the latham appliance. the latham is surgically inserted by use of pins during the child's fourth or fifth month. after it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip or palate repair. if the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. the bone tissue can be acquired from the individual's own chin, rib or hip. at age 1–7 years the child is regularly reviewed by the cleft team. age 7–12 years, for the children born with alveolar clefts, they may need to have a secondary alveolar bone graft. this is where autogenous cancellous bone from a donor site (often the pelvic bone) is transplanted into the alveolar cleft region. this transplant of bone will close the osseous cleft of the alveolus, close any oro-nasal fistulae and will become integrated with the maxillary bone. it provides bone for teeth to erupt into and to allow implants to be placed as a possible future treatment option. the procedure should be carried out before the upper canine has erupted. ideally the root of the canine should be one to two-thirds formed and that there is a space available to place the bone graft. radio-graphs are taken to determine the quantity of missing bone in the cleft area. other surgeries orthognathic surgery – surgical cutting of bone to realign the upper jaw (osteotomy). the bone is cut then re-positioned and held together by wires or rigid fixation plates to ensure there's no anterior-posterior discrepancy, also to reduce scarring as it reduces growth. single piece or multi-piece osteotomy exist. single piece osteotomy is carried out where there is sufficient alveolar continuity achieved from a successful bone graft. multi piece osteotomy is performed when there is a notable residual alveolar defect with a dental gap and oronasal fistula (communication between the oral and nasal cavities). the goal of both single and multi piece osteotomy is to displace the maxilla forward to obtain adequate occlusion as well to provide better support for upper lip and the nose and to close any fistulae. distraction osteogenesis – bone lengthening by gradual distraction. this involves cutting bone and moving ends apart incrementally to allow new bone to form in the gap. this consists of several phases. after attachment of the distracting device and the bone cuts, there is a latency phase of 3–7 days when a callus forms. in the activation phase distraction of the callus induces bony ingrowth which can last up to 15 days depending on the required distraction. once the required bone length is reached, the distraction device is left to remain in situ as it acts as a rigid skeletal fixation device until the new bone has matured (known as the consolidation period). speech velopharyngeal insufficiency (vpi) can occur as a result of an unrepaired or repaired cleft lip and palate. vpi is the inability of the soft palate to close tightly against the back of the throat during speech, resulting in incomplete velopharyngeal closure. in turn, this results in speech abnormalities. velopharyngeal closure is necessary during speech because it forms a seal between the nose and mouth, allowing the production of normal speech sounds. vpi can cause hypernasality (excessive nasal resonance), hyponasality (reduced nasal resonance), or a mixed nasal resonance, which is when hypernasality and hyponasality occur simultaneously. in addition, clp may cause abnormal positioning of individual teeth, which can in turn affect the patient's ability to make certain sounds when speaking such as the "f" or "v" sound and can also result in a lisp. the changes in speech may also be a manifestation on clp's effects on the patient's occlusion. hearing children with cleft palate have a very high risk of developing a middle ear infection, specifically otitis media. this is due to the immature development of the different bones and muscles in the ear. otitis media is caused by the obstruction of the eustachian tube, negative middle ear pressure and fluid build-up in the normally air-filled space of the middle ear. this is associated with hearing impairment or loss. the insertion of a ventilation tube into the eardrum is a surgical treatment option commonly used to improve hearing in children with otitis media. in addition, breast milk has been proven to decrease the incidence of otitis media in infants with clefts. feeding there are different options on how to feed a baby with cleft lip or cleft palate which include: breast-feeding, bottle feeding, spoon feeding and syringe feeding. although breast-feeding is challenging, it improves weight-gain compared to spoon-feeding. nasal regurgitation is common due to the open space between the oral cavity and the nasal cavity. bottle feeding can help (with squeezable bottles being easier to use than rigid bottles). in addition, maxillary plates can be added to aid in feeding. whatever feeding method is established, it is important to keep the baby's weight gain and hydration monitored. infants with cleft lip or palate may require supplemental feeds for adequate growth and nutrition. breast feeding position as suggested by specialists can also improve success rate. breast-feeding babies with cleft lip are more likely to breastfeed successfully than those with cleft palate and cleft lip and palate. larger clefts of the soft or hard palate may not be able to generate suction as the oral cavity cannot be separated from the nasal cavity when feeding which leads to fatigue, prolonged feeding time, impaired growth and nutrition. changes in swallowing mechanics may result in coughing, choking, gagging and nasal regurgitation. even after cleft repair, the problem may still persist as significant motor learning of swallowing and sucking was absent for many months before repair. these difficulties in feeding may result in secondary problems such as poor weight gain, excessive energy expenditure during feeding, lengthy feeding times, discomfort during feeding, and stressful feeding interactions between the infant and the mother. a potential source of discomfort for the baby during or after feeding is bloating or frequent "spit up" which is due to the excessive air intake through the nose and mouth in the open cleft. babies with cleft lip and or palate