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Treatment
There are a number of treatment options for cleft lip and palate. However, the kind of treatment depends on the type and severity of the cleft. Treatment is multidisciplinary and multi-procedural.

Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through to young adulthood at 20 years old. Cleft teams often consist of: cleft surgeons, orthodontists, speech and language therapists, restorative dentists, pyschologists, ENT surgeons and audio-logical physicians. Care can be lifelong and treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 with the argument that  growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries. Other teams correct the jaw earlier with the argument that less speech therapy is needed than at a later age when speech therapy becomes harder. Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.

Cleft lip
Within the first 2–3 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth. Often the preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 where the child is at least 10 weeks of age, weighs at least 10 pounds, and has at least 10g hemoglobin. If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the Millard procedure pioneered by Ralph Millard.

Often, an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of muscles required to purse the lips run through the upper lip. In order to restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip and tuck away stitches as far up the nose as possible. Incomplete cleft often gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.

Pre-surgical devices
In some cases of severe bi-lateral complete cleft, the premaxillary segment will be protruded far outside the mouth.

Nasoalveolar molding prior to surgery can improve long-term nasal symmetry among patients with complete unilateral cleft lip–cleft palate patients compared to correction by surgery alone. A systematic review found in conclusion that nasoalveolar molding had a positive effect on the primary surgery of cleft lip and/or palate treatment and aesthetics.

Cleft palate
Often a cleft palate is temporarily covered by a palatal obturator (a prosthetic device made to fit the roof of the mouth covering the gap). This device repositions displaced alveolar segments and helps reduce the cleft lip separation.The obturator will improve speech as there’s now proper air flow and improve feeding and breathing as the gap in the hard or soft palate is closed over so cannot affect it.

Cleft palate can also be addressed by surgery, usually performed between 6 and 12 months when the child starts to show signs of speech development. Approximately 20–25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance however it is not common. The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip or palate repair.

If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patient's own chin, rib or hip.

Age 1-7 years

Regularly reviewed by the cleft team.

Age 7 -12 years

For the children born with alveolar clefts, they may need to have a secondary alveolar bone graft. This is where autogenous cancellous bone from a donor site (often the pelvic bone) is transplanted into the alveolar cleft region. This transplant of bone will close the osseous cleft of the alveolus, close any oro-nasal fistulae and will become integrated with the maxillary bone. It provides bone for teeth to erupt into and to allow implants to be placed as a possible future treatment option. The procedure should be carried out before the upper canine has erupted. Ideally the root of the canine should be one to two thirds formed and that there is a space available to place the bone graft. Radiographs are taken to determine the quantity of missing bone in the cleft area.

Other surgeries
Orthognathic surgery – surgical cutting of bone to realign the upper jaw (osteotomy). The bone is cut then repositioned and held together by wires or rigid fixation plates to ensure there’s no anterior-posterior discrepancy. Also to reduce scarring as it reduces growth. Single piece or multi-piece osteotomy exist. Single piece osteotomy is carried out where there is sufficient alveolar continuity achieved from a successful bone graft. Multi piece osteotomy is performed when there is a notable residual alveolar defect with a dental gap and oronasal fistula (communication between the oral and nasal cavities). The goal of both single and multi piece osteotomy is to displace the maxilla forward to obtain adequate occlusion as well to provide better support for upper lip and the nose and to close any fistulae.

Distraction osteogenesis – bone lengthening by gradual distraction. This involves cutting bone and moving ends apart incrementally to allow new bone to form in the gap. This consists of several phases. After attachment of the distracting device and the bone cuts, there is a latency phase of 3-7 days when a callus to forms. In the activation phase distraction of the callus induces bony ingrowth which can last up to 15 days depending on the required distraction. Once the required bone length is reached, the distraction device is left to remain in situ as it acts as a rigid skeletal fixation device until the new bone has matured (known as the consolidation period).

