Introduction
Various anomalies prevail in head and neck region. Some are specifically important for dental branch. These are of significance for society and the doctors. Some dental development anomalies need special attention, oral clefts is one of these. Cleft lip and palate are common and these should be studied by the clinicians. Cleft lip- is the failure of fusion of the frontonasal and maxillary processes, resulting in a cleft of varying extent through the lip, alveolus, and nasal floor(an incomplete cleft does not extend through the nasal floor, while a complete cleft implies lack of connection between the alar base and the medial labial element).1 It results from abnormal development of the median nasal and maxillary process.2 Cleft palate-The failure of fusion of the palatal shelves of the maxillary processes, resulting in a cleft of the hard and/ or soft palates.3 It results from a failure of fusion of the two palatine processes.2 Clefts arise during the 4th developmental stage and is known by locations at which fusion of various facial processes failed to occur, this is affected by the time in embryologic life when some interference with development occurred.4
Both are the severest congenital anomalies affecting the mouth and related structures. Also cleft lip and palate are the appropriate terms than a cleft.3, 5, 6 Cleft lip and palate are also associated features in over 300 recognised syndromes.7 Some beliefs unsupported by science (eg. Superstitious beliefs) do exist about these anomalies and among these the scientific casual beliefs are the commonest ones endorsed.8 For eg. It results from past sins, witchcraft, God’s will and casual power when pregnant woman sees a facially deformed child.
Discussion
Cleft types are distributed7 as cleft lip alone 15%, cleft lip and 45%, isolated cleft palate 40%. Treatment of these is complex with interdisciplinary and multidisciplinary approach.9 Also it has to be done at right time and at right age for functions and esthetics. Different branches of dental- oral maxillofacial surgery, orthodontics, prosthodontics, otolaryngology, genetics/dysmorphology, speech/language pathology, and others successfully reconstruct this issue by multiple phase of surgical intervention.10, 11 Cleft lip and palate occurs more frequent and more severe in boys than in girls. Cleft palate is seen more frequently in females than in males. Overall incidence of orofacial clefting is around 1.5 per 1000 live birth (about 220,000 new cases per year) with variations based on geographic areas, ethnic group and nature of cleft itself.12 Also its incidence is high among Asians (0.82-4.04 per live births).13
In the critical period of embryonic confront, cleft lip and palate occurs in embryology. Cleft lip is due to the failed mix between 4th and 6th months of pregnancy, whereas cleft palate occurs between the 6th and 12th months of pregnancy. 14
Causes
Non genetic(cleft not with a cause or malformation for the disorders).15 Genetic (syndromic- van der woude, pierre robin syndrome).
Van der woude syndrome VWS is a rare autosomal dominant developmental disorder, usually associated with lower lip pit(s) and cleft lip and palate.16 Pierre Robin syndrome (PRS)also called as Pierre Robin sequence,17 is congenital condition with cleft palate, retrognathia and glossoptosis.Non genetic factors- some environmental factors included18 are: smoking, alcohol use, others- included are maternal diseases, stress during pregnancy chemical exposure, less blood supply in nasomaxillary region, more maternal, paternal age for cleft lip and more parental age for cleft palate only, also any fetal exposure to retinoid drugs causes severe craniofacial anomalies.15, 19, 16, 20 Monozygomatic twins (60%) are more genetically seen in cleft lip and palate cases. It is seen that syndromic form of cleft lip and palate, follows classic Mendelian inheritance pattern. Also in non-syndromic form, many genes have been identifies for clefting.15, 21, 22
Clinical features
Some physical, dental and behavioral/emotional needs of a child with an oral cleft are 23, 24
Functional effect
Cleft lip: Some difficulty in bottle feeding and in speech (disarticulation).2, 25
Cleft palate: It interferes with swallowing, unable to pronounce the consonant sounds as B,D,K,P,T. In teeth, upper lateral incisors may be small/absent. The maxilla is smaller and crowded teeth are present. In nose, oral organisms contaminate the upper respiratory mucous membrane through cleft palate. In ear, even with repair, acute and chronic otitis media and hearing problems occur.2, 26
This cleft lip and palate shows variation across geographic regions and ethnic groups and has significant medical, psychological, social and economic ramifications.27
Birth defects cause problems and for this, there are some strategies:
Family planning, genetic counseling, prenatal diagnosis
Education for couples to reduce maternal exposure to risk factors as tobacco, alcohol and teratogenic medications
Intake of folic acid
Medical and surgical care for the infants. Also some commitment and national leadership for birth defects and infant mortality.28, 29
Dental problems in cleft lip and palate
Natal, neonatal teeth, microdontia, taurodontism, ectopic eruption and enamel hypoplasia.30, 31, 32 Delayed tooth maturation occurs, modifies odontogenesis and cause abnormalities of the dental lamina.33
Treatment of cleft lip and palate
The team is of the dental specialities (orthodontics, oral surgery, pediatric dentistry, and prosthodontics), the medical specialities (genetics, otolaryngology, pediatrics, plastic surgery and psychiatry), and allied healthcare fields (audiology, nursing, psychology, social work and speech pathology).34 In cleft palate babies, feeding advice is given2 as babies are not able to suck mother's milk. For this, baby's head is elevated by 45° and swallowed air is released during feeding frequently by burping.2 Rule of 10 is followed which is-. HB>10 g%, age 10 weeks, weight>10 lb(4.5kg), TC <10,000/mm3.
Surgery treatment4
A team approach has decreased deformities that affect quality of speech. Surgeons are doing intravelar veloplasty vs a 2 flap palatoplasty with double opposing 2- plasty to get levator muscular repositioning. For severe maxillary retrusion, in cleft lip and palate patients, maxillary distraction is used. The team approach of plastic surgeon, speech therapist, orthodontist, pediatric, ENT and dental is required for patients with cleft lip and palate. NAM 36 nasoalveolar molding benefits cleft lip and palate children as skeletal facial growth is unaltered. Also it leads to improved surgical outcomes, less load of care on the caregivers, less need for revision surgery and overall less cost of care both to the society and the patient. Recently robotic cleft surgery is advantageous to surgeons and patients but economic challenges and high costs have to be reduced.39
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