should be evaluated individually taking into account the size and location of the cleft and the mother's previous experience with breastfeeding. another option is feeding breast milk via bottle or syringe. since babies with clip lip and cleft palate generate less section when breastfeeding, their nutrition, hydration and weight gain may be affected. this may result in the need for supplemental feeds. modifying the position of holding the baby may increase the effectiveness and efficiency of breastfeeding. alternative feeding methods preoperative feeding – using a squeezable bottle instead of a rigid bottle can allow a higher volume of food intake and less effort to extract food. using a syringe is practical, easy to perform and allows greater administered volume of food. it also means there will be weight gain and less time spent feeding. post-operative feeding (isolated lip repair, or lip repair associated or not with palatoplasty) – post palatoplasty, some studies believe that inappropriate negative pressure on the suture line may affect results. babies can be fed by a nasogastric tube instead. studies suggest babies required less analgesics and shorter hospital stay with nasogastric feeding post-surgery. with bottle-feeding, there was higher feeding rejection and pain and required more frequent and prolonged feeding times. treatment schedule each person's treatment schedule is individualized. the table below shows a common sample treatment schedule. the colored squares indicate the average timeframe in which the indicated procedure occurs. in some cases, this is usually one procedure, for example lip repair. in other cases, it is an ongoing therapy, for example speech therapy. in most cases of cleft lip and palate that involve the alveolar bone, patients will need a treatment plan including the prevention of cavities, orthodontics, alveolar bone grafting, and possibly jaw surgery. age 0m 3m 6m 9m 1y 2y 3y 4y 5y 6y 7y 8y 9y 10y 11y 12y 13y 14y 15y 16y 17y 18y palatal obturator repair cleft lip repair soft palate repair hard palate tympanostomy tube speech therapy/pharyngoplasty alveolar cleft grafting orthodontics orthognathic surgery cleft team people with clp present with a multiplicity of problems. therefore, effective management of clp involves a wide range of specialists. the current model for delivery of this care is the multidisciplinary cleft team. this is a group of individuals from different specialist backgrounds who work closely together to provide patients with comprehensive care from birth through adolescence. this system of delivery of care enables the individuals within the team to function in an interdisciplinary way, so that all aspects of care for clp patients can be provided in the best way possible. outcomes assessment measuring the outcomes of clp treatment has been laden with difficulty due to the complexity and longitudinal nature of cleft care, which spans birth through young adulthood. prior attempts to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards for outcomes assessment in cleft care. the international consortium for health outcome measurement (ichom) has proposed the standard set of outcome measures for cleft lip and palate. the ichom standard set includes measures for many of the important outcome domains in cleft care (hearing, breathing, eating/drinking, speech, oral health, appearance and psychosocial well-being). it includes clinician-reported, patient-reported, and family-reported outcome measures. epidemiology cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed world. rates for cleft lip with or without cleft palate and cleft palate alone varies within different ethnic groups. according to cdc, the prevalence of cleft palate in the united states is 6.35/10000 births and the prevalence of cleft lip with or without cleft palate is 10.63/10000 births. the highest prevalence rates for cleft lip, either with or without cleft palate are reported for native americans and asians. africans have the lowest prevalence rates. native americans: 3.74/1000 japanese: 0.82/1000 to 3.36/1000 chinese: 1.45/1000 to 4.04/1000 caucasians: 1.43/1000 to 1.86/1000 latin americans: 1.04/1000 africans: 0.18/1000 to 1.67/1000 cleft lip and cleft palate caused about 3,800 deaths globally in 2017, down from 14,600 deaths in 1990. prevalence of "cleft uvula" has varied from 0.02% to 18.8% with the highest numbers found among chippewa and navajo and the lowest generally in africans. society and culture moche pottery abortion controversy in some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform an abortion beyond the legal fetal age limit, even though the fetus is not in jeopardy of life or limb. some human rights activists contend that this practice of what they refer to as "cosmetic murder" amounts to eugenics. works of fiction the eponymous hero of j.m. coetzee's 1983 novel life & times of michael k has a cleft lip that is never corrected. in the 1920 novel growth of the soil, by norwegian writer knut hamsun, inger (wife of the main character) has an uncorrected cleft lip which puts heavy limitations on her life, even causing her to kill her own child, who is also born with a cleft lip. the protagonist of the 1924 novel precious bane, by english writer mary webb, is a young woman living in 19th-century rural shropshire who eventually comes to feel that her deformity is the source of her spiritual strength. the book was later adapted for television by both the bbc and ortf in france. similarly, the main character in graham greene's 1936 crime noir novel a gun for sale, raven, has a cleft lip which he is sensitive about, and is described as "an ugly man dedicated to ugly deeds". in the 1976 patricia a. mckillip novel the night gift, one of the high-school aged protagonists is shy because she has a cleft lip, but learns to have more confidence in herself. in the first edition of harry potter and the chamber of secrets, one of the people gilderoy lockhart stole credit from was a witch with a harelip who banished the bandon banshee. in later editions, this was changed to a witch with a hairy chin. in chapter 26 of mark twain's the adventures of huckleberry finn, huck finn meets the three wilks sisters, mary