Melbourne Cleft Service

Types of cleft

Cleft lip and palate

A cleft of the lip and palate is an abnormal gap or opening in the upper lip and roof of the mouth which extends from the lip up to the nostril and back through the roof of the mouth. It can affect just one side (called a unilateral cleft lip and palate) or both sides (a bilateral cleft of the lip and palate).

Because the lip and the palate develop separately and at different times during pregnancy it is possible for a baby to be born with only a cleft lip or a cleft palate or a combination of the two.

Cleft lip

A cleft lip is a gap or opening in the upper lip. Sometimes the gum behind the lip (called the alveolus) can also be affected. A complete cleft of the lip is where the gap or opening extends from the lip all the way up to the nostril. An incomplete cleft lip is where the gap in the lip ends before reaching the nostril. Both can occur on one side (unilateral) or both sides (bilateral).

Cleft lip information

Cleft palate

The palate forms the roof of the mouth and normally separates the mouth from the nose. A cleft palate is an opening in the roof of the mouth which may involve just the soft palate at the back of the mouth or extend further forward into the bony, hard palate.

Cleft palate information

Cleft care pathway

Surgery

Surgical repair of the clefts of the lip and/or palate usually occurs in the first 12 months of life, depending on the individual child, their general health and the extent of the cleft. Babies with a cleft of the lip often have their surgery between 3 and 6 months of age while those with a cleft palate will have their surgery around 12 months of age. Infants who have a diagnosis of Robin Sequence as well as a cleft palate may have their palate surgery a little later.

For further information about these first surgeries please see Cleft Lip Repair (pre-operative and post-operative information) and Cleft Palate Repair (pre-operative and post-operative information).

Cleft lip repair preoperative information

Cleft lip repair postoperative information

Cleft palate preoperative information

Cleft palate repair post-operative information

Pre-surgical orthopaedics: Naso-Alveolar-Moulding

Naso-Alveolar-Moulding or NAM may be recommended by the plastic surgeons performing the first surgery in infants with wide unilateral clefts and complete bilateral clefts of both the lip and palate. NAM is carried out by one of our orthodontists and involves using an orthodontic plate to mould and move the segments of the cleft (i.e. the gum pads, lips and nostrils) in to a more favourable position to make the surgery easier. An impression (a mould of the baby’s mouth) needs to be taken soon after birth and a plate is then made that needs to be worn more or less all the time by the baby. The plate needs constant modification from the time it is first fitted until the time of lip surgery (between 3 and 6 months of age) to accommodate growth.

Nasoalveolar moulding information

In addition to the various surgeries, there are a number of important areas to consider in the care of children born with CL/P. These include:

Feeding

The palate is important in generating suction for feeding in babies. Children with an unrepaired cleft palate will typically have difficulties creating enough suction to get sufficient milk from the breast or teat. In addition they may have difficulty compressing a nipple or teat if there is not enough gum or palate to compress against. This can make feeding a long and tiring process for both baby and mother.

These problems can be solved using specialist cleft bottles and teats and help support/advice can be provided by our cleft nurse specialist with help from our speech pathologists and paediatrician as necessary.

Cleft lip and palate infant feeding information

Hearing

Children with a cleft of the palate are prone to hearing difficulties related to fluid in the middle ear. Every baby with a cleft palate should have their hearing monitored closely by an audiologist starting around the age of 4 weeks and repeated again at around 3 months +/- a consultation with an ENT surgeon.

Some babies may require small tubes (called grommets) to be put in to the eardrums to drain the fluid. This is often done at the same time as the palatal surgery.

Cleft and hearing information

Speech

The palate is also important in speech because of its ability to make a seal at the back and sides of the throat which stops air entering the nose. This is particularly important for certain sounds (p, b, t, d, etc) and for the ‘tone’ of voice.  When the palate is not working properly the air can escape in to the nose which makes it difficult for the individual to make all the right sounds and affects their tone of voice both of which can make them difficult to understand. This can be frustrating.

All children with a cleft should be monitored carefully by a specialist cleft speech pathologist as part of their cleft care. Sometimes some speech therapy can help but on other occasions children may need further surgery on their palate.

Cleft palate and speech information

Teeth

Many children born with a cleft of the lip/palate will also have missing teeth, particularly around the area of the cleft gap. They can also have extra teeth (supernumerary) or poorly formed (hypoplastic) teeth and are likely to have crowded or twisted teeth and so may want to have braces as they get older to improve the appearance and health of their teeth. Children with clefts of the lip and palate often need to have two lots of orthodontic (braces) treatment; one sometime between 8 and 12 years of age to expand the upper jaw to help make room for the adult teeth and a second phase of full braces fixed on to both upper and lower teeth later in adolescence.

It is really important for children born with a cleft, to look after their teeth from a very early age. At the RCH, we encourage all infants to be seen by a paediatric dentist in the Department of Dentistry around about 18 months of age to provide advice and information to parents about keeping the mouth healthy. When necessary the paediatric dentist will refer children to the specialist orthodontists. The Department of Dentistry will also provide information on the Medicare Cleft Lip and Palate Scheme which can help to cover the costs of some aspects of dental and orthodontic treatment.

Cleft lip and palate Medicare scheme

Cleft and teeth

For further information please contact Ms Pru Talbot, pru.talbot@rch.org.au or Dr Nicky Kilpatrick, Director of Cleft Services, nicky.kilpatrick@rch.org.au