C33 Cleft Lip and Palate

Objectives What is a cleft lip? What is a cleft palate? What are the causes? Related health problems Detection with Ultrasound  Detection with MRI Surgeries needed to correct a cleft lip and palate Personal story

Thesis This presentation will explain what a cleft lip and palate is, as well as the different modalities that can be used in help diagnosing and setting up surgery plans that will be needed for the child's life. 

What is a Cleft Lip? A cleft lip is when the tissue that makes up the lip does not fuse together properly during the fourth and seventh weeks of pregnancy 1 The opening may be a small slit or a large slit traveling from the lip to the alveolus ridge (the bone that supports the teeth) May appear unilateral or bilaterally https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

What is a Cleft Palate? A cleft palate occurs when the roof of the mouth does not fuse together properly during the sixth and ninth week of pregnancy 1   The opening may fuse together with the cleft lip or it may not May appear unilaterally or bilaterally https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

Types of Cleft Lips and Palates (a) Unilateral cleft lip with alveolar involvement; (b) bilateral cleft lip with alveolar involvement; (c) unilateral cleft lip associated with cleft palate; (d) bilateral cleft lip and palate; (e) cleft palate only 2

What Causes Cleft Lip and/or Palate? Many clefts are thought to be a combination of genetic (inherited) and environmental factors (like certain medications or vitamin deficiencies) 3 Both mother and father can pass on a gene that causes a cleft lip 3 Smoking, drug or alcohol use is another factor that can increase the odds Many doctors do not know the true cause on why a cleft lip and/ or palate occurs 

Related Health Problems Feeding difficulties: Babies with a cleft lip and palate tend to have greater challenges with feeding Air is not being prevented from entering the nose, due to the opening in the roof of their mouth with a cleft palate, causing them to regurgitate through their nose3 Babies can have a hard time latching on to mothers due to the lack of sucking they are not able to do  Special nipples for bottles and breast feeding mothers may be used, such as a breast shield Breast Shield https://www.google.com/search?biw=1920&bih=985&tbm=isch&sa=1&ei=twGdXKStJMOwjwSkqIHAAg&q=+nipple+shield&oq=+nipple+shield&gs_l=img.3.

Related Health Problems Dental problems: Due to the deformation of the palate, the childs teeth may not come through properly These can include small teeth, missing teeth, extra teeth, or teeth that are out of position. They may have a defect in the gums or alveolar 3 Ridge defects can displace, tip, or rotate permanent teeth or prevent permanent teeth from coming in properly

Related Health Problems Speech difficulty About 1 in 5 kids with a cleft palate have speech problems after surgical repair 3 Associated with the dental problems can be pronunciation difficulties Going to a speech therapist can help improve the child with their speech and language skills

Detection with Ultrasound Cleft lip, with or without a cleft palate, happens in every 1 per 700 live births worldwide 4 The use of ultrasound detects a cleft lip but does not properly detect a cleft palate due to overlaying bone shadows  Amniotic fluid volume, maternal body habitus, gestational stage, fetal position and cleft type are all factors in diagnosing a fetus with a cleft lip 4 3D sonography is more accurate in visualizing a cleft lip https://www.google.com/search?q=ultrasound+of+a+fetus&client=firefox-b-1-d&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiD47Ko94nhAhXBx4MKHT3xCMkQ_AUIDigB&biw=1366&bih=654

Images with Ultrasound R unilateral cleft lip  Cleft palate and cleft lip Bilateral cleft lip

Detection with MRI MRI demonstrates coronal views to visualize the fetal nose and lip Axial views are used to demonstrate the alveolus, to see if a cleft palate is present 5 Direct visualization of a soft palate is better seen on MRI A unilateral cleft lip can be subtle on MRI until the third trimester 5 MRI may become more common in detecting cleft lip and cleft palates in vitro because more fetal facial anatomy can me be visualized  https://www.ajronline.org/doi/full/10.2214/ajr.183.1.1830229

Unilateral cleft lip and palate Imaging with MRI Unilateral cleft lip Unilateral cleft lip and palate Cleft soft palate

Who is Responsible for the Plan and Action Team? Many doctors are needed in the process of finding the best surgical plan for an infant with a cleft lip and/or palate Psychologists, surgeons, orthodontists, prosthodontists, pediatric dentists, and speech pathologists, are all used to obtain ideal soft tissue and hard tissue continuity, facial symmetry, functional and esthetic dentitions, excellent nasal architecture to create a subtle lip scar 6 https://www.vectorstock.com/royalty-free-vector/stylish-and-positive-team-of-doctors-vector-21048945

Age Surgery can be Performed Surgery is based on how severe the prognosis is and may be different from child to child On average 7 Cleft lip repair: within the first 3 to 6 months of age Cleft palate repair: by 12 months or earlier if possible Follow-up surgeries: between 2 years old and late teens

