-for Physical Disorders, see below for Birth Defects, esp Cleft Lip & Palate and other Orofacial Disorders.
-for Mental and Drug/Alcohol Disorders, as well as for Bullying and Murder issues, see drop-down menu selections under the Resources tab.
Scroll past the below lists of charities, physicians/surgeons, and books for general information about Cleft Lip and Palate.
BIRTH DEFECTS CHARITIES
These deal with the themes of Cleft Heart. Please consider contributing. To help you decide which charities are most worthy, check out www.charitynavigator.org, or www.charitywatch.org.
Organizations for Cleft Palate/Orocranio Disorders
-The Cleft Palate Foundation (CPF)
-American Cleft Palate-Craniofacial Association (ACPA)
-Children’s Craniofacial Association
-World Craniofacial Foundation
-Let’s Face It USA –inactive. Mtgs at airports.
-Show Your Face
-Shriners Hospitals for Children
-Transforming Faces Worldwide – Canada
-Cleft Lip and Palate Association (CLAPA)- Ireland
-The Craniofacial Society – Great Britain and Ireland
-American Society of Plastic Surgeons plasticsurgery.org
Heart Defect Organizations
-The March of Dimes
-Childrens Heart Foundation,
-Cardiac Kids Foundation
-Congenital Heart Defects Families Association
-American Heart Association
-Adult Congenital Heart Defect Association
Other Medical Organizations Involving Facial Deformities
-American Burn Association
-American Cancer Society re facial deformities from cancer surgery
Depression, Suicide Organizations
-National Alliance on Mental Illness (NAMI ) Apropo of my “chasing normal” subtheme,
“House M.D.” TV stars sell T- shirts s with “Normal’s Overrated”-all proceeds
going to NAMI)
-National Mental Health Association
-American Association of Suicidology
-American Foundation for Suicide Prevention AFSP
-Suicide Awareness Voices of Education – SAVE
-Suicide and Mental Health Association International (SMHAI)
-American Sociological Association
-Society for the Study of Social Problems (SSSP)
Organizations recommended by Operation Smile
For information on how to help a child with a cleft lip, cleft palate or other craniofacial anomaly, try the organizations below. They will appreciate receiving copies of Cleft Heart.
- American Cleft Palate-Craniofacial Association and Cleft Palate Foundation: Operates the CLEFTLINE 1-800-24-CLEFT and produces free publications.
- American Society of Plastic Surgeons: Provides public education about reconstructive plastic surgery.
- Children’s Craniofacial Association: CCA operates a toll-free hotline 1-800-535-3643, provides information and support, and offers financial assistance for lodging and travel.
- Cleft Advocate: Provides educational opportunities, support networks and insurance guidelines.
- FACES: The National Craniofacial Association: Addresses three distinct areas: Client Travel, Public Awareness and Understanding, and Information and Support.
- Family Voices: Aims to achieve family centered care for children with special health care needs.
- Fresh Start: Free reconstructive plastic surgery and related medical services for disadvantaged children.
- Insure Kids Now: A national campaign to connect the nation’s uninsured children to free and low-cost health insurance.
- Miracle Flights for Kids: Provides free flights for children to specialized medical treatment centers.
- National Institute of Dental and Craniofacial Research: Accurate, up-to-date information about oral health, clinical trials and patient resources.
- Prescription Parents: Support groups to help families in the New England area.
- Smiles: A group of dedicated families who have a firsthand understanding of the needs of craniofacial patients.
- Shriners Hospital for Children: Children with cleft lip and cleft palate, orthopedic conditions, burns of all degrees and spinal cord injuries are eligible for admission and receive care at no charge.
- United Healthcare Children’s Foundation: Provides medical grants for eligible children. To see if you qualify, visit the website and see the grant application criteria by clicking on “To Apply > Applicant.”
- World Craniofacial Foundation: Helps patients gain access to medical care on a patient-by-patient basis.
- Disclaimer: The information provided is for reference only. It is not an endorsement of any given doctor or group.
PHYSICIANS/SURGEONS REFERENCE LIST
The list below includes some of Operation Smile’s credentialed medical volunteers. They practice in the states indicated and have graciously given Operation Smile permission to be listed as resources on the U.S. Care Network. They will also appreciate receiving copies of Cleft Heart: Chasing Normal.
