Cleft lip and cleft palate are the most common congenital facial malformations in humans, ranging from slight notches of the lip to complete separation of the lip and palate. They result from failure of fusion of the facial processes during embryonic development. Affected children experience difficulties with feeding, speech, hearing and facial growth. Management involves feeding adaptations, surgical repairs of the lip and palate, dental care and orthodontics from infancy through adolescence to address residual issues and improve function and appearance.

2. Introduction
Cleft lip and cleft palate are the most common congenital malformations
occurring in humans. These structural defects of the facial-oral complex
may vary from slight notching of the lip or a small cleft in uvula to a
complete separation of the lip and absence of the partition between the
oral and nasal cavities.
The children affected with this anomaly are handi-capped right from birth
for breastfeeding, deglutition, improper growth and development of
maxilla and overall face development affecting the total personality of the
individual.

3. Etiology

4. A number of genetic mutations have been implicated in the development
of CLP, the most common being MSX or homeoboxgene, folic acid receptor
gene, etc. Genetic transmission is through recessive genes with variable
penetrance and hence the cleft anomaly may skip several generations.
•
Any untoward event around the 7th or 8th week of intrauterine life, like
folic acid deficiency, alcohol abuse, etc., can lead to the development of
CLP.
•

5. Embryology

6. Embryologically, cleft lip occurs
because of failure of fusion of the
maxillary processes with medial
nasal processes Cleft palate
occurs due to failure of fusion of
the palatine shelves. Failure of
the tongue to descend also
prevents the fusion of the
palatine shelves.

7. Classification

8. Various classification systems can be broadly classified into two
categories:
• Morphological classification
• Embryological classifications.

9. •
The Veau classification (1931) is given below:
Group I: Cleft of the soft palate only.
Group II: Cleft of the hard and soft palate till the incisive foramen.
Group III: Complete unilateral cleft of the soft palate, hard palate, the
alveolar ridge and the lip on one side.
Group IV: Complete cleft of the soft palate, hard palate, the alveolar
ridge and the lip on both sides.

10. •
Kernahan and Stark (1958) classified CLP depending on the embryological
principles.
Group I: Cleft of the primary palate only
• Unilateral • Bilateral
• Total • Subtotal
Group II: Cleft of the secondary palate only
• Total • Subtotal
• Submucous
Group III: Cleft of both primary and secondary palates
• Unilateral — Total, subtotal
• Median — Total, subtotal
• Bilateral — Total, subtotal

11. Clinical
Presentation

12. • In a unilateral cleft lip,there is a discontinuity such that the tissue which
should have met at the philtrum column ends up being attached to the
columella, the nasal septum on one side (noncleft side) and the pyriform
rim of the cleft side.

13. • The underlying orbicularis oris muscle which forms the bulk of the
upper lip, thus does not meet its fellow from the other side, instead is
attached to the maxilla and pyriform rim adjacent to the defect. The
muscular forces on the nasal septum pull it toward the noncleft side,
leading to a nasal septal deviation. Thus, the cleft lip and the nose
form a common cleft defect.

14. • In bilateral cleft lip, the defect occurs on both sides and the
extension of the columella into the upper lip is called the prolabium.

15. • In a complete unilateral CLP, the
defect continues posteriorly, involving
the dental alveolus, the hard palate
and the soft palate.
• Another presentation of CLP is median
cleft and unilateral cleft involving eye.

16. • Speech, which is hypernasal
• Hearing: Cleft palate leads to ineffective patency of the Eustachian
tube due to nonfunctional tensor veli palatine which leads to
secretory otitis media (glue ear) leading to conductive deafness.
• Swallowing:There can be obvious swallowing problems with nasal
regurgitation.
The other clinical features are related to:

17. • Supernumerary teeth
• Congenitally missing teeth
• T-cingulum
• Deep bite, Crossbite, Crowding or spacing of teeth.
• Peg-shaped teeth
• Thick curved hypoplastic incisors
• Normally formed lateral incisors usually absent and replaced by
abnormally formed supernumerary teeth which can erupt as
“Natal Teeth”.
• Geminated conical tooth may also present in the region of lateral
incisors.
• Delayed eruption pattern of permanent teeth.
•

18. Management

19. •
• Child is not able to create negative pressure required for
suckling of milk from the mother’s breast.
• Breast pumps, large nipple, obturators and spoon-feeding are
options for feeding
• To prevent regurgitation of milk through the nose, child’s head
is raised around 45° during feeding.

20. • Birth to 18 months
• The treatment modalities in this stage
are management of feeding problems,
fabrication of feeding obturators, pre-
surgical orthopedics, surgical
management of cleft lip and surgical
management of cleft palate.
• Initial obturator therapy is done from
birth to 3 months.
•

21. • Pre-surgical orthopedics—(birth to 5 months).
• The aim of this is to achieve an upper arch from that conforms to
lower arch
• Surgical lip closure—(3 to 9 months). At the time of surgery the age
of the child should not be less that 10 weeks of age, have no less
that 10 gm% of hemoglobin and should weigh at least 10 pounds.

22. • Surgical plate repair—(10 to 18 months)
• Single stage: von Langeback repair and V-Y push back
palatoplasty at 1½ year
• Two stage repair: Soft palate is repaired around 18 months and then
hard palate is repaired at 4 years by Schweckendiek procedure.

23. •
• 18 months to 5 years of age
• Adjustments to obturators
• Restoration of decayed teeth
• Maintenance of oral hygiene
• Evaluating the erupting dentition.
• Correction of cross bites
• Maxillary expansion
• Secondary grafting.
•

24. • Fixed orthodontic treatments.
• Cosmetic repair.
• Stage IV—Permanent Dentition Stage

26. • Pediatric Dentistry for Special Child , first edition, 2016.
• Pediatric Plastic and Reconstructive Surgery , 2018 .
• Pocket Book of Pedodontics, First edition , 2008.