Cleft Lip and Palate Treatments

During early pregnancy separate areas of a child’s face develop individually and then join together, including the left and right sides of the roof of the mouth and lips. However, if the sections don’t meet the result is a cleft. If the separation occurs in the upper lip, the child is said to have a cleft lip.
A completely formed lip is important not only for a normal facial appearance but also for sucking and to form certain sounds made during speech. A cleft lip is a condition that creates an opening in the upper lip between the mouth and nose. It looks as though there is a split in the lip. It can range from a slight notch in the colored portion of the lip to complete separation in one or both sides of the lip extending up and into the nose. A cleft on one side is called a unilateral cleft. If a cleft occurs on both sides, it is called a bilateral cleft.
A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum into separate parts. A similar defect in the roof of the mouth is called a cleft palate.

Cleft Palate

The palate is the roof of your mouth. It is made of bone and muscle and is covered by a thin, wet skin that forms the covering inside the mouth. You can feel your own palate by running your tongue over the top of your mouth. Its purpose is to separate your nasal cavity from your mouth. The palate has an extremely important role during speech because when you talk it prevents air from blowing out of your nose instead of your mouth. The palate is also very important when eating; it prevents food and liquids from going up into the nose.
As in cleft lip, a cleft palate occurs in early pregnancy when separate areas of the face develop individually and do not join together properly. A cleft palate occurs when there is an opening in the roof of the mouth. The back of the palate is called the soft palate and the front is known as the hard palate. A cleft palate can range from just an opening at the back of the soft palate to a nearly complete separation of the roof of the mouth (soft and hard palate).
Since the lip and palate develop separately, it is possible for a child to be born with a cleft lip, palate or both. Cleft defects occur in about 1 out of every 800 babies. Cleft lip and palate may or may note be associated with other syndromes, but the majority remain as isolated findings in a child.
Children born with one or both of these conditions usually need the skills of several professionals to manage the problems associated with the defect such as feeding, speech, hearing, and psychological development. In most cases, surgery is recommended at various stages of growth and development.

Cleft Lip Treatment

Cleft lip surgery is usually performed when the child is about ten years old. The goal of surgery is to close the separation, restore muscle function, and provide a normal shape to the mouth. The nostril deformity may be improved as a result of the procedure, or may require a subsequent surgery.

Cleft Palate Treatment

A cleft palate is initially treated with surgery safely when the child is between 7 to 18 months old. This depends upon the individual child and his/her own situation. For example, if the child has other associated health problems, it is likely that the surgery will be delayed.

The major goals of surgery are to:

1. Close the gap or hole between the roof of the mouth and the nose
2. Reconnect the muscles that make the palate work
3. Make the repaired palate long enough so that it can perform its function properly

There are many different techniques that surgeons will use to accomplish these goals. The choice of techniques may vary between surgeons and should be discussed between the parents and the surgeon prior to surgery. After the palate has been fixed children will immediately have an easier time swallowing food and liquids. However, in about one out of every five children that have the cleft palate repaired, a portion of the repair will split, causing a new hole to form between the nose and mouth. If small, this hole may result in only an occasional minor leakage of fluids into the nose. If large however, it can cause significant eating problems, and most importantly, can even affect how the child speaks. This hole is referred to as a “fistula,” and may need further surgery to correct.

Alveolar Cleft Treatment

The cleft hard palate (alveolus) is generally repaired between the ages of 8 and 12, when the canine (eye) teeth begin to develop. The procedure involves placement of bone from the hip into the bony defect, and closure of the communication from the nose to the gum tissue in three layers. It may also be performed in teenagers and adults as an individual procedure, or combined with corrective jaw surgery.

Fast Facts About the Alveolar Bone Graft:

1. An alveolar bone graft is a surgery to add bone to the gum ridge in a child who was born with both a cleft lip and a cleft palate.
2. The alveolar bone graft is done several years after the child’s first cleft lip and cleft palate repairs.
3. The timing of the alveolar bone graft is very important because it must be done as the child begins losing his or her baby teeth, before the permanent teeth come in.  
4. As every child is different, the best age at which to do the alveolar bone graft will be different for every child. Most children who have an alveolar bone graft are between the ages of 7 and 9 years old.
5. Your child’s alveolar bone graft surgery will be done under general anesthesia, which means that he or she will be sound asleep during the surgery and will have no memory of it.
6. When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.
7. This surgery usually takes between 1.5 and 2.5 hours, depending on the type and size of graft your child needs.
8. Your child is will usually only need to spend 1 night in the hospital.

What Is An Alveolar Bone Graft?

Some children who are born with both a cleft lip and a cleft palate also have a problem with the alveolar bone, which makes up the gum ridge or front portion of the roof of the mouth. The alveolar bone is a thin layer of bone that forms the sockets around the roots of the upper teeth under the gum tissue.

When there is a cleft in the alveolar bone, it means there is a fistula or hole from the mouth to the nose. This cleft in the bone and gums prevents teeth from growing properly and the floor of the nose from developing normally. Fixing the cleft to allow for proper tooth development is important to a child’s health because missing teeth can have a negative effect on eating, digestion, facial growth and appearance. In addition, a child’s smile is an important part of his or her personality, and missing or poorly aligned teeth can have a huge negative impact on a child’s self-esteem. 

The alveolar bone graft repairs the hole in the gum ridge and stabilizes the bone arch, providing better support for the base of the nose and new bone for the roots of the developing teeth to grow into. The surgery usually is done when the child’s permanent canine teeth are three-quarters formed.

