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Cleft Lip And Palate: Dilemma Of The Face

low cost cleft lip and palate surgery in india

What Is Cleft Lip And Palate?

A congenital deformity of the face where the upper lip and/or the palate have a defect/discontinuity is known as cleft lip and palate. This condition is seen since birth and poses a host of problems for the newborns as well as the parents. The cleft may only involve the bone of the palate leaving the mucus membrane loosely adhered to it or may cause a cleft of both. Similarly, the mucus membrane and skin of the upper lip can both be affected. The cleft can be partial or complete, unilateral or bilateral when it affects the upper lip. However it occurs more commonly in females than the male counterparts. Breathing, feeding and speech are affected at various stages of life, apart from the facial esthetics that is severely affected. Various treatment modalities can be put to use for the correction of this defect, one treatment at a time, at a certain age.

Causes Of Cleft Lip And Palate:

  • Heavy smoking and alcohol abuse during the first trimester leads to a disturbed organogenesis resulting in facial clefts. It is during the first three months when the complete differentiation of tissues and organs take place
  • Exposure to ultraviolet rays during the first trimester causes mutations in genes, namely homeobox and MSX 1 and 2 genes which determine the formation of facial structures
  • Drugs such as aspirin, retinoic acid, valium when consumed by the mother have a tendency to cross the placenta and enter the fetal blood to cause disturbance in the metabolic activities of the facial structures formation
  • Tremendous amount of stress, anxiety or malnutrition in the early stages of pregnancy also can increase the chances of having a child with cleft lip and or palate

Diagnosis Of Cleft Lip And Palate:

  • History taking: This begins by taking a familial or genetic history which will tell whether the condition runs in the family. History of what all medications were taken during the first trimester, the drugs or exposure to radiation will help in determining the etiology that led to the development of the condition.
  • Ultrasonography:  There may be a chance that the defect be detected in the USG since the tissues involved in the cleft are soft tissues and rarely be seen in the sonograph.
  • Anomaly testing: These are advanced tests which have become mandatory these days. These help in the detection of cleft in the prenatal period and help in to act accordingly.
  • Genetic testing: These tests take blood samples of the parents and are sent in labs where they undergo a genetic testing so as to determine the chance of acquiring the defect and passing it on to the off springs.
  • 3D/4d testing: This is an advanced technology test which gives a three dimensional image of the cleft palate and lip which will later help in the surgical planning.

Classification of Cleft Lip and Palate:

There are various authors and associations that have come up with their ideologies of classifying both the cleft of the lip and palate. These are as follows:

  • A simple way of classifying clefts is whether they are unilateral (on one side only) or bilateral (on both sides). This applies for both the cleft of the palate as well as the upper lip
  • Clefts can be either complete or incomplete/partial
  • Veau classification:
    • Class I: Isolated soft palate cleft
    • Class II: Isolated hard and soft palate 
    • Class III: Unilateral cleft lip and palate
    • Class IV: Bilateral cleft lip and palate
  • Millard’s Classification:

A horse shoe shaped diagram with hourglass on its upper end is made. The inverted triangles are representative of the nasal arch and the upright triangles represent the nasal floor

  • LAHSHAL classification:
    • L: lip
    • A: Alveolus
    • H: Hard palate
    • S: Soft palate

Signs And Symptoms Of Cleft Lip And Palate:

  • The earliest sign of a cleft is seen in the sonography/anamoly test/3D or 4D images, counseling of the parents should begin right away
  • Once the child is born, feeding is the major problem faced by both the mother and the child. Clefting of the palate leads to entry of milk from the oral cavity into the nose which causes discomfort to the child. Also since the milk from breasts  does not reach the stomach, the child is constantly hungry and cranky
  • It is also common for the child to get frequent ear and nose infections since the Eustachian tube is open and viable for transmission of infections
  • Velophayngeal insufficieny occurs due to inadequate fusion between the soft and the hard palate. As a result of this, speech is hampered. The child also has a shrilled voice while crying which has a low pitch and often resembles the crying of a cub
  • Teeth eruption timings are delayed, tooth positions are disturbed due to inadequate bone in the primary and the secondary palatal regions. Hence various types of malocclusions are seen in cases with cleft palate
  • Facial esthetics are tremendously disturbed, it gets psychologically depressing for the parents and the relatives around to see such a child

