cleft lip and cleft palate cleft lip and cleft palate a cleft lip contains an opening in the upper lip that may extend into the nose. the opening may be on one side, both sides, or in the middle. a cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. the term orofacial cleft refers to either condition or to both occurring together. these disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. less than half the time the condition is associated with other disorders. cleft lip and palateother nameshare-lip, cleft lip and palatechild with cleft lip and palatespecialtyoral and maxillofacial surgery, otorhinolaryngology, pediatricssymptomsopening in the upper lip that may extend into the nose or palatecomplicationsfeeding problems, speech problems, hearing problems, frequent ear infectionsusual onsetpresent at birthcausesusually unknownrisk factorssmoking during pregnancy, diabetes, obesity, older mother, certain medicationstreatmentsurgery, speech therapy, dental careprognosisgood (with treatment)frequency1.5 per 1000 births (developed world)deaths3,800 (2017) cleft lip and palate are the result of tissues of the face not joining properly during development. as such, they are a type of birth defect. the cause is unknown in most cases. risk factors include smoking during pregnancy, diabetes, obesity, an older mother, and certain medications (such as some used to treat seizures). cleft lip and cleft palate can often be diagnosed during pregnancy with an ultrasound exam. a cleft lip or palate can be successfully treated with surgery. this is often done in the first few months of life for cleft lip and before eighteen months for cleft palate. speech therapy and dental care may also be needed. with appropriate treatment, outcomes are good. cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed world. cleft lip is about twice as common in males as females, while cleft palate without cleft lip is more common in females. in 2017, it resulted in about 3,800 deaths globally, down from 14,600 deaths in 1990. the condition was formerly known as a "hare-lip" because of its resemblance to a hare or rabbit, but that term is now generally considered to be offensive. signs and symptoms cleft lip if the cleft does not affect the palate structure of the mouth, it is referred to as cleft lip. cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft), or it continues into the nose (complete cleft). lip cleft can occur as a one-sided (unilateral) or two-sided (bilateral) condition. it is due to the failure of fusion of the maxillary prominence and medial nasal processes (formation of the primary palate). unilateral incomplete unilateral complete bilateral complete a mild form of a cleft lip is a microform cleft. a microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. in some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. it is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft. six-month-old girl before going into surgery to have her unilateral complete cleft lip repaired the same girl, one month after the surgery the same girl, age eight, the scar almost gone cleft palate cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. the soft palate is in these cases cleft as well. in most cases, cleft lip is also present. palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). when cleft palate occurs, the uvula is usually split. it occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, or the median palatine processes (formation of the secondary palate). the hole in the roof of the mouth caused by a cleft connects the mouth directly to the inside of the nose. note: the next images show the roof of the mouth. the top shows the nose, the lips are colored pink. for clarity the images depict a toothless infant. incomplete cleft palate unilateral complete lip and palate bilateral complete lip and palate a result of an open connection between the mouth and inside the nose is called velopharyngeal insufficiency (vpi). because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions while talking. secondary effects of vpi include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations and mispronunciations (e.g., glottal stops and posterior nasal fricatives). possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures. submucous cleft palate can also occur, which is a cleft of the soft palate with a split uvula, a furrow along the midline of the soft palate, and a notch in the back margin of the hard palate. the diagnosis of submucous cleft palate often occurs late in children as a result of the nature of the cleft. while the muscles of the soft palate are not joined, the mucosal membranes covering the roof of the mouth appear relatively normal and intact. teeth tooth development can be delayed with increasing severity of clp. some of the dental problems affect the primary teeth, but most of the problems arise after the permanent teeth erupts. problems may include fused teeth, missing teeth, and extra teeth erupting behind normal teeth. missing teeth or extra teeth are both normal occurrences. typically, the lateral incisors are missing. the enamel (outermost layer of the tooth) is commonly found to be hypomineralized and hypoplastic, making the teeth more likely to decay. as clp can make oral hygiene more difficult, there is an increased rate of cavities. in addition, abnormal positioning of individual teeth may affect occlusion, which can create an open bite or cross bite. this in turn can then affect the patient's speech. complications