Dr. James C. Grotting One Inverness Center Parkway, Suite 100 Birmingham, AL 35242 205-930-1600
Dr. Wan Ho 5891 Donlyn Drive Huntington Beach, CA 92649 562-657-4994
Labib Samarrai, M.D. Department of Plastic and Reconstructive Surgery Kaiser Hospital 5601 De Soto Avenue Woodland Hills, CA 91367 818-719-4527
Dr. Kelly Gallego, MD 1810 Fullerton St, Suite 101 Corona, CA 92881 240 Newport Center Dr, Suite 105 Newport Beach, CA 92660 949-502-6500 email@example.com
R.C.A. Weatherley-White, MD (retired) Biomedical Consultants, Inc. 2101 E. Hawthorne Place Denver, CO, 80206, USA
phone: (office and mobile) 303-329-5800 phone (home) 303-388-6804 e-mail: firstname.lastname@example.org or
David M. Bass, M.D., F.A.C.S. 85 Seymour Street Suite 718 Hartford, CT 06106-5536 860-247-3479 email@example.com
John Persing, M.D. Yale Craniofacial Center Yale University School of Medicine 330 Cedar St. New Haven, CT (203)785-2570
Dr. Joel Levin 8700 North Kendall Drive, Suite 206 Miami, FL 33176 305-665-1017
Don Parsa, MD, FACS John A. Burns School of Medicine 1329 Lusitana St. Suite 807, Honolulu, HI 96813 phone: 808-526-0303 fax: 808-536-8836
Dr. Thomas Crabtree 810 H North Kalaheo Ave Kailua, Hawaii 96734 808-261-3135
Hatem Galal, M.D. 28 E. Burlington Street Riverside, IL 60546-2125 Phone: 708-447-2288 Fax: 708-447-3058 firstname.lastname@example.org
Robert C. Russell, MD Heartland Plastic Surgery 320 E. Carpenter Springfield, IL 62702 Phone: 217-523-0808 Fax: 217-523-9859
Geoffrey M. Randolph, M.D. 11141 Park View Plaza Drive, Suite 300 Fort Wayne, IN 46845 Phone: 260-490-7111 Fax: 260-490-9301 email@example.com
Dr. James Paul (oral-maxillo-facial surgeon) 3385 Dexter Court Suite 115 Davenport, IA 52807 Phone 563-359-4777
John Canady, M.D. Departments of Surgery and Otolaryngology University of Iowa Hospitals and Clinics 200 Hawkins Drive Iowa City, IA 52242 319-356-2168
Therese K. White, M.D. Plastic and Hand Surgical Associates 244 Western Avenue South Portland, ME 04106 207-775-3446
Craig A. Vander Kolk, M.D. Associate Director, Plastic Surgery Mercy Medical Center Weinberg 6th Floor 227 St Paul Place Baltimore, MD 21202 410-332-9700
John G. Meara, MD, DMD Department of Plastic & Oral Surgery Children’s Hospital Boston 300 Longwood Avenue Boston, MA 02115 Phone: 617-355-7252 www.childrenshospital.org/plastic
Dr. Steven Naum Michigan Hand Center 1111 Lefingwell, Suite 200 Grand Rapids, MI 49525 616-957-4263
Paul Rottler, MD, FACS Plastic and Reconstructive Surgery 13625 Big Bend Rd. St. Louis, MO 63122 314-966-8880 Office 314-966-5811 Fax website: www.dr-rottler.com e-mail: firstname.lastname@example.org
Robert M. Olson, M.D. Plastic Surgery Arts 78 Easton Avenue New Brunswick, NJ 08901 Phone: 732-418-0709
Fax: 732-418-0747 www.psanj.com email@example.com
