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Perspectives.

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Perspective
A P E D I AT R I C

January/February 2003 Volume 12, Number 1

Improving Outcomes of Children


With C l e f t L i p a n d P a l a t e
by Cheryl Cermin, D.D.S.

Custom orthodontic appliances are becoming a key part of recommended


treatment protocol for cleft lip/palate. The pre-surgical appliance therapy
Figure 1 — called nasal alveolar molding — is used in combination with surgery to
One-week-old infant significantly reduce the facial disfigurement of children born with cleft
with a bilateral cleft lip/palate. These appliances help with feeding before surgery, because
lip/palate. Photo is the baby now has something covering the roof of the mouth against which
before orthodontic
to compress the nipple.
appliance therapy.
Note: nasal slumping
and large alveolar Cleft lip/palate occurs during the fifth or sixth week of pregnancy, when
gap. (Figures 1, 2 and the face is forming. Normally, the lip comes together from three places:
3 show the same the nose, and the right and left sides of the face. Usually, the lip fuses, but
patient.) in certain children, it leaves a crevice or cleft instead. The palatal cleft
occurs when the palatine structure doesn’t drop and fuse at the middle
with the premaxilla. This occurs at eight to 12 weeks in utero.

Infants born with cleft lip/palate are typically referred to a cleft team
immediately after birth. If an in-utero diagnosis is made, the referral
should be made prior to birth. The cleft team may include a craniofacial
surgeon, orthodontist, speech pathologist, lactation specialist, nurse
Figure 2 practitioner and pediatrician.
Patient at 3 months
with orthodontic
appliance inserted Because the physical features of cleft lip/palate can be unsettling to
(patient is nearing the parents, it’s important for them to be informed of treatments, which
end of the appliance typically begin the week after birth.
therapy). Note: nasal
changes. Pre-surgical and Surgical Treatments
Each appliance is custom-made by an orthodontist and used as a
pre-surgical therapy to improve outcomes of children with cleft lip/palate.
Many orthodontists and craniofacial surgeons estimate that patients who
have the appliance therapy need 20 to 30 percent fewer reconstructive
surgeries.

Figure 3 The appliance (see figure 4) attempts to bring the gum segments together,
Patient at 3 months reducing the size of the gap in the mouth, stretching the lip muscles, and
after the appliance giving the nose a more even shape. This is done in an attempt to
therapy. Note:
“normalize” the condition as much as possible.
narrowing of the
alveolar gap on
infant’s right side and Early use of the appliance (usually the first week is best) typically
left nostril opening. enhances outcomes. Early use takes advantage of the plasticity of

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Figure 4
Nasal alveolar molding appliance
Types of Clefts a) Acrylic base b) Nasal stents.
A cleft lip can range in severity from a simple
notch in the upper lip to a complete opening in
the lip that extends into the floor of the nostril.
The upper gum may be involved. Clefts can
occur on one or both sides, with or without a
involvement of the palate.

