaptable they are. You will also see improvements in appearance almost immediately. Although you will feel “all thumbs” to begin with, it will soon become routine and very rewarding as you see the fruits of your labours in the permanent improvement you have helped make in your baby’s appearance.

Here are the things you need to do to care for your baby and his/her appliance before surgery:

  • Clean the appliance and palate at least once per day (see details below).
  • Change the lip tape several times a day making sure to keep pressure on the lip and underlying tissue.
  • Change the base tape and steristrips as needed. The base tape can be left on for up to a week before changing it. This protects the cheeks from the more frequent changing of the lip tape and steristrips.

Care of the Plate

After feeding, or at least once a day, remove the plate and rinse it in cool water. You may also hold the plate in the palm of your hand and use a toothbrush and toothpaste to brush the plate. Remember to rinse the plate well with water to remove the taste of the toothpaste. The plate must be treated with care. Since the plate is made of plastic, please do not:

  • Boil or heat the plate in any way - it will distort;
  • Put it in your pocket or drop it - it will get broken;
  • Wrap it in tissue or a napkin - someone will throw it out;
  • Leave it lying around - pets and children are very curious.

The safest place for the plate is in your baby’s mouth. When you need to take it out, please put it in the case provided. Your name, address and phone number should be clearly marked on the case. Another very important point to remember is that if the plate is not worn for long periods, the mouth can change slightly and the plate will no longer fit. Therefore, please try to keep the plate in most of the time and call your orthodontist to have the plate checked if you are having significant problems.

Common Issues & Concerns

Here are some of the common issues and concerns you may encounter when caring for your baby:

  • The Plate is loose. Try tightening elastics by moving the steristrips higher on the plastic skin, or add some denture adhesive to the plate.
  • Skin rashes. Try to move the tape or plastic skin to different areas, or if the problems persist, phone Lorin Scott at the Cleft clinic. She has some great ideas and remedies.
  • Sore, red or bleeding areas on the palate of nose. Call Dr. Loo to arrange an adjustment.
  • Baby pulling plate out. This may happen especially later in treatment. It is important to keep the plate in. Use more denture adhesive, put mitts or socks on the hands. If the plate is left out the tongue can push up into the cleft and possibly widen the cleft. This makes the palate surgery more difficult and prone to complications. For some babies, it may only be possible to have the wear it at night and during feedings. Others will refuse to wear it all. If this happens at this stage, we are often able to discontinue the plate and still provide your baby with a very good result.
  • Plate not fitting because of teeth coming in. Contact Dr. Loo and make an appointment to have the plate adjusted as soon as possible. Often a sliht adjustment will make the plate comfortable again for your baby to wear.
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Treatment Considerations

Timeline

  • Impression at the OR when 7 to 14 days of age
  • Fit appliance within a couple of days
  • Addition of the nasal stent
  • Adjust appliance weekly
  • Remove wire components just prior to surgery
  • Lip repair surgery at approximately 3 to 4 months of age
  • Acrylic plate to stay in after lip surgery
  • Palate surgery at 10 to 14 months after which acrylic plate is not needed

 

What's Next

Your baby's lip will be repaired by a plastic surgeon; with some exceptions, the surgery usually takes place at approximately 3 to 4 months of age. The day before your baby’s surgery, clean the plate and mouth of any denture adhesive, and reinsert the plate free of the adhesive. Dr. Loo also removes the nasal stent the day before the lip surgery, leaving the original plate.

When the lip has been repaired, taping usually stops permanently and the plate may be removed temporarily while the lip heals. If the plate is not in your baby’s mouth after the surgery, keep the plate in a safe place and leave it out until your plastic surgeon recommends you start 24-hour-a-day wear again. If the plate is in your baby’s mouth after the surgery, leave it in place for 7 to 10 days before you remove it to clean. Then return to 24-hour-a-day wear with more frequent cleanings.

This second phase of presurgical orthopedics is directed at encouraging the roof of the mouth to close naturally as much as possible prior to the palate repair surgery at 9 to 12 months. During this second phase of presurgical orthopedics, the plate should again be worn 24 hours per day and should be checked every 2 months or as recommended by Dr. Loo.

If you find the plate is not staying in place after the lip surgery, even with denture adhesive, call Dr. Loo and make an appointment to have the plate adjusted or possibly remade.

 

Helpful Links for Cleft Lips & Cleft Palates