Demonstration of a Cleft Lip Repair https://www.youtube.com/watch?v=zH7g3NFVHeA

Personal Story My sister was pregnant with a baby girl that was diagnosed with a suspected cleft lip at her 20th week growth ultrasound She then came back for a re-check and the doctors could not get a good look at the palate but suspected a bilateral cleft lip and cleft palate in the 3-D images With this being the worst case scenario, she was advised to meet with a cleft team and was warned that the baby may need over 20 surgeries to correct Speech, eating and hearing could all be effected with a bilateral cleft lip and a cleft palate

Personal Story Continued With much research, she met with a cleft team from UW Madison Children's Hospital at 32 weeks pregnant The cleft team included a plastic surgeon, an ENT, speech pathologist, dentist and a social worker Jayde was then born with a unilateral cleft lip and the worst case scenario was not an issue anymore She was able to start breastfeeding right away Surgery needed to be performed to have her cleft lip repaired At 5 days old they started to use tape to help pull the skin to make it more flexible for her lip reconstruction at 10 weeks old At age 5 a nose realignment will be done Bone graft for her cleft alveolus will be performed around age 9-10

Give Back There are many organizations that raise money to help families who struggle with the financial burden they may face  There are also groups that bring people together to share their story and meet people in the same situation they are in  If you are interested in learning more about these groups, please visit them: CLAPA Little Baby Face Foundation Operation of Hope Smile Train Smiletrain.org

Conclusion A cleft lip and/or palate is one of the most common birth defects in children world wide There are also many forms, such a unilateral or bilateral cleft lip Ultrasound is the number one way of diagnosing this defect but with MRI, more facial anatomical features can be visualized Many people are a part of the surgery process due to overlying issues that may arise Speech, eating, and dental With this being so common, look around your area to help those in your community

References https://www.clapa.com/what-is-cleft-lip-palate/ Mossey, P. A., PhD, Little, J., PhD, Munger, R. G., PhD, Dixon, M. J., PhD, & Shaw, W. C., PhD. (n.d.). The Lancet. Cleft Lip and Palate, 374(9703), 1773-1785. Retrieved March 07, 2019.  Brito, Meira, Kobayashi, & Passos-Bueno. (2012, November 1). Cleft lip and Palate. Retrieved March 7, 2019, from https://www.asha.org/practice-portal/clinical-topics/cleft-lip-and-palate/ Gupta RC. Cleft lip and Palate. UW Health . https://www.uwhealthkids.org/kidshealth/en/parents/cleft-lip-palate.html/. Published October 14, 2014. Accessed March 5, 2019 Kim DW, Chung SW, Jung HD, Jung YS. Prenatal ultrasonographic diagnosis of cleft lip with or without cleft palate; pitfalls and considerations. Maxillofac Plast Reconstr Surg. 2015;37(1):24. Published 2015 Aug 14. doi:10.1186/s40902-015-0019-z    Prenatal Diagnosis of Cleft Lip and Cleft Palate Using MRI : American Journal of Roentgenology : Vol. 183, No. 1 (AJR) https://www.ajronline.org/doi/full/10.2214/ajr.183.1.1830229 Guerrero CA. Cleft lip and palate surgery: 30 years follow-up. Ann Maxillofac Surg. 2012;2(2):153- 7.  1998-2019 Mayo Foundation for Medical Education and Research (MFMER) https://www.mayoclinic.org/diseases-conditions/cleft-palate/diagnosis-treatment/drc-20370990 https://www.clapa.com/what-is-cleft-lip-palate/

Image References https://www.clapa.com/what-is-cleft-lip-palate/ https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html Mossey, P. A., PhD, Little, J., PhD, Munger, R. G., PhD, Dixon, M. J., PhD, & Shaw, W. C., PhD. (n.d.). The Lancet. Cleft Lip and Palate, 374(9703), 1773-1785. Retrieved March 07, 2019.  https://www.google.com/search?biw=1920&bih=985&tbm=isch&sa=1&ei=twGdXKStJMOwj wSkqIHAAg&q=+nipple+shield&oq=+nipple+shield&gs_l=img.3..0i67j0l9.595010.596538..5968 40...0.0..0.62.151.3....3..0....1..gws-wiz-img.......0i7i30.T_1ETMlF8is https://www.google.com/search?q=ultrasound+of+a+fetus&client=firefox-b-1- d&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiD47Ko94nhAhXBx4MKHT3xCMkQ_AUIDigB &biw=1366&bih=654 Prenatal Diagnosis of Cleft Lip and Cleft Palate Using MRI : American Journal of Roentgenology : Vol. 183, No. 1 (AJR) https://www.ajronline.org/doi/full/10.2214/ajr.183.1.1830229 Youtube.com surgery of cleft lip https://www.youtube.com/watch?v=zH7g3NFVHeA https://www.vectorstock.com/royalty-free-vector/stylish-and-positive-team-of-doctors- vector-21048945 Smiletrain.org