Feeding
Nasal regurgitation is also common due to the open space between the oral cavity and the nasal cavity. Bottle feeding is also an option, with squeezable bottles being easier to use than rigid bottles. In addition, maxillary plates can be added to aid in feeding. Although breast-feeding is challenging, it improves weight-gain compared to spoon-feeding.(22) Whatever feeding method is established, it is important to keep the baby’s weight gain and hydration monitored. Infants with CL/P may require supplemental feeds for adequate growth and nutrition. Breast feeding position as suggested by specialists can also improve success rate. (23)

Breastfeeding
Babies with cleft lip are more likely to breastfeed successfully than those with cleft palate and cleft lip and palate. Larger clefts of the soft and/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 fatigue, prolonged feeding time, impaired growth and nutrition. Changes in swallowing mechanics may result in coughing, choking, gagging and nasal regurgitation. Even after cleft repair, the problem may still persist as significant motor learning of swallowing and sucking was absent for many months before repair (21). These difficulties in feeding may result in secondary problems such as poor weight 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 discomfort 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. (23) Babies with cleft lip and or palate should be evaluated individually taking into account the size and location of the cleft and the mother’s previous experience with breastfeeding.

Breastfeeding protects against otitis media, which is a condition in the ear common in babies with cleft lip and palate. 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, hydration 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 effectiveness and efficiency of breastfeeding.

Alternative Feeding Methods
1. Preoperative feeding

Using a squeezable bottle instead of a rigid bottle can allow a higher volume of food intake and less effort to extract food from the squeezable bottle. Using a syringe is practical, easy to perform and allows greater administered volume of food. It also means there will be weight gain and less time spent feeding.

2. Post-operative feeding (isolated lip repair, or lip repair associated or not with palatoplasty) Post palatoplasty, some studies believe that inappropriate negative pressure on the suture line may affect results – babies can be fed by a nasogastric tube instead. Studies suggest babies required less analgesics and shorter hospital stay with nasogastric feeding post-surgery. With bottle–feeding, there was higher feeding rejection and pain and required more frequent and prolonged feeding times. (11)

References for Treatment and Psychosocial Issues:

1. Orthodontics: Principles and Practice, textbook pg. 255, Daljit S. Gill, Farhad B. Naini, 2011,

2. Correlation between Nasoalveolar Molding and Surgical, Aesthetic, Functional and Socioeconomic Outcomes Following Primary Repair Surgery: a Systematic Review, systematic review, Sophie Maillard, Jean-Marc Retrouvey, Mairai K. Ahmed, Peter J. Taub, 30/09/17,

3. Orthodontics: Principles and Practice, textbook pg. 257, Daljit S. Gill, Farhad B. Naini, 2011,

4. Orthodontics: Principles and Practice, textbook pg. 258, Daljit S. Gill, Farhad B. Naini, 2011,

5. Maxillary distraction osteogenesis versus orthognathic surgery for cleft lip and palate patients, systematic review, Dimitrios Kloukos, Piotr Fudalej, Patrick Sequeira-Byron, Christos Katsaros, 10/08/18,

8. Gill, Daljit S. FBN. Orthodontics: Principles and Practice. John Wiley & Sons, Incorporated; 2011. 254-262 p.

9. Guidelines for breastfeeding infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate, Revised 2013, USA Guidelines, Sheena Reilly, Julie Reid, Jemma Skeat, Petrea Cahir, Christina Mei, Maya Bunik, and the Academy of Breastfeeding Medicine, 2013,

10. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate, systematic review, Alyson Bessell, Lee Hooper, William C Shaw, Sheena Reilley, Julie Reid, Anne-Marie Glenny, 16/02/11,

11. Feeding methods for children with cleft lip and/or palate: a systematic review, systematic review, Geisse Albeche Duarte, Ramon Bossardi Ramos, Maria Cristina de Almeida Freitas Cardoso, 06/07/15,

12. Steele D, Adam GP, Di M, Halladay C, Pan I, Coppersmith N, et al. Tympanostomy Tubes in Children With Otitis Media. Tympanostomy Tubes Child With Otitis Media [Internet]. 2017;(185).

13. Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database Syst Rev. 2010 Oct 6;(10).

15. Nasser M, Fedorowicz Z, Newton T, Nouri M. Interventions for the management of submucous cleft palate. In: Nasser M, editor. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2008.

17. Kummer AW. Cleft Palate and Craniofacial Anomalies: The Effects on Speech and Resonance. 2nd ed. New Albany, NY: Delmar Cengage Learning; 2008.

18. Dhakshaini MR, Pushpavathi M, Garhnayak M, Dhal A. Prosthodontic Management in Conjunction with Speech Therapy in Cleft Lip and Palate: A Review and Case Report. J Int oral Heal  JIOH. 2015;7(Suppl 2):106–11.

19. Shetty NB, Shetty S, Nagraj E, D’Souza R, Shetty O. Management of velopharyngealdefects: A review. Vol. 8, Journal of Clinical and Diagnostic Research. Journal of Clinical and Diagnostic Research; 2014. p. 283–7.

20.  Scalzone, A. et al,. Secondary alveolar bone grafting using autologous versus alloplastic material in the treatment of cleft lip and palate patients: systematic review and meta-analysis. Progress in orthodontics, 2019;20(1), p. 6.

(21) Bessell  A, Hooper  L, Shaw WC, Reilly  S, Reid J, Glenny AM. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003315. DOI: 10.1002/14651858.CD003315.pub3.

(22) Reilly, S., Reid ,J., Skeat, J. Cahir, P., Mei, C. and Bunik, M (2013) 'ABM clinical protocol #18: guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate, revised 2013.', Academy of Breastfeeding Medicine,, pp. [Online]. Available at: (Accessed: 6th November 2019).

https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/17-cleft-lip-cleft-palate-protocol-english.pdf

(23)Goel, S. and Hedge, A.M. (2015) Feeding In Cleft Lip And Cleft Palate Infants, Saarbrucken, Germany: LAP LAMBERT Academic Publishing.

(24) https://www.ncbi.nlm.nih.gov/pubmed/31435341

Al-Namankany, A. and Alhubaishi, A (August 2018) 'Effects of cleft lip and palate on children's psychological health: A systematic review', Journal of Taibah University Medical Sciences, 13(4), pp. 311-318 [Online]. Available at: https://doi.org/10.1016/j.jtumed.2018.04.007 (Accessed: 6th November 2019).

(25) Gill, Daljit S., and Farhad B. Naini. Orthodontics : Principles and Practice, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, https://ebookcentral-proquest-com.queens.ezp1.qub.ac.uk/lib/qub/detail.action?docID=693786.

(26) Peterson-Falzone, S.J., Trost-Cardamone, J.E., Karnell, M.P. and Hardin-Jones, M.A. (2017) The Clinician's Guide to Treating Cleft Palate Speech, 2nd edn., St. Louis, Missouri, USA: Elsevier Inc.

(27) Littlewood, S., Mitchell, L., Lewis, B., Barber, S. and Jenkins, F. (2017). An introduction to orthodontics. 5th ed. Oxford.

(28) Gill, D. (2008). Orthodontics at a glance. Oxford, U.K.: Blackwell Munksgaard.

29. Hodgkinson, P. et al. 2005. Management of children with cleft lip and palate: A review describing the application of multidisciplinary team working in this condition based upon the experiences of a regional cleft lip and palate centre in the United Kingdom. Fetal and Maternal Medicine Review, 16(1), pp. 1-27.

(30) CRANE Database 2019

(31) Hunt O, Burden D, Hepper P, Johnston C. The psychosocial effects of cleft lip and palate: a systematic review. Eur J Orthod. 2005;27(3):274–285. doi:10.1093/ejo/cji00