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CONTENTS:
At what age can the surgical correction of a Cleft be done?
How are the surgical corrections done?
What are the post-surgical complications?
What are the Dental problems associated with clefts?
What is the need for orthodontic treatment?
Some Points and Facts To Remember about Clefts

At what age can the surgical correction of a Cleft be done?
A person with cleft have to undergo 4 to 5 surgeries to correct the problem. It is important to note that every child is different. Some children may require more surgeries than others, while others may require less. This all depends on the severity of their cleft and how the child heals after surgery is completed.

How are the surgical corrections done?
Through an operation, usually done at an early age (but not necessarily), where the surgeon peels the tissues that covers the bone on both sides of the cleft and attaches the tissues of the two sides together with the help of sutures.

cleft lip/palate            cleft lip/palate           cleft lip/palate
To repair a cleft lip, the surgeon will make an incision on either side of the cleft from the mouth into the nostril. Then the dark pink outer portion of the cleft is pulled downward, and the muscle and the skin of the lip are stitched together to close the separation. Muscle function and the normal "cupid's bow" shape of the mouth are restored. The nostril deformity often associated with cleft lip may also be improved at the time of lip repair or in a later surgery through Rhinoplasty.
       Elbow restraints may be necessary for a few weeks to prevent the baby from rubbing the stitched area. If dressings have been used, they'll be removed within a day or two, and the stitches will either dissolve or be removed within five days. Your doctor will advise you on how to feed your child during the first few weeks after surgery. It's normal for the surgical scar to appear to get bigger and redder for a few weeks after surgery. This will gradually fade, although the scar will never totally disappear. In many children, however, it's barely noticeable because of the shadows formed by the nose and upper lip.
       Repairing a cleft palate involves more extensive surgery and is usually done when the child is 9 to 18 months old, so that the baby is bigger and better able to tolerate the surgery. To repair a cleft palate, the surgeon will make an incision on both sides of the separation, moving tissue from each side of the cleft to the center or midline of the roof of the mouth. This rebuilds the palate, joins muscles together, and providing enough length in the palate so the child can eat and learn to speak properly. No bone is introduced into the "space". The intent of the operation is to allow the body to fill in the space with bone. Sort of like peeling back the wrapper at one end of two candy bars and sewing the wrappers together, leaving the candy bars touching each other. Under the proper circumstances (like heat, pressure, etc) they could fuse together and become one big candy bar.
cleft lip/palate            cleft lip/palate
Children with a cleft palate are particularly prone to ear infections because the cleft can interfere with the function of the middle ear. To permit proper drainage and air circulation, a small plastic ventilation tube maybe inserted in the eardrum. This relatively minor operation may be done later or at the time of the cleft repair. In addition, surgery may be recommended by your plastic surgeon when your child is older to refine the shape and function of the lip, nose, gums, and palate.

What are the post-surgical complications?
SCAR FORMATION. Certain individuals are prone to excessive scar formation. This can be a minor problem, or severe enough to require later treatment. The overwhelming majority of scars heal normally over a reasonable period of time
Hypertrophic scars are raised, red, "angry-looking" scars. Often after a few months these scars become soft and flat and fade in color. Frequently the only treatment required is patience. If after a reasonable amount of time, they are still a problem, cortisone injections, laser treatment or surgical revision may be used to achieve a more aesthetic result.
Keloids are a form of tumor made up of actively growing fibrous tissue. Keloids are a response to trauma (surgical or accidental). Some become itchy or have a burning sensation, which may cause a child to pick at or scratch them. This can worsen the problem.
FISTULA. Despite the best of intentions and techniques, occasionally the healing process after cleft repair is disrupted by the formation of a fistula. A fistula is a hole that allows air and fluids to pass from one space to another. There are many reasons for fistula formation, but the most common causes are infection, trauma from eating the wrong foods, blood clots under flaps of the closure, and tension at the sutured edge of the wound. Some of these, such as tension, may be unavoidable in extremely wide clefts or other circumstances where tissue flaps are moved a long way to achieve closure. Tension can also occur due to crying. Patient’s diet is to be restricted to liquids or soft foods for some period of time after surgery. If blood clots are present in the wound they can provide an environment where it is easy for infections to develop. This may cause the newly formed scar to break down in the post-operative period. Sometimes the patients may disrupt their own wound if they get their arms out of their restraints.