Adam R. Kolker, M.D., F.A.C.S., P.C. Plastic and Reconstructive Surgery 710 Park Avenue New York, NY 10021
Phone: 212-744-6500 Fax: 212-794-0760 www.kolkermd.com firstname.lastname@example.org
Lisa R. David, M.D. Department of Plastic and Reconstructive Surgery Wake Forest University Baptist Medical Center Medical Drive Center Blvd. Winston-Salem, NC 27157 Phone: 336-716-0803 Fax: 336-716-0759 email@example.com
Andrew M. Schneider, M.D., F.A.C.S. Forsyth Plastic Surgery 2901 Maplewood Avenue Winston-Salem, NC 27103
Phone: 336.765.8620 Fax: 336.768.6236 firstname.lastname@example.org
James A. Lehman Jr., M.D. 300 Locust St, Suite 590 Akron, OH 44302 330-374-9100 email@example.com
Arthur G. H. Bing, M.D. Olentangy Professional Plaza 3814 Olentangy River Road Columbus, OH 43214 Phone: 614-457-2233
Fax: 614-457-3012 firstname.lastname@example.org
Dr. Dan H. Shell III MD 6209 Poplar Ave #200 Memphis, TN 38119 901-761-4844
William P. Magee, Jr., D.D.S. M.D. Magee-Rosenblum Plastic Surgery, Inc. 400 W. Brambleton Avenue Suite 301
Norfolk, VA 23510 Phone: 757-627-6700 Fax: 757-627-8973 email@example.com
Saeed Marefat, M.D. 14908 Jefferson Davis Hwy Woodbridge, VA 22191 703-560-9583 3833 N. Fairfax Dr, Suite 350 Arlington, VA 22203 703-516-7600 www.drmarefat.com firstname.lastname@example.org
Craig Merrell, M.D., F.A.C.S. President Plastic Surgery Associates of Tidewater 5818 Harbour View Boulevard Suite 200 Suffolk, VA 23435 (Brooke Jarnegan, Secretary and Cosmetic Coordinator) 757.673.6000 email@example.com
Dr. Elizabeth Peterson, MD Plastic and Reconstructive Surgery 105 West 8th Ave Spokane, Washington 99204 509.838.3937
BOOKS, FURTHER READING regarding the discrimination themes of this site.
-The Hero with a Thousand Faces by Joseph Campbell 1949
-Heroes, Villains, and Fools: The Changing American Character by Orrin
-Heroes, Gods, and Monsters of the Greek Myths by Bernard Evslin
Coming of Age Stories
AKA, Bildungsromans or novels of personal development
–Cleft Heart: Chasing Normal by Karl Schonborn 2014
-The Story of Edgar Sawtelle: A Novel by David Wroblewski 2009
-Old School and This Boy’s Life: A Memoir by Tobias Wolff (PEN/Faulkner winner) 1989, 2003
-The Longest Trip Home by John Grogan (Marley and Me author) 2001
Outsiders, Facial Discrimination
-Brothers and Keepers: A Memoir by John Edgar Wideman 1984
-Ugly: Memoir by Constance Briscoe (judge, bestselling author) 2006
Cleft Lip, Cleft Palate, Disfigurement, Facial Anomalies
-Marked for Life: a Memoir by Joie Davidow (journalist) 2003
-The Three Worlds of Johnny Handsome, 1972, John Godey (novelist)
-Life and Times of Michael K by J. M. Coetzee (Booker award-winning novelist)
-See the many blogs re these topics on this website.
Heart Defect, Cardiac Invalidism
-At the Will of the Body: Reflections on Illness by Arthur W. Frank, 2002.