To do the bone graft, a piece of bone usually will be taken from your child’s iliac crest, the upper ridge of the hip bone. The doctor will make a 2-4 cm incision or cut in the skin just over the hip bone and in the bone itself to remove the inner portion of the bone. This part of the bone, called marrow or cancellous bone, is soft and can be shaped to form the patch that will close the hole in the alveolar bone. Gum tissue inside your child’s mouth then will be closed around the bone and sutures or stitches will hold the tissue in place as it heals. 

Home Preparation

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery. If these instructions are not followed exactly, it is likely your child’s surgery will be cancelled.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age. Following are the usual instructions given for eating and drinking.

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, juices with pulp, and chewing gum or candy.
• Up to 2 hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid® and juices you can see through, such as apple or white grape juice.
• In the 2 hours before the scheduled arrival time, give nothing to eat or drink.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold during the surgery.

The Surgery

Your child’s alveolar bone graft will be done at BC Children’s Hospital or Nanaimo Regional General Hospital.  When you have checked in, you and your child will be called to an examination room where your child’s health history will be taken and vital signs will be checked.

You will meet with one of the doctors on your child’s surgical team to go over the surgery. They will answer any last-minute questions you might have at this time. A member of the anesthesia staff also will meet with you and your child to review his or her medical information and decide which kind of sleep medication he or she should get. As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
When it is time for your child to go the operating room, you will be asked to wait in the surgical family waiting area.  

A Parent’s/Guardian’s Role

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

While Your Child is Asleep

While your child is asleep, his or her heart rate, blood pressure, temperature and blood oxygen level will be checked continuously. To keep your child asleep during the surgery, he or she may be given anesthesia medication by mask, through the IV or both. When the surgery is over, the medications will be stopped and your child will begin to wake up.

After Surgery

When your child is moved to the recovery room, you will be called so that you can be there as he or she wakes up. 

Your child will need to stay in the recovery room to be watched until he or she is alert and vital signs are stable. The length of time your child will spend in the recovery room will vary because some children take longer than others to wake up after anesthesia.

Children coming out of anesthesia may react in different ways. Your child may cry, be fussy or confused, feel sick to his or her stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off. 

Your child will have sutures (stitches) in the roof of his or her mouth. These sutures are all “dissolvable,” meaning that they do not need to be removed. As the skin inside the mouth heals, the parts of the sutures under the skin will dissolve on their own, and the parts you can see on the outside of the skin will melt away in the normal course of eating and drinking over the next 2 weeks. 

Your child also will have sutures on his or her hip where bone for the graft was taken out. These sutures also are dissolvable. The parts of the sutures under the skin will dissolve on their own, and the parts you can see on the outside of the skin will dry up and fall off. The sutures on the hip may be covered by a gauze dressing.

Some children may receive a special kind of retainer called a “splint” to keep the teeth stable as the bone graft heals. If your child gets a splint, it may be the kind that pops in and out of the mouth or the kind that is glued into the mouth, depending on your child’s surgery. The glued-in splints usually are taken out about 2 to 4 weeks after surgery by an orthodontist.

Your child may complain of a dull ache at the site of the hip incision. This ache is normal and can be controlled with pain medication. Your child can be given pain medication every 4 to 6 hours, as needed, when he or she wakes up.

When your child is alert, he or she will be moved to a hospital room so the nursing staff can continue his or her care. If you need help, the nurse will show you how to feed your child and clean his or her scar so that you will become comfortable caring for your child at home.

Going Home

After the surgery, and for the weeks afterward at home, your child will only be allowed to drink liquids or semi-liquids from a cup. No utensils or straws should be used until your child’s surgeon says it is OK.

Within the first 24 hours after the surgery, while your child is still in the hospital, he or she will be allowed to drink clear liquids from a bottle or cup. Your child will stay in the hospital until he or she is drinking well and urinating normally.

Your child may be given a prescription medication for pain relief when he or she leaves the hospital, but most children only need over-the-counter Tylenol or ibuprofen once they get home. Your child may be given an antibiotic to take for the first couple of days after surgery.

At-Home Care

A complete list of instructions for taking care of your child at home will be given to you before you leave the hospital. The main things to remember are:

If you notice any of the following changes in your child, call the surgeon right away:

• Fever higher than 38˚C/101˚F
• Trouble breathing or skin color changes (pale, blue or gray)
• Bleeding or foul-smelling drainage from the scar
• Signs of dehydration, including lack of energy, sunken eyes, dry mouth, or not urinating enough

Your child can drink any kind of liquid once he or she gets home. Your child may also eat any kind of food that can be watered down and poured from a cup or syringe, including yogurt, pudding, milkshakes, or anything that you can grind in a blender to be as smooth as baby food. Remember, though — no utensils or straws! After drinking any milk products, have your child drink clear water to wash out the mouth and prevent the buildup of milk along the incision. 

Your child will be allowed to shower once he or she goes home. Ususally there is a clear plastic dressing glued onto the hip incision — leave this water-tight barrier in place and your child may shower regularly.  

When your child’s mouth has fully healed, usually about 6 weeks after surgery, he or she will be ready to resume orthodontic treatment to prepare for his or her permanent teeth to come in. Once the canine teeth have come in, the orthodontist can put on braces to guide the teeth into their proper position.

Your child should not participate in any strenuous physical activity for 1 week after surgery. Your child’s doctor will tell you when your child may resume contact sports, usually 4 to 6 weeks after surgery.

Special Needs

If your child has any special needs or health issues you feel the doctor needs to know about, or if you have any questions, please call 250-753-6671 before the surgery and ask to speak with the cleft clinic coordinator. It is important to notify us in advance about any special needs your child might have.