What are the Dental problems associated with clefts?
       It is not unusual for tooth development to be delayed in the child or the tooth maybe congenitally missing, particularly those at the site of the cleft. Clefts most often occur in the alveolar area between the maxillary central incisor (top front tooth) and the cuspid. These children must therefore be examined periodically and treatment plans may have to be modified and often compromised, depending on the severity of the cleft, the growth of the jaws and the status of the developing deciduous and permanent teeth. Some of the teeth adjacent to the cleft may be rotated (twisted) when they erupt. Also common in cleft children is the presence of ectopic (abnormally positioned) teeth. They may be placed in the palate and completely blocked out of the dental arch. Supernumerary (extra) teeth may also be present next to the cleft site. Some emerge into the oral cavity, while others may remain unerupted. The supernumerary may have to be removed to facilitate the treatment of the remaining dentition. Occasionally a tooth may be switched in position with another tooth (transposition). Complete alveolar collapse is quite common in children with bilateral cleft palates, primarily due to scar contraction of the palate. The degree of collapse is variable, but usually the growth of the maxilla (upper jaw) is retarded, resulting in a “dish face”.
Orthodontic treatment is needed to help the growth of the dental arches and correct the malalignment. Prosthodontic treatment may be needed to replace any missing teeth.

What is the need for orthodontic treatment?
       The need of orthodontic intervention is necessary to unlock impacted palatal segments and permit more normal growth. Orthodontic appliances of various types, removable or fixed, in the upper jaw can widen the lateral segments and move the front segment forward. Orthodontic treatment is started between the ages of six to nine. Although it can be done when the milk teeth are in the mouth, most clinicians prefer to wait until the permanent molars (big back teeth) and incisors (front teeth) are present. Once jaw segments have been moved they must be retained (held) either with a removable or a fixed retainer. Further expansion involving "braces" may be necessary when all the permanent teeth have erupted. Orthodontic treatment can do much to establish or approximate the normal dental arch, and then maintain the integrity of that arch. It is often a fairly lengthy, multi-staged process, lasting till adulthood, and later they still may have to undergo Orthognathic surgery. There are 5 reasons for orthodontic treatment on a continuing basis from childhood through adulthood:

  1. To provide symmetry in the dental arch of the infant and bony support for the initial nasal and palatal repair.
  2. To align the distorted and constricted palatal segments of the maxilla (upper jaw).
  3. To maintain the gains made by expansion and dental alignment procedures.
  4. To assist the eruption of permanent teeth.
  5. To support surgical positioning of the jaws when orthognathic surgery is necessary.

Some Points and Facts To Remember about Clefts

RELATED TOPICS:
What is a Cleft?
What are the causes of cleft?
What are the problems associated with clefts?
How to Feed a child with a cleft?

* Know your teeth * Know your Gums (Gingiva) * Eruption Dates * Six Golden Rules * Brushing\Flossing Technique * Wisdom tooth * Tooth Decay * Extraction * Dental Implant * Surgical Extraction * Orthognathic Surgery * Asymmetry of the face * Gummy Smile * Prognathism{Long Jaw} * Beggs\Straight wire{Orthodontia} * Bleaching{Tooth Whitening} * Habit Breaking * Interceptive Orthodontics * Discolouration\Veneers * Composite\Amalgam Fillings * Root Canal Treatment{RCT} * Crown{Porcelain\Castmetal} * Flap Surgery/Splinting * Bridges{Porcelain\Castmetal} * TMJ (Joint) Disorders * Bell's Palsy {Facial Paralysis} * Ankylosis{Difficulty in mouth opening} * Cleft Lip and Palate * Trigeminal Neuralgia * In a Lighter vein


This site is produced, designed and maintained by
Dr Antony George, Trichur Institute of Head And Neck Surgery (TIHANS),
Shornur Road,Trichur,Kerala-680001,India.
Ph: 0091-0487-335145, 335185
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updated Aug2002.