-Mac’s Secret Weapon by Mackinzie Kline (teen golf phenom) and Marjorie
-Love you to pieces Anthology of a slew of writers/poets by susan kamata
-My Baby Rides the Short Bus: The Unabashedly H… by Yantra Bertelli
-This Lovely Life by Vicki Forman
-You Will Dream New Dreams: Inspiring Personal… by Stanley D. Klein
-A Cup of Comfort for Parents of Children with Special Needs… by Colleen Sell
-Married with Special-Needs Children: A Couple… by Laura E. Marshak
-The Elephant in the Playroom: Ordinary Parents W… by Denise Brodey
-Steps to Independence: Teaching Everyday Skills… by Bruce L. Baker
-More Than a Mom: Living a Full And Balanced Li… by Heather Fawcett
-Shut Up About Your Perfect Kid: A Survival Guid… by Gina Gallagher
-A Different Kind of Perfect: Writings by Parents… by Cindy Dowling
Abnormal/Normal, Rejection/Acceptance, Outsider/Insider
-Every Crooked Pot by Renee Rosen (advertiser, writer) 2007
-Stutterin’ Boy by Mel Tillis (country singer) 1984
-Not a Genuine Black Man by Brian Copeland (TV personality) 2006
Suicide, Depression, Mental Illness –Esp in the Case of Mothers
-In Her Wake: A Child Psychiatrist Explores the Mystery of Her Mother’s Suicide
by Nancy Rappaport 2009
-Blue Genes: A Memoir of Loss and Survival by Christopher Lukas 2008
-A Tale of Love and Darkness by Amos Oz (trans.fr Hebrew) 2003
-Adventures of a Novelist, Gertrude Atherton, re cardiac invalidism
-Crashing Through… The Man Who Dared to See by Robert Kurson 2008
-Waking: A Memoir of Trauma and Transcendence by Matthew Sanford (car
crash quad) 2008
-Life in the Balance: A Physician’s Memoir…of Life, Love, and Loss…
by Thomas Graboys, MD and Peter Sheutlin 2008
CLEFT LIP AND PALATE —GENERAL INFORMATION WIKIPEDIA
Child with cleft lip and palate.
Cleft lip and cleft palate, also known as orofacial cleft and cleft lip and palate, is a group of conditions that includes cleft lip (CL), cleft palate (CP), and both together (CLP). A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate is when the roof of the mouth contains an opening into the nose. These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.
Cleft lip and palate is due to tissues of the face not properly joining together during development. They are a type of birth defect. The cause in most cases is unknown. Risk factors include smoking during pregnancy, diabetes, an older mother, obesity, and certain medications such as some used to treat seizures. They can often be diagnosed during an ultrasound done during pregnancy.
A cleft lip or palate can be successfully treated with surgery. This is often done in the first few months of life for cleft lip and before eighteen months for cleft palate. Speech therapy and dental care may also be needed. With appropriate treatment outcomes are good.
Cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed world. CL is about twice as common in males as females, while CP without CL is more common in females. In 2013 it resulted in about 3,300 deaths globally down from 7,600 deaths in 1990. The condition was previously known as a hare-lip due to similarity to a rabbit, but that term is now generally considered to be offensive.
- 1 Signs and symptoms
- 2 Cause
- 3 Diagnosis
- 4 Treatment
- 5 Epidemiology
- 6 Society and culture
- 7 Other animals
- 8 See also
- 9 References
- 10 Further reading
- 11 External links
Signs and symptoms
If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).
A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.
Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide.
Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a ‘hole’ in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes (formation of the secondary palate).
The hole in the roof of the mouth caused by a cleft connects the mouth directly to the inside of the nose.
Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant.
A result of an open connection between the mouth and inside the nose is called velopharyngeal inadequacy (VPI). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions while talking. Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations and mispronunciations (e.g., glottal stops and posterior nasal fricatives). Possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures.
Submucous cleft palate (SMCP) can also occur, which is a cleft of the soft palate with a classic clinical triad of a bifid, or split, uvula which is found dangling in the back of the throat, a furrow along the midline of the soft palate, and a notch in the back margin of the hard palate.
Most children who have their clefts repaired early enough are able to have a happy youth and social life. Having a cleft palate/lip does not inevitably lead to a psychosocial problem. However, adolescents with cleft palate/lip are at an elevated risk for developing psychosocial problems especially those relating to self-concept, peer relationships and appearance. Adolescents may face psychosocial challenges but can find professional help if problems arise. A cleft palate/lip may impact an individual’s self-esteem, social skills and behavior. There is research dedicated to the psychosocial development of individuals with cleft palate. Self-concept may be adversely affected by the presence of a cleft lip and/or cleft palate, particularly among girls.
Research has shown that during the early preschool years (ages 3–5), children with cleft lip and/or cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and possible speech impediments. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft lip and/or cleft palate. Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers, but these children were similar to their peers in regard to “how well they liked themselves.”
The relationship between parental attitudes and a child’s self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children. Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip and/or cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft lip and/or cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences.
