Written for Prescription Parents. Dr. Mulliken can be reached at Department of Plastic Surgery, Children's Hospital, 300 Longwood Ave., Boston, MA 02115
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All too soon, children grow to adolescence and become young adults. This period of rapid change is difficult for all teenagers (and their parents). There are the usual concerns about acceptance by peers and anxiety about appearance. This can be a particularly stressful time for the young person with a repaired cleft lip. Recollections of the many years of treatment for the cleft will affect reactions to the pressures of young adulthood. Hopefully the child will communicate any anxiety to sensitive, understanding parents so that appropriate steps can be taken to correct any residual problems.
Studies of older children born with cleft lip/palate reveal that, in general, they are pleased with the soft tissue correction, speech, and hearing. They may be unhappy with their teeth. The young adult should have normal hearing and should no longer be bothered by episodes of otitis media. Children born with cleft lip/palate have a 5-20% chance of abnormally nasal speech, depending on the severity of the cleft. Secondary surgical procedures to correct nasal escape are usually done in childhood. Thus, the youngster's speech should be normal so that when he/she enters a room of students or attends a party with new friends, no one will know of the repaired cleft palate.
The final steps in habilitation for the older cleft child can be divided into two phases: 1) procedures done in the age range 10-14 years and 2) procedures done after completion of growth, typically age 15 years in females, age 17 years in males.
PRIOR TO COMPLETION OF GROWTH: AGE 10-14 YEARS
It is difficult to predict whether a particular teenager will request further surgical procedures. Every child is unique. If a teenager wants a change, there are procedures that are well worth considering before growth is completed.
The cleft in the gum is usually repaired during the mixed dentition, about age 8-10 years. Any residual connection between the gum/palate or nose (oro-nasal fistula) should be closed. Such an opening can affect speech or permit passage of food/liquids into the nose.
Orthodontia is part of many young teenager's lives. For the child born with cleft lip/palate, however, orthodontia is the rule. The orthodontic program resumes during the early teen years. Orthodontia alone may be all that is needed to align the teeth. Alternatively, orthodontia is done in preparation for surgical correction of the jaw(s). Many children with cleft lip/palate are missing a tooth at the repaired cleft site. This gap can be temporarily filled with a tiny prosthetic tooth, suspended to an orthodontic wire or attached to a removal retainer.
Revision of the lip scar probably should be delayed until the end of the pubertal growth spurt. However, minor procedures on the red portion of the lip can be done at this time. An operation from inside the nose can help to improve the symmetry of the nasal tip. Straightening and/or narrowing the nose, and correction of a deviated septum should await completion of growth.
AFTER COMPLETION OF GROWTH: AGE 15-17 YEARS
Some children with repaired cleft lip/palate will have excessive growth of the lower jaw after age 12 years. Often, however, forward growth of the upper jaw does not keep pace with the lower jaw. The result is an under-bite (Class III malocclusion). Orthodontic tipping the teeth cannot correct a major discrepancy between the two jaws. Instead, surgical advancement of the upper jaw is necessary (LeFort I maxillary advancement). Sometimes, the lower jaw is also surgically set-back or the projection of the chin is adjusted. Orthodontic preparation for these procedures is carried out in the last years of growth. Correction of the upper or lower jaw can usually be done from inside the mouth (no external scars). Sometimes the cheekbone(s) is flat; this can be corrected at the time of the jaw operation by augmentation with a bone graft or plastic implant.
It is important that the final correction of the teeth be completed before the graduation photograph (for the yearbook). Sometimes teeth need to be capped. If teeth are missing, there are two alternatives: 1) a bridge or 2) osseo-integrated dental implants. The latter involves placement of a tiny socket into the gum; often this requires another bone graft. Then, several months later, the implanted socket is exposed and a single prosthetic tooth, of proper size/shape/color, is attached.
The final operations on the lip and nose can be scheduled after completion of skeletal growth. The young adult usually enjoys being responsible for the decision as whether to have other operations. Perhaps the appearance of the scar on the lip can be improved. Other considerations are symmetry at the junction of the skin and red lip (Cupid's bow), fullness of the lip and muscle balance. The tip of the nose may be depressed on the side of the cleft repair; the tip and/or pyramid of the nose is often wide. Partial obstruction of the nasal air-passage on the side of the repaired cleft lip is common. Correction of the deviated nasal septum can usually be accomplished with straightening and narrowing of the external nose. Perhaps a minor change in the nasal tip shape or projection is indicated.
The young adult who has grown-up with repaired cleft lip/palate deserves the very best that life has to offer. There is no reason why these children cannot follow their bliss and be free to become whatever their abilities allow.
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