Understanding Cleft Lip and Palate Care and Impact

Cleft Lip and Palate

A congenital condition where structures in the face do not fuse properly during fetal development, resulting in openings in the lip, palate, or both.

Submucous Cleft

A type of cleft palate where the soft palate is affected but is covered by a layer of skin.

Bifid Uvula

A condition characterized by a cleft or split in the uvula.

Cleft Lip (CLO)

A cleft that affects the lip, ranging from a slight notch to complete separation extending into the nose.

Cleft Palate (CPO)

A cleft that occurs when the roof of the mouth, including the soft and hard palate, has not joined completely.

Unilateral (UCL / UCLP)

A cleft that affects one side of the lip or palate.

Bilateral (BCL / BCLP)

A cleft that affects both sides of the lip or palate.

Antenatal Identification of CLP

The process of diagnosing cleft lip and palate before birth, which can be challenging, with cleft palate and submucous cleft being particularly difficult to locate on antenatal scans.

Threshold Theory

A concept explaining the development of cleft lip and palate as a result of a combination of genetic predispositions and environmental factors exceeding a certain threshold.

Orthognathic Surgery

Surgical procedures performed in adulthood to correct jaw and facial deformities, often necessary for individuals with cleft lip and palate. Serves to fix class 111 malocclusion
lots of screws involved

Cleft Lip Repair

3 -6 months target

Cleft Palate repair

9 - 13 months, predominantly for speech feeding and hearing
designed to seal gap between oral and nasal cavities

Alveolar Bonegraft

A surgical procedure typically done around 9-10 years of age to repair the alveolar ridge affected by cleft palate.

Pharyngeal Flap

A surgical technique used to improve velopharyngeal competency in individuals with cleft palate.

Pharyngoplasty

Acts as a speed bump. Secondary palatal surgical procedure in which a muscular flap is cut from the posterior pharyngeal wall, raised, and attached to the velum
Openings on either side of the flap allow for nasal breathing, nasal drainage, and production of nasal sounds.
Helps close the VP port and reduces hypernasality.

Grommets

Tubes inserted into the eardrum to alleviate middle ear infections, a common issue in individuals with cleft palate.

Hypodontia

Can be missing teeth

Hyperdontia

Can be extra teeth, may be in palate rather than alveolar gum area

Malocclusion

Teeth in bottom jaw may approximate to unusual positions to accommodate upper jaw teeth position

Class III malocclusion

Retracted maxilla in cleft palate cases, may require orthognathic surgery to correct

Class II malocclusion

Retracted mandible in Pierre Robin cases

Otitis media

More common for children with cleft palate due to exposure of Eustachian tube

Considerations for Aotearoa

New Zealand has high rates of CLP; Māori have highest rate of isolated Cleft Palate; no routine Clinical Psychology provision for cleft in Aotearoa

Cleft lip Speech

Normal incidence of articulation errors once lip repair complete, unless hearing difficulties remain

Cleft palate speech

incomplete articulation surface - passive (obligatory) errors
vowels don't tend to be affected as they are nasal

Non-pneumatic velopharyngeal closure

closure is high up and dramatic - swallowing, gagging and vomiting

Pneumatic velopharyngeal Closure

+ve pressure: blowing whistling and speech
-ve pressure: Sucking and kissing

Hypernasality

Increased or excessive nasal resonance heard on vowels and voiced consonants

Hyponasality

Decreased or reduced nasal resonance heard on vowels and nasal consonants
blocked nose

Mixed Resonance

Combination of hypernasality on oral consonants and hyponasality on nasal consonants

Abnormal Nasal Airflow - VPI

Nasal air emission and/or nasal turbulence that distorts oral high-pressure consonants
accompanied with and distorts any of all oral high-pressure consonants in a language

Weak or omitted consonants, short utterance length due to nasal air emission

Passive Speech Errors

Weak or omitted consonants
Short utterance length
Nasalized Phonemes

Active (compensatory) errors in speech

generally the manner of articulation is preserved but place of articulation is moved backwards

What is VPI

Velopharyngeal insufficiency resulting in nasal emission, nasal turbulence, hypernasality, hyponasality, and mixed resonance

places of articulation compromised

Palate, alveolar ridge, velum, uvula

Abnormal airflow

Nasal Emission, nasal turbulence

PROMs

Patient Reported Outcome Measures used to understand patient priorities and evaluate treatment efficacy

Biofeedback

Using techniques like a nasal mirror or teaching stethoscope to provide feedback for reducing nasality in speech

Treatment for hypernasality

exaggerated articulation, decreasing speaking rate, auditory training (increase patient awareness of excessive nasal emissions)

UK Adult Services Project

A project (2018-2021) studying the needs of adults with cleft, aiming to develop support interventions

Interpersonal Relationships

Reflects positive family and friend relationships, experiences of bullying/discrimination, and social competence in individuals with cleft

Treatment Experiences

Concerns, surgeries, and outcomes related to dental visits, entitlement to treatment, and surgical decisions in individuals with cleft, 1/3 were concerned about visiting the dentist

Face development during Utero

structures move towards the midline and fuse together starting at the lip (6 weeks) and progressing to the soft palate which will be sealed by around the 16th week

global average of cleft

1/700 live births

New Zealand average of cleft

1/550

Māori population and Cleft

highest incidence of isolated cleft Palate in the world - 1/460

Cause of CLAP

multifactorial - a combination of genes and environment

Syndromic link

something else if happening, for example genes

nonsyndromic

happening in isolation

Chances of CLAP if one parent has cleft

1 in 50

Chances of CLAP if both parents have cleft

1 in 10