From Infancy to Adulthood – What to Expect
Ages Birth to Five Years.
During the first two years of life, the cleft lip and/or palate are surgically repaired. Timing of these events is detailed in previous sections.
The first five years is a time when ear problems may be present, especially in children with cleft palate. Regular assessments by the otolaryngologist are necessary to check the grommet tubes, to maintain a healthy middle ear and to prevent hearing loss.
Regular six-month checkups are performed by the plastic surgeon to assess the effects of cleft lip, cleft palate and nose surgery. If no complications arise and aesthetic and functional results are satisfactory to the parents, additional surgery will not be performed. At a later age, some changes in appearance or function may require surgical correction.
In children who have more marked deformities, secondary lip or nasal surgery may be recommended. In addition, surgery may be necessary to correct any residual deformity, excessive scarring or other problems. Six month checkups will also be performed by the speech pathologist to monitor the functioning of the speech mechanism and speech development. If speech problems arise at four to five years of age, another surgery to correct speech production may be necessary.
The pedodontist will also see the child regularly to assure good oral hygiene and to correct any problems involving the primary (baby) teeth. Maintaining healthy primary teeth is important to good development of the secondary or permanent teeth. Regular six-month checkups are recommended.
The early years lay the foundation of the child’s healthy social and psychological development. A psychosocial evaluation is available through a physician’s referral if problems in this area arise.
Ages Five to Ten Years.
During the ages of five to ten years, the child is placed in active orthodontic treatment. If bone grafting is required to correct the alveolar ridge, it is usually done during this time. Final speech assessment is also completed.
If speech problems are diagnosed, speech therapy begins. Speech problems that are caused by a shortening of the soft palate or velopharynx are called velopharyngeal insufficiency and may require additional surgery. One of the procedures used to surgically correct velopharyngeal insufficiency is a pharyngeal flap. Another procedure is a pharyngoplasty.
Periodic assessments by all members of the cleft palate team allow for the timely discovery of problems that require additional intervention. The problems may require surgical treatment by a plastic surgeon, the continuation of treatment by ear specialists, additional speech evaluation or several consultations with psychologists and social workers.
Ages Ten Years to Adult.
During adolescence, orthodontic treatment is completed and residual speech problems are corrected. Surgery is aimed at balancing and refining facial appearance, as well as at achieving normal function.
Secondary nasal surgery is aimed at improving the shape of the nose and relieving any obstruction to facilitate the easy flow of air through the nostrils. Surgery may be required to correct any deformity or crookedness of the nasal septum. External reconstruction of the nose may involve cartilage grafts taken from the nasal septum or the ear. These grafts help to repair contour deficiencies or irregularities of the nasal shape. To improve breathing, the surgeon may need to straighten the septum.
Many patients have nasal congestion because of the enlargement of hypertrophy of the nasal turbinates. The nasal turbinates are the three small bones which project into the nasal cavity and serve to clean and warm inhaled air as it passes over them during breathing. If enlargment of the turbinates obstructs breathing, surgical correction may be needed. The procedure may involve removal of part or all of the affected nasal tubinates.
As indicated in the section on orthodontic treatment, approximately ten percent of patients, primarily those with complete unilateral ceflt of the lip, alveolus and palate and expecially those with bilateral cleft of the lip, alveolus and palate – may require secondary surgical correction of jaw deformities. Achieving facial balance requires assessment of the size and positioning of the jaws. Through orthodontic and dental treatment, good alighment, positioning and occulsion of the teeth may be obtained even though the jaws may remain underdeveloped (mostly the upper jaw) or overgrown (mostly the lower jaw).
One cleft abnormality is related to the size and position of the upper jaw because of its dficient growth and development. The upper jaw may not only be smaller than normal, but also may be positioned too far bac k into the face (retrodisplacement). In this condition, the upper jaw does not properly meet with the lower jaw, and the face appears flattened.
If the teeth occlude well, the facial bones can be built up by using autgenous or demineralized bone grafts. This surgery can be performed at the same time as the alveolar bone grafting or at a later time when nasal reconstruction or final jaw positioning and facial contouring is performed. All incisions are made inside the mouth to avoid the scarring of facial skin.
Left: Obtaining the bone graft from the hip (iliac crest). Right: Bone chips packed intot he alveolar cleft.
Bony defect in the alveolus of a patient with unilateral cleft lip, alveolus and palate.
Following bone grafting, eruption of the normal dentition in the upper jaw.
If occlusion is abnormal despite orthodontic treatment, surgery is performed to correct the jaws and position of the teeth in proper occlusion. Surgery on the jaws in which the bones are cut and moved in called orthgnathic surgery. When bone is cut, the procedure is called an osteotomy. After the bones are cut, repositioned and placed appropriately, they are fixed in position with special plates, screws and/ or prosthetic devices.
Secondary deformity following unilateral cleft lip/ nose repair performed outside of our institution. Note the severe nasal asymmetry. The same patient after correction of the nasal deformity completed by using Dr. Salyer’s technique.
Note the severe nasal asymmetry. Perfect nasal Symmetry after corrective surgery.
In the cleft patient, the upper jaw often must be moved forward as well as lengthened vertically in order to correct the existing deficiencies. A change in the position or contour of the chin may also be required. when the lower jaw grows too far forward, it must be moved backward to balance the upper jaw and to fit the position of the upper teeth.
Lip and Nasal Deformity following bilateral cleft lip/ nose repair performed outside of our institution. Correction of the Lip, Nose and Skeletal Deformity. Result shown one year after surgery.
With contemporary surgical techniques and abilities, orthognathic surgery is done efficiently. new techniques for immobilizing the reconstructed jaws during healing eliminate the need for wiring the jaws together. the healing time for the bony segments is approximately six weeks to three months. during this time, jaw activity myst be limited. A soft or pureed diet is necessary during the healing period.
A bone transplant fromt he skull is used to improve the contour of the cheekbone.
The optimal time for surgery to correct skeletal deformities is after the complete eruption of the secondary dentition (permanent teeth) and after the proper positioning of teeth by the orthodontist. the child is usually fourteen to sixteen years of age. Proper early care reduces the chance that your child will have to undergo this surgery. Other refinements include secondary scar revisions, final touch ups of the lip and dermabrasion. The decision to pursue these refinements is based ont he opinions of the sdolescent and his or her parents.