Syndromes/Medical conditions Associated With Cleft Lip And Palate:

Cleft lip and/or palate can occur in isolation or may be associated with certain symdromes. If they occur with any syndrome, the other signs and symptoms need to be addressed concomitantly with the cleft signs and symptoms

  • Pierre Robin syndrome is a triad of cleft palate, retrognathic lower jaw and large tongue
  • Velocardiofacial syndrome shows a cleft palate, cardiac anomalies, vertical maxillary excess and feeding problems
  • Median facial dysplasia is characterized by clefts in the median plane of the face, such as the nasal septum, the hard palate and the upper lip

Treatment Procedure For Cleft Lip And Palate:

Treatment for correction of the soft tissues of the cleft lip and palate and that of the alveolus can begin as early as 10 weeks. Also the treatment plan will change as per the needs and complaints of the patient and/or parents depending upon the age at which the patient is brought to the clinic/hospital.

Who All are Involved In The Treatment?

  • Gynecologist: They are needed to tell the panel about the entire gestation period and give insight into the etiological factors that led to the development of the defects.
  • Radiologist: They are required to show the radiographs taken at various stages of the defects
  • Pediatrician: They keep a check on the overall health of the newborn such as the birth weight, vaccination schedules, complete blood and hemoglobin counts which are all pre requisites for the surgical corrections for the correction of soft tissue defects
  • Speech therapist: They are needed once the child starts speaking. Clefting of the palate disturbs the junction of the soft and the hard palate making the pronunciation of certain sounds difficult. A speech therapist will help the child in making those sounds and help complete the sentences
  • Councilor: It becomes mandatory to psychologically counsel both the parents and the individual. It is essential to explain to them that the condition can be very well taken care of only if they co operate and keep motivated
  • Oral surgeon: Lip and alveolus repairing is the job of the oral surgeon
  • Orthodontist: Presurgical nasoalveolar moulding is the latest treatment trend that is followed in newborns with cleft palate so as to seal the cleft and enhance the breast feeding. The decision for making space for the teeth that are still inside the jaw or bringing the teeth into the normal position is the duty of the orthodontist. this requires a six monthly visit to the orthodontist to decide the treatment protocol accordingly

Protocol For Correction Of Cleft Lip And Palate:

Prenatal counseling of the parents to be of the child by the team leader when detected on the USG

  • 0-3 months: 
    1. This includes detailed history taking of the prenatal and the post natal development.
    2. Lip sealing and pre surgical naso-alveolar moulding is done to help the alveolus grow and develop a competent lip seal. This can be done both by the prosthodontist or the orthodontist. The procedure also helps the mother to breast feed without any major difficulty. However it may be a little discomfort able for the newborn and may require repeated wearing and removal of the appliance by the mother. 
    3. Screeing for hearing by the ENT specialist
    4. Genetic counseling
    5. Evaluating for the need for a palatal obturator
  • 3-6 months:
    1. Lip and anterior palate repair surgeries can be undertaken at this stage following the Millard’s rule of 10. The child has to be 10 weeks old, 10 hemoglobin to qualify for the surgical procedure 
  • 6-12 months:
    1. Eruption timing and sequence is continuously monitored
    2. Audiology assessment is also done with frequent follow ups
  • 12-18 months:
    1. Speech therapy is begun
    2. Posterior palatal repair surgery is done by the plastic surgeon
  • 3-5 years:
    1. Evaluation by the plastic surgeon at 5 years of age for velopharyngeal insufficiency and consider for its management by intensive speech therapy or pharyngeal flap surgery
  • 6-9 years:
    1. Six monthly visit to the orthodontist for the monitoring of eruption timing and sequence. Timely radiographs for the assessment of bone and deciding for the bone grafts
  • 9-12 years:
    1. Comprehensive diagnosis and treatment planning to be charted by a team of orthodontists, plastic surgeon and oral surgeon regarding alveolar bone grafting, pre graft maxillary expansion, fistula closure and lip revision and extraction of any supernumerary teeth
  • 12-18 years:
    1. Full bonded orthodontic treatment in cases of severely ma positioned teeth.
    2. Records taken for the planning of orthognathic surgery such as splint fabrication
    3. Post surgical orthodontic care
    4. Retention planning