As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft lip and/or cleft palate will deal with the typical challenges faced by most of their peers including issues related to self-esteem, dating and social acceptance. Adolescents, however, view appearance as the most important characteristic above intelligence and humor. This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Adolescent boys typically deal with issues relating to withdrawal, attention, thought, and internalizing problems and may possibly develop anxiousness-depression and aggressive behaviors. Adolescent girls are more likely to develop problems relating to self-concept and appearance. Individuals with cleft lip and/or cleft palate often deal with threats to their quality of life for multiple reasons including: unsuccessful social relationships, deviance in social appearance and multiple surgeries.
Cleft may cause problems with feeding, ear disease, speech and socialization.
Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby’s nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the Haberman Feeder, or by using a combination of nipples and bottle inserts like the one shown, is commonly used with other infants. A large hole, crosscut, or slit in the nipple, a protruding nipple and rhythmically squeezing the bottle insert can result in controllable flow to the infant without the stigma caused by specialized equipment.
Individuals with cleft also face many middle ear infections which may eventually lead to hearing loss. The Eustachian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self-cleaning. Hearing is related to learning to speak. Babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at risk for receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist.
The development of the face is coordinated by complex morphogenetic events and rapid proliferative expansion, and is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial malformations. During the first six to eight weeks of pregnancy, the shape of the embryo’s head is formed. Five primitive tissue lobes grow:
- a) one from the top of the head down towards the future upper lip; (Frontonasal Prominence)
- b-c) two from the cheeks, which meet the first lobe to form the upper lip; (Maxillar Prominence)
- d-e) and just below, two additional lobes grow from each side, which form the chin and lower lip; (Mandibular Prominence)
If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face).
The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These back portions are called palatal shelves, which grow towards each other until they fuse in the middle. This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two cabinets, and the way they are glued together, are quite complex and obscure despite intensive scientific research.
Genetic factors contributing to cleft lip and cleft palate formation have been identified for some syndromic cases, but knowledge about genetic factors that contribute to the more common isolated cases of cleft lip/palate is still patchy.
Many clefts run in families, even though in some cases there does not seem to be an identifiable syndrome present, possibly because of the current incomplete genetic understanding of midfacial development.
A number of genes are involved including cleft lip and palate transmembrane protein 1 and GAD1, one of the glutamate decarboxylases. Many genes are known to play a role in craniofacial development and are being studied through the FaceBase initiative for their part in clefting. These genes are AXIN2, BMP4, FGFR1, FGFR2, FOXE1, IRF6, MAFB (gene), MMP3, MSX1, MSX2 (Msh homeobox 2), MSX3, PAX7, PDGFC, PTCH1, SATB2, SOX9, SUMO1 (Small ubiquitin-related modifier 1), TBX22, TCOF (Treacle protein), TFAP2A, VAX1, TP63, ARHGAP29, NOG, NTN1, WNT genes, and locus 8q24.
- The Van der Woude Syndrome is caused by a specific variation in the gene IRF6 that increases the occurrence of these deformities threefold.
- Another syndrome, Siderius X-linked mental retardation, is caused by mutations in the PHF8 gene (OMIM 300263); in addition to cleft lip and/or palate, symptoms include facial dysmorphism and mild mental retardation.
In some cases, cleft palate is caused by syndromes which also cause other problems.
- Stickler’s Syndrome can cause cleft lip and palate, joint pain, and myopia.
- Loeys-Dietz syndrome can cause cleft palate or bifid uvula, hypertelorism, and aortic aneurysm.
- Hardikar syndrome can cause cleft lip and palate, Hydronephrosis, Intestinal obstruction and other symptoms.
- Cleft lip/palate may be present in many different chromosome disorders including Patau Syndrome (trisomy 13).
- Malpuech facial clefting syndrome
- Hearing loss with craniofacial syndromes
- Popliteal pterygium syndrome
- Treacher Collins Syndrome
Many genes associated with syndromic cases of cleft lip/palate (see above) have been identified to contribute to the incidence of isolated cases of cleft lip/palate. This includes in particular sequence variants in the genes IRF6, PVRL1 and MSX1. The understanding of the genetic complexities involved in the morphogenesis of the midface, including molecular and cellular processes, has been greatly aided by research on animal models, including of the genes BMP4, SHH, SHOX2, FGF10 and MSX1.
Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. An example for how environmental factors might be linked to genetics comes from research on mutations in the gene PHF8 that cause cleft lip/palate (see above). It was found that PHF8 encodes for a histone lysine demethylase, and is involved in epigenetic regulation. The catalytic activity of PHF8 depends on molecular oxygen, a fact considered important with respect to reports on increased incidence of cleft lip/palate in mice that have been exposed to hypoxia early during pregnancy. In humans, fetal cleft lip and other congenital abnormalities have also been linked to maternal hypoxia, as caused by e.g. maternal smoking, maternal alcohol abuse or some forms of maternal hypertension treatment. Other environmental factors that have been studied include: seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids — which are members of the vitamin A family; anticonvulsantdrugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and illegal drugs (cocaine, crack cocaine, heroin, etc.).
Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. In 1976, Paul Tessier described fifteen lines of cleft. Most of these craniofacial clefts are even rarer and are frequently described as Tessier clefts using the numerical locator devised by Tessier.
Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft.
Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young adulthood. Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: 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.
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 (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. Millard performed the first procedure at a Mobile Army Surgical Hospital (MASH) unit in Korea.
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 (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.
Post-operation, the lip is swollen from surgery and will get a more natural look within a couple of weeks. See photos in the section above.
In some cases of a 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, according to a retrospective cohort study. In this study, significant improvements in nasal symmetry were observed in multiple areas including measurements of the projected length of the nasal ala (lateral surface of the external nose), position of the superoinferior alar groove, position of the mediolateral nasal dome, and nasal bridge deviation. “The nasal ala projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the nasoalveolar molding group” this study concluded.
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).
Cleft palate can also be corrected by surgery, usually performed between 6 and 12 months. 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. 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 and/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 patients own chin, rib or hip.
Speech and hearing
Children with cleft palate typically have a variety of speech problems. Some speech problems result directly from anatomical differences such as velopharyngeal inadequacy. Velopharyngeal inadequacy refers to the inability of the soft palate to close the opening from the throat to the nasal cavity, which is necessary for many speech sounds, such as /p/, /b/, /t/, /d/, /s/, /z/, etc. This type of errors typically resolve after palate repair.
However, sometimes children with cleft palate also have speech errors which develop as the result of an attempt to compensate for the inability to produce the target phoneme. These are known as compensatory articulations. Compensatory articulations are usually sounds that are non-existent in normal English phonology, often do not resolve automatically after palatal repair, and make a child’s speech even more difficult to understand.
Speech-language pathology can be very beneficial to help resolve speech problems associated with cleft palate. In addition, research has indicated that children who receive early language intervention are less likely to develop compensatory error patterns later.
Hearing impairment is particularly prevalent in children with cleft palate. The tensor muscle fibres that open the eustachian tubes lack an anchor to function effectively. In this situation, when the air in the middle ear is absorbed by the mucous membrane, the negative pressure is not compensated, which results in the secretion of fluid into the middle ear space from the mucous membrane. Children with this problem typically have a conductive hearing loss primarily caused by this middle ear effusion.
Sample treatment schedule
Note that each individual patient’s schedule is treated on a case-by-case basis and can vary per hospital. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases this is usually one procedure (for example lip repair) in other cases this is an ongoing therapy (for example speech therapy).
|Repair cleft lip|
|Repair soft palate|
|Repair hard palate|
|Bone grafting jaw|
|Further cosmetic corrections (Including jawbone surgery)|
A craniofacial team is routinely used to treat this condition. The majority of hospitals still use craniofacial teams; yet others are making a shift towards dedicated cleft lip and palate programs. While craniofacial teams are widely knowledgeable about all aspects of craniofacial conditions, dedicated cleft lip and palate teams are able to dedicate many of their efforts to being on the cutting edge of new advances in cleft lip and palate care.