a baby being fed using a customized bottle. the upright sitting position allows gravity to help the baby swallow the milk more easily. cleft may cause problems with feeding, ear disease, speech, socialization, and cognition. due to lack of suction, an infant with a cleft may have trouble feeding. an infant with a cleft palate will have greater success feeding in a more upright position. gravity will help prevent milk from coming through the baby's nose if he/she has cleft palate. gravity feeding can be accomplished by using specialized equipment, such as the haberman feeder. another equipment commonly used for gravity feeding is a customized bottle with a combination of nipples and bottle inserts. a large hole, crosscut, or slit in the nipple, a protruding nipple and rhythmically squeezing the bottle insert can result in controllable flow to the infant without the stigma caused by specialized equipment. individuals with cleft also face many middle ear infections which may eventually lead to hearing loss. the eustachian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self-cleaning. hearing is related to learning to speak. babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of speech. thus, even before expressive language acquisition, the baby with the cleft palate is at risk for receptive language acquisition. because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist. tentative evidence has found that those with clefts perform less well at language. psychosocial issues there is research dedicated to the psychosocial development of individuals with cleft palate. a cleft palate/lip may impact an individual's self-esteem, social skills and behavior. self-concept may be adversely affected by the presence of a cleft lip or cleft palate, particularly among girls. negative outcomes can also be associated with the long durations of hospitalization. psychological issues could extend not just to the individual with clp but also to their families, particularly their mothers, that experience varying levels of depression and anxiety. research has shown that during the early preschool years (ages 3–5), children with cleft lip or cleft palate tend to have a self-concept that is similar to their peers without a cleft. however, as they grow older and their social interactions increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. experts conclude that this is probably due to the associated stigma of visible deformities and possible speech impediments. children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft lip or cleft palate. children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers, but these children were similar to their peers in regard to "how well they liked themselves." the relationship between parental attitudes and a child's self-concept is crucial during the preschool years. it has been reported that elevated stress levels in mothers correlated with reduced social skills in their children. strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. in the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. a cleft lip or cleft palate may affect the behavior of preschoolers. experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft lip or cleft palate. a child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. the ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences. as children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. an adolescent with cleft lip or cleft palate will deal with the typical challenges faced by most of their peers including issues related to self-esteem, dating and social acceptance. adolescents, however, view appearance as the most important characteristic, above intelligence and humor. this being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. adolescent boys typically deal with issues relating to withdrawal, attention, thought, and internalizing problems, and may possibly develop anxiousness-depression and aggressive behaviors. adolescent girls are more likely to develop problems relating to self-concept and appearance. individuals with cleft lip or cleft palate often deal with threats to their quality of life for multiple reasons including unsuccessful social relationships, deviance in social appearance, and multiple surgeries. cause most clefts are polygenic and multifactorial in origin with many genetic and environmental factors contributing. genetic factors cause clefts in 20% to 50% of the cases and the remaining clefts are attributable to either environmental factors (such as teratogens) or gene-environment interactions. the polygenic/multifactorial inheritance model predicts that most individuals will be born without clefts; however with a number of genetic or environmental factors, it can result in cleft formation. the development of the face is coordinated by complex morphogenetic events and rapid proliferative expansion, and is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial malformations. during the first six to eight weeks of pregnancy, the shape of the embryo's head is formed. five primitive tissue lobes grow: a) one from the top of the head down towards the future upper lip (frontonasal prominence);b-c) two from the cheeks, which meet the first lobe to form the upper lip (maxillar prominence);d-e) and just below, two additional lobes grow from each side, which form the chin and lower lip (mandibular prominence). if these tissues fail to meet, a gap appears where the tissues should have joined (fused). this may happen in any single joining site,