What Is A Cleft Palate?

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What Is A Cleft Palate?

Group Works To Correct Cleft, Palate Cleft In Xian
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A cleft palate is a common congenital facial anomaly treated by plastic surgeons. A cleft palate is identified by a gap in the roof of the mouth.

A cleft palate develops in a fetus when the two halves of the palate do not come together and fuse in the middle. In most cases, a cleft lip is also present. Cleft palate causes problems with dental development (see ​photo), speech, hearing, eating, and drinking. A child may also experience frequent colds, fluid in the ears, sore throat, and problems with the tonsils and adenoids.

A cleft palate is different from a cleft lip. A cleft lip affects the upper lip, whereas a cleft palate affects the roof of the mouth. Not all individuals with cleft palate have a cleft lip, and not all individuals with a cleft palate have a cleft lip. It is possible for an individual to have both a cleft lip and a cleft palate.

In this article, you will learn what a normal palate looks like. You will also learn about the different types of cleft palates –- complete versus incomplete. Complete indicates that the cleft in the palate involves the entire length of the palate. An incomplete palate involves only the back part of the palate. A cleft palate can also be unilateral or bilateral. Unilateral means the palate has a cleft on one side. Bilateral means there is a cleft on both sides of the palate.

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Normal Palate Anatomy

Hard Palate and Soft Palate. Photo © Millicent Odunze, M.D., M.P.H.

Understanding what a normal palate looks like will help you better understand the anatomy of cleft palate.

  • Mucosa: The mucosa is moist, pink tissue that lines the inside of certain body parts. It lines the nose, mouth, lungs, and the urinary and digestive tracts.​
  • Hard Palate: The hard palate is the bony part of the roof of the mouth. It makes up the front part of the palate. It is in front of the soft palate. You don’t see the bone when you open your mouth because it is covered by the mucosa. With either your tongue or your finger, you can feel when the palate changes from hard to soft.

    The hard palate separates the mouth from the nose. Without the hard palate, there is communication between the nasal cavity and the oral cavity. This communication between the two makes speech, eating and drinking difficult. The hard palate keeps food from going up the nose. The hard palate is also important for speaking as it keeps air from going out of the nose instead of the mouth.

  • Soft Palate: The soft palate is the posterior fleshy part of the palate. If you run your tongue from the front of the roof of your mouth to the back, you can feel when the hard palate becomes the soft palate. If you open your mouth and take a deep breath in, you’ll see your soft palate lift. The soft palate moves up and down because of the action of the muscles in the palate.

    When there is a cleft in the palate muscle, it does not function and speech is impaired. Specifically, speech becomes difficult to understand because air is going out of the nose instead of the mouth. Additionally, because the soft palate pushes food to the back of the throat when a person is swallowing, eating is more difficult in patients with a cleft of the soft palate.

  • Uvula: The uvula is the part of the soft palate that hangs down the middle in the back of the mouth. In some people, it is very well-defined. Others may have a small one or may not have one at all.​
  • Alveolar Ridge: The alveolar ridge is also known as the “dental arch” or “gums.” The alveolar ridge is where the teeth emerge from. There is an upper alveolar ridge and a lower alveolar ridge.​
  • Primary Palate: The primary palate is the portion of the palate in front of the incisive foramen. It includes the front portion of the hard palate and is triangular in shape. It also includes the four central front teeth and the alveolar ridge.​
  • Secondary Palate: The secondary palate is the back portion of the hard palate (the portion behind the incisive foramen), including the posterior alveolar ridge, and all of the soft palate and uvula.​
  • Incisive Foramen: The incisive foramen is a structure that separates the primary palate from the secondary palate. It is an opening in the bony palate through which the blood vessels and nerves for the palate pass. It is directly behind the two front teeth. In a palate without a cleft, the incisive foramen cannot be seen as it is covered by the mucosa of the palate.

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Cleft Palate Classification

palate
The Primary Palate and Secondary Palate. Photo © Millicent Odunze, M.D., M.P.H.

