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Unilateral
Unilateral cleft lip may involve part of the lip or the entire height of the lip. The degree of clefting in partial cleft lip may range from vermilion only to two-thirds of lip height. The orbicularis oris muscle may be divided only at the lower portion of the lip while the rest of the muscle and skin remain intact. In many cases of partial unilateral cleft lip, the orbicularis oris muscle may be divided completely, creating a groove of the skin. Separation of the muscle may cause it to bulge on both sides of the cleft.
In complete cleft lip, the asymmetric division of the orbicularis oris muscle causes a functional imbalance which impairs the function of the lip created by the abnormal attachment of the muscle on each side of the cleft.
To surgically repair the cleft and to provide for normal facial movement, the surgeon must free the muscle on each side of the cleft from its abnormal attachment and reconstruct it in a normal, horizontal configuration.
The partial or complete unilateral cleft always follows the philtral column on the affected side. Also, completely displaced is the Cupid's bow which must be reconstructed at the time of primary lip repair
Unilateral Incomplete Cleft of the Lip. A single cleft of the upper lip may be a simple notch on the border, or it may extend vertically into the upper lip in a V-shaped fashion. Those clefts that extend slightly beyond the vermilion border may change the shape of the nostril on the cleft side.
Unilateral Cleft Lip on the left side (Partial). Note the co-existing nasal deformity.
The same child following cleft lip/nose repair after using Dr. Salyer's technique.
In the great majority of cases, unilateral cleft lip is associated with a very typical nasal deformity. The nostril on the cleft side is larger than on the normal side, and it is more horizontal than oblique. The tip of the nose is lower on the cleft side, and the columella is shorter.
Unilateral cleft lip is the mildest cleft form, affecting only the lip and not affecting speech nor dentition (the development and erupting of teeth). Surgery is the only treatment required and is usually performed at approximately three months of age when the child weighs at least ten pounds. Secondary corrections, when necessary, may be performed between the ages of one and five years.
Unilateral Cleft of the Lip and Alveolus
In this cleft form, the lip is split completely and involves both the alveolar bone and ridge. This cleft is a deficiency of tissue in the floor of the nose and bony deficiency in the alveolus. Usually the lateral incisor is missing and the teeth next to the alveolar cleft may be rotated or displaced. The deformity of the lip and nose is the same as that previously described. However, the treatment of unilateral cleft lip and alveolus requires more than surgery. It also requires orthodontic treatment.
Unilateral Complete Cleft of the Lip and Alveolus. The lip is split completely on one side, and the cleft extends through the horseshoe-shaped alveolar bone and into the palate. The nose may be severely deformed in this cleft form. Also, significant disruption in tooth growth and position can be expected.
Surgical treatment involves cleft lip and nose repair in the first operation and is usually performed at three months of age. In most cases, further correction of both the lip and nose is necessary, but the age at which the second surgery is performed depends upon the growth and development of the facial structures. Surgical treatment also involves alveolar bone grafting which may be performed between seven and nine years of age.
Unilateral Complete Cleft of the Lip, Alveolus and Palate
In this cleft form, which is the most common, clefting involves the lip, alveolus and palate. Since the cleft is asymmetrical, it splits the lip, upper jaw and palate into two uneven portions. These two bony segments are often malpositioned and may require proper realignment before the first surgery is performed. In this cleft, the lip is completely separated, the nasal floor is absent and the alveolus and palate have space between the two halves. The palatal defect creates an open communication between oral and nasal cavities so that food and fluids from the mouth can pass easily into the nose. This requires special feeding precautions which will be discussed later.
The presence of a palatal cleft interferes with normal speech production, and, even after the palatal cleft is closed, speech may still be affected, requiring further treatment by speech pathologists and surgeons. The width of the space may vary; the wider the cleft is, the more difficult the treatment will be. This cleft presents one of the most difficult surgical problems and requires a very skilled and experienced surgeon.
Unilateral Complete Cleft of the Lip, Alveolus and Palate. This is the most severe and most common form of unilateral cleft. All anatomical structures--the lip, alveolus and palate--are split into two uneven segments. These segments may be in different positions. The nose is severely affected. The dentition bordering the cleft is always displaced and may require long-term orthodontic treatment. After palatal surgery, speech may remain affected in approximately twenty-five percent of patients. When this occurs, another surgery is required.
The treatment usually starts with presurgical orthodontic treatment which approximates the bony segments into a better position to facilitate lip and nose repair. This operation is performed at approximately three months of age. It is followed by cleft palate repair which is performed between nine to eighteen months of age. Most patients require further lip and nose corrections which are performed at a later age at the discretion of the surgeon and parents. Orthodontic treatment may continue for several years until normal occlusion is achieved. In the great majority of cases, there is a need for alveolar bone grafting which is performed between seven to nine years of age. This cleft requires close interaction with a speech pathologist since these patients may need long-term speech therapy, and approximately twenty percent of them need a pharyngeal flap.
Unilateral Complete Cleft of the Lip. Note the malpositioning of the orbicularis oris muscle and the flattened nostril.
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