1. C33 Cleft Lip and Palate

2. 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

3. 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. 

4. 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

5. 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

6. 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

7. 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 

8. 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

9. 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

10. 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

11. 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

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

13. 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 

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

15. 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

16. 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

17. Demonstration of a Cleft Lip Repair

18. 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

19. 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

20. 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

21. 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

22. 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), Retrieved March 07, 2019. 
Brito, Meira, Kobayashi, & Passos-Bueno. (2012, November 1). Cleft lip and Palate. Retrieved March 7, 2019, from
Gupta RC. Cleft lip and Palate. UW Health . Published October 14, 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: /s z
   Prenatal Diagnosis of Cleft Lip and Cleft Palate Using MRI : American Journal of Roentgenology : Vol. 183, No. 1 (AJR)
Guerrero CA. Cleft lip and palate surgery: 30 years follow-up. Ann Maxillofac Surg. 2012;2(2):  
Mayo Foundation for Medical Education and Research (MFMER)

23. Image 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), Retrieved March 07, 2019. 
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Prenatal Diagnosis of Cleft Lip and Cleft Palate Using MRI : American Journal of Roentgenology : Vol. 183, No. 1 (AJR)
Youtube.com surgery of cleft lip 
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Smiletrain.org