July is Cleft and Craniofacial Awareness Month, which aims to raise awareness and improve understanding of cleft lip and palate defects. About 6,000 to 8,000 babies are born in the United States with such defects each year. UAB School of Dentistry Professor and Chair at the Department of Orthodontics Chung H. Kau, BDS, MScD, Ph.D., works with more than 100 of these infants annually through the Cleft and Craniofacial Center at Children’s of Alabama. Recently, the center has introduced slightly newer appliances that can reduce the number of clinic visits by half.

Chung H. Kau, BDS, MScD, Ph.D.Q: What are cleft lip and cleft palate defects?

Kau: Cleft diagnosis begins in utero. You can look at a pre-natal 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. 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. Babies can’t put their lips together, so they have feeding problems. Milk comes out through their nose. They’re very uncomfortable.

Q: What can be done to treat this?

Kau: The first thing we (orthodontists) do is try to bring the cleft closer together. 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. So, one of the things we do early on is try to bring the cleft together so the surgeon will find it easier to put the lip together and shape the nose in a way that makes sense. One of the simplest things we can do is place a surgical tape across the cleft site. After a while, the cleft will be greatly reduced, and all the tissues will be approximated well. In lay terms that essentially means the tissues are “touching” one another. We start every child with a taping process to bring the tissues close together. If this process is tolerated well by the baby and the parents, we proceed with a feed plate and 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 when 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 doesn’t have to find tissue to bring the lips together when they operate. All these wonderful surgical improvements are done by our plastic surgeon John Grant who is an experienced surgeon with excellent outcomes.

Q: And this is all done during infancy?

Kau: Yes. As soon as the parents present in the clinic with their baby, I encourage 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. 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 process with the NAM plate.

Q: What happens after that first year?

Kau: Orthodontists take care of the babies at infancy, then come back and take care of them again at about age seven to eleven years. The cleft may be repaired, but the bony structures of the teeth and everything else is not. As clinicians, we don’t repair the bony components of the gums in infancy because the bony aspects of the face need to grow significantly, and any repair stops that growth. We work with our maxillofacial surgeon Kathlyn Powell who does the repair. She takes bone from the child’s hip and puts it in the cleft site, then sews it up. Then I come back to align the teeth to give the patient the opportunity to erupt all their teeth. In some circumstances, we rely on a rigid external device (RED), which acts as an anchor in the front of the face while we pull everything forward in the mid-face. The surgeon does all the surgical aspects, we allow it to heal for a week, and then we move the mid-face forward about a millimeter a day. Once the bite is positive, and you see an immediate change in the face, we consider the surgery to be a success. The child looks more like everyone else at school.

Q: How many of these types of patients do you treat each year?

Kau: We see about 60 to 80 cleft lip palate births at Children’s Hospital each year and another 60 to 80 adoptions from other countries which we participate in helping. Our team is involved with them in multiple ways every year of their life from infancy until about age 20. As an orthodontist and a dentist, my role is to first give them the function to be able to eat, and then later to give them great confidence in their smile. So it’s function, aesthetics, and confidence.

Q: Is this a case where the aesthetics are nearly as important as the function?

Kau: Definitely. A lot of how you develop as a person begins in the formative years of your life when you first go to school. So roughly from the age of seven to eleven, a lot of social factors come into play for a child, and about 70 percent of how people perceive us comes from our face and lower portions of that face. It really does play a big part. For these kids, the change that happens to their faces gives them a different perspective on life. They change their hairstyle. They put on makeup. Really, we get to change lives, and that’s very, very rewarding. 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.

For more on Dr. Chung Kau and other UAB School of Dentistry experts, visit UAB News Experts in Dentistry.