Cleft lip and palate are among the most common craniofacial birth differences, affecting about 6,000 to 8,000 babies in the United States each year. Chung H. Kau, BDS, MScD, Ph.D., of UAB Dentistry Orthodontics works with more than 100 of these infants annually through the Cleft and Craniofacial Center at Children’s of Alabama. The center has introduced newer appliances that can reduce the number of clinic visits by half.

Cleft lip and cleft palate defects

Cleft diagnosis begins in utero, Kau explains. You can look at a prenatal diagnosis and see the cleft lip on an ultrasound. The cleft of the lip forms during the early trimester. It can be caused by various factors: genetics, alcohol, smoking, or medications.

“Basically, the embryological parts of the midface don’t really come together,” Kau said. It’s part of the formation of the face, and some kind of disruption happens that stops the lip and palate from forming.

It can happen just in the lip, it can happen on one side or both sides, and it can happen right through the gums and affect the back side of the soft palate. When you look down the cleft, you’ll see right to the base of the nose.

“This causes multiple problems,” Kau said. Babies can’t put their lips together, so they have feeding problems. Milk comes out through their nose. They’re very uncomfortable.

Treatment of cleft lip and palate

“The first thing we do is try to bring the cleft closer together,” Kau said. Most cleft lips are repaired at about four months, the soft palate at twelve months, and then nothing else happens in terms of orthodontics until about seven or eight years of age. They have to go through speech therapy, dental care, and some revisions to the lip.

“My job is to maximize the care during the first four months of their life,” he said.

Early treatment focuses on bringing the cleft closer together so the surgeon can more easily repair the lip and shape the nose. One of the simplest approaches is placing surgical tape across the cleft site. After a period of time, the cleft is reduced, and the tissues are brought into closer alignment.

In lay terms, that essentially means the tissues are “touching” one another, Kau noted.

Each child begins with a taping process to bring the tissues close together. If this process is tolerated well by the baby and the parents, treatment progresses to a feeding plate with nasal support. This technique is called the nasal alveolar molding (NAM) plate. It has the advantage of approximating the gums, lips, and nose to a more natural position.

In circumstances where the cleft is on two sides, or bilateral, the taping and plate significantly bring the front portions of the lip and nose down and lengthen it. As a result, the surgeon does not have to locate additional tissue to bring the lips together during repair. All these surgical improvements are performed by plastic surgeon John Grant, who is an experienced surgeon with excellent outcomes.

Care during infancy

As soon as the parents present in the clinic with their baby, Kau encourages them to immediately start the process of taping the lip. This brings all the soft tissues really close together.

“The way I describe it to them is that you have an opportunity to get on a bus to go to a destination, which you will reach in about four months,” Kau said. “You have the right to get off at any time. But if you miss the bus, you’ll miss the opportunity.”

As mentioned, if the taping process goes well, we proceed with the NAM plate.

Care after the first year

Orthodontists provide care during infancy, then again between about ages seven and eleven. The cleft may be repaired, but the bony structures of the teeth and surrounding areas are not.

As clinicians, the bony components of the gums are not repaired in infancy because facial growth must continue, and early repair can restrict that development, Kau said.

The team works with UAB Dentistry maxillofacial surgeon Kathlyn Powell, who performs the repair. She takes bone from the child’s hip and places it in the cleft site before closing it. Orthodontic care then focuses on aligning the teeth to support proper eruption.

In some circumstances, a rigid external device (RED) is used, which acts as an anchor at the front of the face while the mid-face is gradually moved forward. After surgery, healing begins, and the mid-face is advanced about a millimeter a day. Once the bite is positive and changes in facial structure are visible, the procedure is considered successful. The child looks more like their peers at school.

Care team and patient experience

The team sees about 60 to 80 cleft lip and palate births at Children’s Hospital each year, along with another 60 to 80 adoptions from other countries, which they help support, Kau said. Care continues in multiple ways each year of a patient’s life, from infancy through about age 20.

As an orthodontist and dentist, Kau says his role is to first give patients the function to eat and then to help build confidence in their smile. It comes down to function, aesthetics, and confidence.

The role of appearance and confidence

A lot of how a person develops begins in the formative years when they first go to school, Kau explained. From about ages seven to eleven, many social factors come into play, and much of how people are perceived is based on the face and lower portion of the face. It plays a significant role.

For these patients, the changes in facial structure can shift how they see themselves and how others respond to them. They may change their hairstyle or begin using makeup as they grow.

“Really, we get to change lives, and that’s very, very rewarding,” Kau said. “I’m an orthodontist. My job is to make teeth straight and create smiles. But this aspect of clinical care is the part where orthodontics truly becomes medicine.