When one side is affected, it is a unilateral cleft cartilage during the first six weeks after birth. Beginning appliance therapy
(one side of the lip fails to fuse); when both after six weeks results in less dramatic nasal cartilage changes. Once a month
sides fail to fuse, it’s a bilateral cleft. — until the first surgery is performed at 3 months — a new appliance is made
A complete cleft separates the lip through the to address growth.
gum and the floor of the nostril. A complete
cleft palate separates the palate through the The appliance is made of hard and soft acrylic and wires (the same material
entire palatal structure. In unilateral cleft lips, that is used for oral retainers). Areas where the appliance touches the mouth
the incidence is higher for the cleft to occur on or nose are made with soft acrylic, making it easier for the baby to tolerate. The
the left side. A bilateral cleft lip is more severe wires connect the hard acrylic base of the appliance to nasal stents, which
and involves more surgeries. helps lift up the nose on the cleft side. The base of the appliance brings the
bony segments closer together.
Etiology
The etiology of cleft lip/palate is unknown, but Inserting the Appliance
studies suggest that a number of genes and Removing the appliance from the baby’s mouth for cleaning — and reinserting
environmental factors — such as medications, it — is easy for parents. A small amount of denture cream is inserted inside the
infections, maternal illnesses, maternal smoking, base of the appliance in the trough area. The appliance is then inserted into
alcohol use and folic acid deficiency — may be the mouth by turning it 90 degrees and gently slipping one corner into the
involved. infant’s mouth. Once the appliance is properly positioned over the gums, it is
rotated, and upward pressure is applied. Using the index finger, pressure is
Prevalence of Cleft Lip/Palate applied to the appliance for several seconds to help the denture cream make
One of every 700 babies born in the United contact with the gums and to hold the appliance in place.
States has a cleft lip or a cleft lip/palate, making
it the second most common congenital Surgical Procedures
deformity in the United States (after clubfoot). Surgery follows use of the appliance. The timing and type of surgery depend
More than 70 percent of babies with a cleft lip upon a number of factors, including the preference of the surgeon, the health
also have a cleft palate. of the baby and the nature of the cleft.
Boys are more often affected by cleft lip/palate Cleft Lip Surgery
or cleft lip than girls, but girls are more likely to Most craniofacial surgeons agree that cleft lip should, in most cases, be
have cleft palate alone. Cleft lip/palate is more repaired by about 3 months of age. This operation separates the lip from the
prevalent among Asians and certain Native muscles underneath, rotates flaps of tissue and muscle into a more normal
American groups than among Caucasians and position, then brings it all together in layers to make a continuous lip.
African Americans. Parents who have one
child born with cleft lip/palate have a Cleft Palate Surgery
15-percent chance of having subsequent Cleft palate surgery, which restores the partition between the nose and mouth,
children born with this condition. usually isn’t done until a baby is about 9 months old, giving the bones in the
area time to grow before they’re altered. Reaching inside the infant’s mouth,

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Author’s
surgeons work with tissue, muscle and bone from either side of
the hole, bringing it together in the middle.
Profile
Additional surgical procedures may be required as the child
grows.

Associated Conditions
Cleft lip/palate may occur alone or with other abnormalities,
which may be obscure or obvious. Up to 13 percent of babies
with cleft lip/palate have other birth defects. Some cases involve
genetic syndromes, which may pose specific problems for the
baby and may affect others in the family. For this reason, babies
with cleft lip/palate should be thoroughly examined by a
physician soon after birth and referred for a genetic workup if
indicated.

Problems associated with cleft lip/palate include: ear difficulties, Cheryl Cermin, D.D.S.
speech defects, dental anomalies and growth issues.

Ear Problems Cheryl Cermin, D.D.S., an orthodontist, specializes in


Infants born with cleft lip/palate typically have recurrent middle orthodontic care for patients who undergo plastic and
ear infections. This happens because the muscles in the back of reconstructive surgery. Cermin is part of the Minnesota
the throat are split, which doesn’t allow for proper drainage of the Center for Craniofacial Surgery team at Gillette Children’s
Eustachian tube. Tubes are commonly placed in the ears of cleft Specialty Healthcare.
lip/palate patients at 3 months of age (at the time of the lip
surgery) to help alleviate the frequent infections. In her practice, Cermin uses a pre-surgical appliance
therapy, called a nasal alveolar molding, for children
Speech Defects who have cleft lip/palate. The appliance, used before
Those children who have only a cleft lip generally have normal or initial lip surgery is performed, helps pull the cleft areas
near-normal speech. Some children with cleft palate (isolated or together, improving the ability of newborns to suck and
as part of cleft lip/palate) may develop speech a little more slowly swallow.
than other children. Their words may sound nasal, and they may
have difficulty producing some consonant sounds. However, Cermin holds bachelor of science and doctor of dental
after cleft palate repair, most children eventually catch up and surgery degrees from the University of Minnesota. She
develop normal speech, although some will require speech completed a general practice residency at Brigham and
therapy or additional surgery to increase soft palate function. Women’s Hospital at Harvard School of Dentistry in
Boston and an advanced graduate residency in
Dental Issues orthodontics at the Goldman School of Dentistry at
Children whose cleft lip/palate extends into the upper gums Boston University. She completed a fellowship in surgery
(which contain the teeth) have special dental needs. Some at the University of Texas Southwestern Medical School
primary and permanent teeth may be missing, abnormally in Dallas.
shaped, or out of position around the cleft. There are higher
incidences of decay in children born with cleft lip/palate. Cermin is an assistant clinical professor at Baylor College
Pediatricians should refer these children to a dentist by the age of of Dentistry and in the division of oral and maxillofacial
12 months. surgery and the department of plastic and reconstructive
surgery at the University of Texas Southwestern Medical
Weight Gain School.
Physicians also should watch the weight of infants born with cleft
lip/palate. Babies with cleft lip/palate should gain about 1 ounce She is a member of the American Dental Association,
a day during the first six weeks of life. Infants should weigh at the American Association of Orthodontics and the
least 10 pounds before the first surgery. American Cleft Palate Association.

