Cleft Lip and Palate Treatment Program

Cleft lip and palate are among the most prevalent congenital craniofacial anomalies, affecting the structural formation of the lip, alveolus, and palate. These defects result from incomplete fusion of facial tissues during embryogenesis, typically occurring between the 4th and 12th weeks of gestation. The severity and extent of the cleft can vary widely, ranging from subtle notching of the lip to complete separation of the lip, alveolar ridge, and both hard and soft palates.

Beyond their visible characteristics, cleft lip and palate can disrupt fundamental functions critical to a child’s development and quality of life. Impairments in oral feeding, proper speech articulation, auditory function (due to eustachian tube dysfunction and recurrent otitis media), and respiratory efficiency are common. The anatomical abnormalities often result in velopharyngeal insufficiency, making it difficult to produce normal speech sounds, and can interfere with maxillofacial growth and dental occlusion.

Timely diagnosis and treatment are essential for optimal outcomes. Early intervention not only addresses feeding and breathing difficulties but also prevents complications related to speech development, hearing, dental alignment, and facial growth. Surgical repair typically begins within the first year of life, with additional procedures and therapies planned as the child grows.

Why Cuba

Because of their complex and long-term effects, cleft lip and palate in Cuba are managed through a coordinated, multidisciplinary approach. Cuban treatment teams typically include oral and maxillofacial surgeons, otolaryngologists (ENT specialists), pediatricians, speech-language therapists, audiologists, orthodontists, prosthodontists, and mental health professionals. These specialists often work together under a unified care model, ensuring that both the functional and psychological aspects of the condition are addressed. Management extends well beyond surgery, focusing on long-term rehabilitation, speech development, social integration, and emotional support for the child and their family throughout infancy, adolescence, and adulthood.

Types and Classification of Cleft Lip and Palate

The types and classification of cleft lip and palate are based on the location, severity, and combination of the defects, which helps guide treatment planning and surgical timing.

• Cleft Lip Only (CL):
  • A cleft lip is a physical split or separation in the upper lip.
  • It may appear as a small notch or extend from the lip into the base of the nose.
  • This occurs when the tissues of the upper lip fail to join during fetal development.
  • Cleft lips may occur on one side (unilateral) or both sides (bilateral) and may involve the alveolus (gum line).

• Cleft Palate Only (CP):
  • A cleft palate is an opening in the roof of the mouth caused by incomplete fusion of the palatal shelves.
  • It can affect the hard palate, soft palate, or both.
  • This condition can lead to issues with feeding, speech, and ear infections due to improper separation between the oral and nasal cavities.

• Cleft Lip and Palate (CLP):
  • Combination of both deformities where both the upper lip and the roof of the mouth (palate) fail to fuse properly during fetal development.
  • This condition often presents with a gap in the lip that may extend into the nostril and continue through the alveolar ridge and the hard and soft palate.
  • The severity can range from a small notch in the lip to a complete separation involving both sides of the lip and palate.

Clefts are further classified by laterality, completeness, and anatomical involvement (primary or secondary palate).

• Laterality (One side or both sides):
  • Unilateral cleft: Affects only one side of the lip or palate.
  • Bilateral cleft: Affects both sides of the lip or palate.
  • Bilateral clefts are usually more severe and involve more complex reconstructive procedures.

• Completeness (Extent of the cleft):
  • Complete cleft: The cleft extends through the entire structure (e.g., from the lip through the nostril or from the hard palate into the soft palate).
  • Incomplete cleft: The cleft does not extend through the full anatomical structure; it may appear as a notch or partial separation.

• Anatomical Involvement:
  • Primary palate: Includes the lip, alveolus (gum ridge), and front part of the hard palate.
  • Secondary palate: Includes the back part of the hard palate and the soft palate.
  • A cleft may involve only the primary palate, only the secondary palate, or both.

Causes and Risk Factors of Cleft Lip and Palate

Cleft lip and palate are caused by a number of factors including:

• Genetic predisposition
• Environmental exposures during pregnancy (e.g., tobacco, alcohol, certain medications)
• Nutritional deficiencies (e.g., folic acid)
• Maternal illnesses or infections
• Syndromic associations (e.g., Pierre Robin sequence, Van der Woude syndrome)

Pre-treatment Diagnosis for Cleft Lip and Palate

A coordinated evaluation is conducted by a cleft care team that typically includes pediatricians, maxillofacial surgeons, ENT specialists, audiologists, orthodontists, and social workers to determine an individualized treatment plan.

• Comprehensive Clinical Examination
  • A detailed visual and physical examination is performed to identify any visible clefts of the lip and/or palate. The assessment includes:
    • The extent of the cleft (unilateral, bilateral, complete, or incomplete)
    • Feeding difficulties
    • Signs of associated anomalies

• Palatal Assessment
  • A thorough intraoral inspection is done to evaluate the hard and soft palate. Submucous clefts, which may not be visually obvious, are assessed by palpating the roof of the mouth for defects.