Plastic surgeons classify clefts by their involvement of the primary palate, the secondary palate, or both. Cleft palate classification guides the plastic surgeon, dentist, otolaryngologist, speech therapist, and all others members of the "Cleft Team" in formulating an appropriate treatment plan. However, it may be simpler to think of a cleft of the palate as either “complete” or “incomplete.”

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Complete Cleft Palate

complete cleft palate
Complete Cleft Palate: Cleft extends from the uvula to the alveolar ridge. Photo © Millicent Odunze, M.D., M.P.H.

A "complete" cleft involves the entire primary and secondary palates. It extends from the uvula all the way into the alveolar ridge. It involves both the primary palate and secondary palate.

A complete cleft palate can be unilateral or bilateral. If the cleft palate is bilateral, both sides may be complete, or one side may be complete and the other side may be incomplete.

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Incomplete Cleft Palate

An incomplete cleft starts at the back of the palate with the uvula and extends forward. It may or may not reach the incisive foramen. In simpler terms, it only involves the secondary palate as it does not extend all the way forward to include the alveolar ridge. The length to which the cleft can extend forward from the uvula varies in severity of appearance. However, any amount of palate clefting can have a detrimental effect on speech development. The various types of incomplete cleft palates are as follows:

  • Bifid Uvula: The least severe of the incomplete clefts in appearance, a bifid uvula is the most common palatal cleft. It is also referred to as a “cleft uvula.” A bifid uvula appears as a splitting or forking of the uvula. It may be very subtle, evidenced only by a small notch, or the uvula may appear as two distinct entities. A bifid uvula in and of itself is not problematic. This occurs in about 2 percent of the population. However, usually, a bifid uvula is indicative of a submucosal cleft.​
  • Submucosal Cleft: A submucosal cleft is a cleft that is under the mucosa that lines the roof of the mouth -- hence the term “sub.” Because a submucosal cleft is under the mucosa, the only physical indicator of its presence may be a bifid uvula. Even though not seen from the surface, the muscles of the palate are not joined at the midline in a submucosal cleft. This creates an inability to move the palate for some speech sounds. Hence, a submucosal cleft is usually diagnosed when a child has abnormal speech development and a bifid uvula is present.​
  • Soft Palate Cleft: A cleft of the soft palate runs from the tip of the uvula and stops before or at the junction of the soft and hard palate. Not only is it more obvious in its appearance than a submucosal cleft, it creates the same speech problems as a submucosal cleft. The more severe (longer) soft palate clefts are detected at birth due to feeding difficulties. The cleft of the palate makes it difficult for the infant to create a tight oral seal around the nipple. As a result, the infant may not be able to suckle. A partial or shorter soft palate cleft may not show symptoms at birth or may reveal itself as nasal reflux of liquids or foods.​
  • Soft and Hard Palate Cleft: A cleft that involves both the hard and soft palate will include the entire soft palate and any part of the hard palate up to the incisive foramen. The most severe form involves the entire secondary palate, seen as a gap in the palate from the tip of the uvula to the incisive foramen. This is the most overt of the incomplete palate clefts. Similar to the isolated soft palate clefts, the combined soft and hard palate cleft is usually detected at birth because of feeding problems. Speech development will be impaired.

Sources

Boutros SG, Cutting C. Cleft Palate. In: McCarthy JG, RD Galiano, Boutros SG, eds. Current Therapy in Plastic Surgery, 1st Ed. Philadelphia: Elsevier, Inc, 2006.

Gosman, AA. Cleft Palate. In: Janis JE, ed. Essentials of Plastic Surgery. St. Louis: Quality Medical Publishing, Inc., 2007.

Hopper RA, Cutting C, Grayson B. Cleft Lip and Palate. In: Thorne CH, Beasely RW, Aston SJ, Bartlett SP, Gurtner GC, Spear S, eds. Grabb and Smith’s Plastic Surgery, 6th ed. Philadelphia: Lippincott, 2007.

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