Complications And Risk Factors Associated With Cleft Lip And Palate:

  • Pre surgical naso-alveolar moulding causes discomfort to the newborn and is a tedious task for the mother as well while breast feeding
  • The tray/palatal obturator can cause lacerations in the oral cavity of the child
  • Interference with suckling and sucking both
  • Regurgitation of food into the nasal cavity
  • Hearing and speech defects
  • Velophayngeal incompetence
  • Midface development
  • Abnormal Eustachian tube formation
  • Delayed eruption of teeth
  • Malocclusion
  • Reduced muscle function, scarring, infections at the site of the wound, incomplete fusion can occur after the surgical management of the cleft lip and palate
  • Non reunion of the secondary alveolar bone graft, loose grafts may also occur

Am I Good Candidate For Cleft Lip And Palate Treatment?

  • If your child is born with either a cleft lip or a cleft palate or both, you must start with the treatment and counseling right away. This is the most apt time for you and your partner to get thorough with the anomaly and save your child from the mental trauma
  • If facial esthetics is your concern, you can seek an oral or a plastic surgeon post 18 years of age
  • Placement of bone grafts and orthodontic treatment will be done after you have 14 years of age
  • If an orthognathic surgery is to be done, you will have to wait till 18 years of age

Recovery Time Of Cleft Lip And Palate:

A repair of the either the cleft lip or palate takes a minimum of two to three weeks to heal completely. Face has a very good and rich blood supply due to which the healing process completes rapidly. However the areas are still fragile and need to be handled with care.

Success Rate Of Cleft Lip And Palate:

The plastic correction occurs in about 60 to 70 percent cases, after multiple operations have been done on the repair of the palate and the lip. Malocclusion is corrected in nearly about 89 percent cases with certain chances of relapse. Nasal regurgitation problem is solved in almost all the cases once the secondary alveolar bone grafts have been placed. If an orthognathic surgery is done, the correction is nearly about fifty percent since it will largely depend upon the plasticity and the elasticity of the facial tissues, taking into consideration the vital structures in and around the face.

Benefits Of Cleft Lip And Palate Treatment:

An attempt to repair or intervene with the cleft lip and/or palate will benefit you in the following ways:

  • Enhance your facial appearance, help boost your morale and self confidence
  • Correct the speech and hearing defects, eliminate the chances of ear infections
  • Prevent the regurgitation of food, water into the nasal cavity and passage
  • Correct the delayed eruption of teeth and bring the teeth into their proper positions

Cost Comparisons For Cleft Lip And Palate Treatment:

The treatment for cleft lip and palate is available in all the major cities in India. It costs about 1,50,000 to 2,00,000 INR for the surgical repair. Similar will be the cost for the orthognathic surgery in the adulthood. Orthodontic treatment for the correction of malocclusion would cost you around 50,000 to 60,000 INR. The surgical as well as the dental treatments are roughly 60 percent lesser than the charges in the US/UK.

Why choose India?

India being a land of versatile medical knowledge, offers excellent treatment modalities at the hands of highly skilled plastic and cosmetic surgeons as well as oral surgeons and orthodontists/pediatricians that are very well versed with the anomaly. The treatments are available in all the major cities of the country, at affordable prices, guaranteeing the best treatment outcomes.

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