• Feeding and Airway Evaluation
  • Because cleft conditions often interfere with feeding and breathing, specialists assess:
    • Ability to suck and swallow effectively
    • Signs of nasal regurgitation or aspiration
    • Respiratory effort and airway stability

• Audiologic Screening
  • Children with cleft palate are at high risk for middle ear effusions and conductive hearing loss due to Eustachian tube dysfunction. A hearing evaluation is carried out using otoacoustic emissions (OAE) or auditory brainstem response (ABR) testing.

• Speech and Language Assessment (depending on the child’s age)
  • Early baseline assessments by a speech-language pathologist are critical to monitor early vocalizations and prelinguistic development.

• Imaging (if needed)
  • Though not routine in initial diagnosis, imaging studies such as nasoendoscopy or lateral skull X-rays may be ordered if the cleft anatomy is complex or if planning for secondary surgeries.

• Genetic and Syndromic Evaluation
  • A clinical geneticist may be involved when there are features suggestive of a genetic syndrome. This includes:
    • Detailed family history
    • Physical assessment for syndromic traits
    • Referral for chromosomal or molecular testing if indicated

Symptoms and Challenges of Cleft Lip and Palate

• Difficulty feeding or latching
• Nasal regurgitation of food
• Delayed or unclear speech development
• Frequent ear infections or hearing loss
• Dental problems (e.g., missing or displaced teeth)
• Psychosocial concerns due to appearance

Surgical Treatment Approach for Cleft Lip and Palate

Surgical management of cleft lip and palate is highly individualized, guided by the specific type, severity, and anatomical complexity of the defect, as well as the child’s age, overall health, and any associated syndromic conditions. While the overarching goal is to restore function and appearance, each case requires a customized timeline and approach. Broadly, the treatment plan includes two primary surgical procedures: cleft lip repair (cheiloplasty) and cleft palate repair (palatoplasty), each performed at strategic developmental milestones.

• Primary Cleft Lip Repair (Cheiloplasty)
  • Cleft lip repair is typically the first surgical intervention and focuses on restoring both function and aesthetics of the upper lip and surrounding nasal structures.

• Key objectives of the procedure include:
  • Reconstructing the normal anatomy and contour of the upper lip
  • Correcting associated nasal deformities
  • Constructing the floor of the nostrils and aligning the maxillary alveolar ridge (gum line)
  • Repositioning soft tissues and muscles to restore normal lip movement

• Timing:
  • Cheiloplasty is usually performed when the infant is between 3 to 6 months old, depending on medical readiness and weight gain. Early intervention supports feeding, social interaction, and psychosocial bonding.

• Bilateral Cleft Lip Repair:
  • In cases of bilateral cleft lip, repair may be performed in a single-stage surgery or in two separate stages, spaced at least 6 to 8 weeks apart, depending on tissue tension and surgeon assessment.

• Primary Cleft Palate Repair (Palatoplasty)
  • Palatoplasty is a more complex procedure aimed at restoring the roof of the mouth and is critical for the development of normal speech, swallowing, and middle ear function.

• Surgical goals include:
  • Closing the cleft in the hard and soft palate
  • Reconnecting and realigning the palatal muscles (especially the levator veli palatini) to restore proper function
  • Facilitating normal speech and phonation
  • Supporting facial skeletal development and Eustachian tube function

• Timing:
  • This surgery is generally carried out between 9 to 18 months of age, ideally before the child begins forming words. Delaying beyond this age may increase the risk of persistent speech impairments.

• Additional Surgical and Supportive Interventions
  • Depending on the child’s growth, response to initial surgery, and overall treatment goals, additional procedures may be necessary:

• • Secondary speech surgeries: For children with persistent velopharyngeal insufficiency or hypernasal speech following palatoplasty.
  • Alveolar bone grafting: Performed between ages 6–10 to provide bone support in the cleft area for permanent teeth eruption.
  • Nasal revision or rhinoplasty: To refine nasal shape and function, often done in late childhood or adolescence.
  • Orthognathic surgery: Corrective jaw surgery in adolescence for significant skeletal misalignment.
  • Orthodontic treatment and dental rehabilitation: To correct malocclusion, crowding, and spacing issues.
  • Psychosocial and speech therapy support: Essential for long-term emotional and functional recovery.

These procedures are typically performed under general anesthesia and are considered open surgical approaches, although some steps may incorporate minimally invasive techniques, particularly in nasal or soft tissue revisions. Comprehensive care requires close coordination among pediatric surgeons, orthodontists, speech therapists, and psychologists to ensure the best possible functional and aesthetic outcomes over the child’s developmental timeline.