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Nonprofit
A PEDIATRIC

Perspective
Organization
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P A I D
St. Paul, MN
Volume 12,Number 1 200 East University Avenue Permit No. 5388
January/February 2003 St. Paul, Minnesota 55101
651-291-2848
TDD 651-229-3928
A Pediatric Perspective focuses on specialized 1-800-719-4040
topics in pediatrics, orthopaedics, neurology and www.gillettechildrens.org
rehabilitation medicine.

Please send your questions or comments to:


A Pediatric Perspective
Marketing Communications
200 East University Avenue • St. Paul, MN 55101
651-229-1744

Editor-in-Chief.............Steven Koop, M.D.


Editor..................Beverly Smith-Patterson
Designer.............................Kim Goodness
Photographer........................Anna Bittner

Back issues of A Pediatric Perspectives are available


at: www.gillettechildrens.org/ resourcecenter/
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2-03SEXTON7600GG
Upcoming Conferences
Referral Information
Sixth Annual Cause for Concern
Gillette accepts referrals from Assessment and Intervention Topics for the Primary-Care Provider
physicians, community professionals
and outside agencies. Contact the Friday, April 11, 2003
admitting manager at the number listed Location: Minnesota History Center, St. Paul, Minn.
below. Physicians who are on staff may Registration Deadline: March 31, 2003
admit patients through our Admitting This conference offers assessment tools to help primary-care providers determine whether
department from 7 a.m. to 4:30 p.m. there is “cause for concern” when children and teens present symptoms that could reflect a
Physicians who are not on staff should serious underlying condition. This conference also helps providers determine appropriate
contact the admitting manager. evaluation and intervention strategies.

Admitting Manager
651-325-2145 Infant and Toddler
Program Cerebral Palsy: Musculoskeletal Management Issues Over a Lifetime
Admitting 651-229-3917
651-229-3944 Friday and Saturday, March 14 - 15, 2003
Neuromuscular Location: Minnesota History Center, St. Paul, Minn.
Arthritis Program Program
651-229-3914 651-229-1716 Registration Deadline: March 1, 2003

This conference will focus on the management of musculoskeletal issues related to the
Brain and Spinal-Cord Orthopaedic Program
Injury Program 651-229-1758 secondary effects of cerebral palsy, from infancy through adulthood. Participants will gain
651-229-3915 knowledge regarding the effects of spasticity, as well as decreased tone, on bone, joint and
Spina Bifida Program strength for individuals with diplegia, hemiplegia and quadriplegia. Intervention strategies,
Cerebral Palsy 651-229-3878 including orthopaedic surgery, spasticity reduction, strengthening and improving selective
Program motor control, will be presented. The role of gait analysis in the decision-making and long
651-290-8712 Spine Orthopaedics/ term planning processes will complement the presentation. The effects of aging and ways
Upper Extremities
to maintain comfort and mobility will be emphasized at each stage of the decision-making
Craniofacial Program Program
651-229-1702 651-229-1758 process. Case discussions will assist the audience in choosing interventions and measuring
functional outcomes.
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For more information on these conferences, and to register, log on to
www.gillettechildrens.org. You can also register over the phone by calling Amy Schall at
651-229-1721.