Cleft Lip and Palate: The Unsolicited Streak

Cleft palate is the third most common congenital deformity
subsequent to clubfoot and the cleft lip [1]. It is seen as anatomical...


Introduction
Cleft palate is the third most common congenital deformity subsequent to clubfoot and the cleft lip [1]. It is seen as anatomical changes which involves the upper lip, nose, and the palate [2].
It represents roughly about 65% of the malformations of the craniofacial section [3]. In this, unilateral cleft lip and palate have been found to have the majority at 46%, followed by isolated cleft palate accounting for 33% of cases. These two being the most common diagnosis among the cleft lip and palate population followed by the others [1].Cleft lips show racial unpredictability, with the highest incidence seen among Asian and Native Americans (1:450 live births) and the lowest incidence seen in the African Americans (1:2,000 live births) [4]. Isolated cleft palate is seen more commonly in females (57%) than in males (43%), with gender differences attributable to the differences in the timing of the embryologic development [4]. About 50% of the isolated cleft palates are found to be in relation with a malformation syndrome, in comparison 15% of combined cleft lip and palate patients without any syndrome [5]. Velocardiofacial syndrome (VCFS) has been found to be the most common syndrome, which is associated with isolated cleft palate [6]. Other etiological factors associated with cleft palate are gestational exposures to alcohol, cigarette smoking, steroids, rubella, anticonvulsants, retinoids, advanced paternal age, folate deficiency and hypoxia [7][8][9]. An affected parent having a child with a cleft palate is 7%. If one sibling has a palatal cleft with no parental clefts, then future siblings have 2% jeopardy of developing a cleft. That risk upsurges to about 17% if there is one affected sibling and a parent with a cleft [10].

Anatomy
The palate is divided into the primary and the secondary palate.
The primary palate comprises of the alveolar arch and secondary palate comprises of the hard and the soft palate. The hard palate is formed by the palatine processes of the maxillae and by the horizontal lamina of the palatine bones. It is covered by oral and nasal mucosa [11].

Cleft classification
A cleft palate may be either unilateral or bilateral and is either complete or incomplete [12]. The Veau System classifies orofacial

Abstract
Cleft palate is the third most common congenital deformity subsequent to clubfoot and the cleft lip. It may be either unilateral or bilateral and is either complete or incomplete. A multidisciplinary team approach is important to accomplish the various façades pretentiously observed by orofacial cleft. The optimum time of surgical repair is based on the surgeon's preference, anesthetic risks, co-morbid congenital anomalies, and the apparent psychological impact on the family. Most surgeons repair the cleft lip around 10-12 weeks of age. Cleft palate and lip need early care and attention with a long-term follow-up which requires a team approach involving many specialties.

Management
A multidisciplinary team approach is important to accomplish the various façades pretentiously observed by orofacial clefting. The reconstructive surgeon, otolaryngologists, dentists, orthodontists, speech pathologists, audiologists, geneticists, psychiatrists, maxillofacial surgeons, prosthodontists, and social workers form the most important crucial members of the team treating the patients [17]. The procedure of cleft palate repair has been suggested and gained popularity over many years and is not a one-day ideology.
These techniques have undergone numerous modifications that are practiced today. The task of contemporary palatoplasty is not just the closure of the cleft palate but also is to enable optimal speech without compromising the maxillofacial growth [18]. hemoglobin 10g/dL, and white blood cell count <10,000mm3 [19].
It was Mallard who proposed the commonly used "rule of order 10" for the timing of repair stated as weight over 10lbs, hemoglobin over 10g/dL and over 10 weeks [20].

Volume 4 -Issue 5
Copyrights @ Karthik D Yadav, et al. Inter Ped Dent Open Acc J 358 speech development. Early repair has been shown to benefit speech development but may inhibit facial growth to a greater extent as transverse facial growth is not complete until 5 years of age. In the past, surgery on the palate was often delayed until maxillary growth was completed or when deciduous molars achieved proper occlusion. Recently, speech outcomes have taken precedence and as a result, most experts repair cleft palates beginning at 10 months of age [25][26][27][28]. Some advocate waiting until 2 years of age to operate on large cleft palates. Surgery on isolated soft palate clefts has been advocated as early as 3 months of age. The most common surgical techniques for repair of the soft palate are the Furlow doubleopposing Z-plasty and the intralveolar veloplasty. The bony palate is often repaired using the Von Langenbeck palatoplasty, the Veau-Wardill-Kilner palatoplasty, or a Bardach two-flap palatoplasty.
Vomer flaps are used in conjunction with the above hard palate repairs to repair the nasal mucosa [29,30]. Rhinoplasty in cleft lip and nose patients can lead to the formation of inclusion cysts, which can be either epidermoid or the mucous cysts, which is based on the type of the epithelium seen [31].  [32]. Vertical excess of the premaxilla has been a challenge for orthodontists and surgeons according to Meazzini et al. constituting a serious cosmetic problem that does not improve spontaneously with growth [33]. Orthodontic intrusion during the growth phase offers advantages such as the use of low-intensity forces, improves the relationship between the front teeth and upper lip due to control of the premaxilla, and allows further growth of the impaired maxilla in patients with bilateral cleft. In severe cases, such as 7-8 mm superior bulge, orthodontics alone is not enough to achieve the intended objectives and should not be indicated because of the risk of root resorption and, considering the expected mandibular growth, the good positioning of the premaxilla is important [33]. The two most common abnormalities after primary lip repair according to Koh are the loss of the philtrum setting and the obliteration of the cupid's bow [34]. Cleft lip and palate patients are at higher risk for chronic middle ear disease, hearing loss, hypochromic anemia, and hypoproteinemia, [35] particularly individuals from lower social classes. Patients undergoing Millard lip repair are at increased risk for development of cholesteatoma and tympanic membrane perforation. However, the type of palatoplasty and age did not influence the otologic and audiologic indicators of children of 5-6 years with unilateral cleft [36].

Conclusion
Cleft palate and lip need early care and attention with a longterm follow-up which requires a team approach involving many specialties. However, there are many complications associated with the cleft palate and lip, therefore a systematic approach is, was and always will be the need of the hour.