Many of the top pediatric hospitals are developing their own CLP clinics in order to provide patients with comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child throughout their cleft lip and palate treatment (which is ongoing) allows for the best outcomes in every aspect of a child’s care. While the individual approach can yield significant results, current trends indicate that team based care leads to better outcomes for CLP patients. .
Rates for cleft lip with or without cleft palate and cleft palate alone varies within different ethnic groups.
- Native Americans: 3.74/1000
- Japanese: 0.82/1000 to 3.36/1000
- Chinese: 1.45/1000 to 4.04/1000
- Caucasians: 1.43/1000 to 1.86/1000
- Latin Americans: 1.04/1000
- Africans: 0.18/1000 to 1.67/1000
Rate of occurrence of CPO is similar for Caucasians, Africans, North American natives, Japanese and Chinese. The trait is dominant.
It caused about 4,000 deaths globally in 2010 down from 8,400 in 1990.
Society and culture
Cleft lip may be technically known as cheiloschisis and cleft palate as palatoschisis.
In some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform abortion beyond the legal fetal age limit, even though the fetus is not in jeopardy of life or limb. Some human rights activists contend this practice of “cosmetic murder” amounts to eugenics.
|John Henry “Doc” Holliday||American dentist, gambler and gunfighter of the American Old West, who is usually remembered for his friendship with Wyatt Earp and the Gunfight at the O.K. Corral|||
|Tutankhamen||Egyptian pharaoh who may have had a slightly cleft palate according to diagnostic imaging|||
|Thorgils Skarthi||Thorgils ‘the hare-lipped’—a 10th-century Viking warrior and founder of Scarborough, England.|||
|Tad Lincoln||Fourth and youngest son of President Abraham Lincoln|||
|Carmit Bachar||American dancer and singer|||
|Jürgen Habermas||German philosopher and sociologist|||
|Ljubo Milicevic||Australian professional footballer|||
|Stacy Keach||American actor and narrator|||
|Cheech Marin||American actor and comedian|||
|Chin-Chin||American magician and stage illusionist|||
|Owen Schmitt||American football fullback|||
|Tim Lott||English author and journalist|||
|Richard Hawley||English musician|||
|Dario Šarić||Croatian professional basketball player|||
|Antoinette Bourignon||Flemish mystic|||
Works of fiction
The eponymous hero of J.M. Coetzee‘s 1983 novel Life & Times of Michael K has a cleft lip. However, the cleft lip is more frequently portrayed negatively in popular culture. Examples include Oddjob, the secondary villain of the James Bond novel Goldfinger byIan Fleming (the film adaptation does not mention this but leaves it implied); the fanciful portrayal of Roman Emperor Commodus in the 2000 film Gladiator,; and serial killer Francis Dolarhyde in the film Red Dragon.
Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in sheep, cats, horses, pandas and ferrets. Most commonly, the defect involves the lip, rhinarium, and premaxilla. Clefts of the hard and soft palate are sometimes seen with a cleft lip. The cause is usually hereditary. Brachycephalic dogs such as Boxers and Boston Terriers are most commonly affected. An inherited disorder with incomplete penetrance has also been suggested in Shih tzus, Swiss Sheepdogs, Bulldogs, and Pointers. In horses, it is a rare condition usually involving the caudal soft palate. In Charolais cattle, clefts are seen in combination with arthrogryposis, which is inherited as an autosomal recessive trait. It is also inherited as an autosomal recessive trait in Texel sheep. Other contributing factors may include maternal nutritional deficiencies, exposure in utero to viral infections, trauma, drugs, or chemicals, or ingestion of toxins by the mother, such as certain lupines by cattle during the second or third month of gestation. The use of corticosteroids during pregnancy in dogs and the ingestion of Veratrum californicum by pregnant sheep have also been associated with cleft formation.
Difficulty with nursing is the most common problem associated with clefts, but aspiration pneumonia, regurgitation, and malnutrition are often seen with cleft palate and is a common cause of death. Providing nutrition through a feeding tube is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks. For cleft palate, there is a high rate of surgical failure resulting in repeated surgeries. Surgical techniques for cleft palate in dogs include prosthesis, mucosal flaps, and microvascular free flaps. Affected animals should not be bred due to the hereditary nature of this condition.
Same dog as in top picture, one year later.