Cleft Lip and Palate
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Direct answer
Cleft lip and palate, the commonest craniofacial birth defect, arises from failure of the medial nasal and maxillary processes to fuse in the sixth week for the lip and primary palate, and of the palatal shelves in the tenth to twelfth week for the secondary palate. Reported incidence is about one in seven hundred to one in a thousand live births, higher in Asian populations. Care is staged from birth to adulthood by a team: feeding support, lip repair near three months, palate repair before eighteen months, then grafting, orthodontics and corrective surgery.
What you must remember
- Embryology separates primary from secondary clefts: the lip, alveolus and palate anterior to the incisive foramen form first, so early failure cleaves the lip, later shelf failure the secondary palate; the Veau classification grades from soft palate only to bilateral complete clefts, and LAHSHAL notation records each element.
- Genetics: most cases are isolated and multifactorial with familial recurrence; syndromic associations include van der Woude with lip pits and Stickler; isolated cleft palate is syndromic more often than cleft lip.
- Neonatal problems: feeding — specialised teats, upright positioning and frequent feeds, since the cleft prevents suction; Pierre Robin sequence with micrognathia threatens the airway; Eustachian dysfunction causes recurrent effusion needing ventilation tubes.
- Timeline: nasoalveolar moulding where available; lip repair near three months by the rule of tens — ten weeks old, ten pounds, haemoglobin ten grams per decilitre; palate repair at nine to eighteen months; alveolar bone grafting at eight to eleven years before canine eruption; orthodontics; septorhinoplasty in adolescence; orthognathic surgery after growth.
- Named techniques: Millard rotation-advancement and Tennison triangular flap for the lip; von Langenbeck and Veau pushback for the palate; Furlow double-opposing Z-plasty, lengthening the palate and reorienting the levator for speech.
- Sequelae: velopharyngeal insufficiency needing therapy or pharyngoplasty, palatal fistulae, midfacial growth disturbance, dental anomalies and nasal deformity — all managed by the cleft team.
Common confusion
Cleft lip with or without palate and isolated cleft palate are distinct: the former is commoner in males, more often left-sided and multifactorial; isolated cleft palate is commoner in females and more often syndromic — a distinction that changes counselling. Submucous cleft is also missed: intact mucosa over a bifid uvula and notched hard palate hide the defect, which declares itself as nasal regurgitation or speech.
Exam-focused takeaway
Write embryology first — it explains the classification — then classification, birth problems and the staged timeline, one line per stage. Viva questions include the rule of tens, why the palate is repaired before speech, and what van der Woude adds. During postings, attend a cleft clinic if possible: watch feeding counselling, hear a speech assessment, follow one infant to lip repair — the timeline, not any single operation, is the real content.
Frequently asked questions
What is the rule of tens?
The classical readiness criterion near three months: ten weeks old, ten pounds and haemoglobin around ten grams per decilitre, reflecting safe anaesthetic tolerance in infancy.
Why is the palate repaired before eighteen months?
Velopharyngeal competence must exist as speech develops; later repair leaves abnormal articulation that persists even after competent surgery.
What is the Furlow technique?
A double-opposing Z-plasty of the soft palate that lengthens it while reorienting the levator muscles into a functional sling, improving speech.
When is alveolar bone grafting done?
Around eight to eleven years, before the canine erupts through the cleft, providing bone for eruption and stabilising the arch.
What is van der Woude syndrome?
An autosomal dominant syndrome combining cleft lip or palate with lower lip pits — the cleft syndrome most likely to recur in families, so examine the parents' lips.