Category: General

Cleft Palate Repair

Cleft Palate Repair

Posted on by The Cleft Dentist


The second surgery!!! This is always a nice one to be finished with because it’s a major milestone for the baby! The main issues involved with cleft lip & palate are resolved at this point. Up until now, the baby is unable to suck or nurse effectively.  Special feeding cups are used to help the baby eat. Prior to the surgery being done, baby must be off of a bottle and drinking only from the special feeding cups.

It is a difficult surgery to go through because the baby is not used to not having an opening in the roof of the mouth. And also, a baby with stitches in the roof of the mouth can be rather difficult. 

In today’s post, we will discuss the surgery and what’s involved, as well as post-op care. A lot of you have asked:

What’s normal, and what’s not?

So we will dive into that too.

If the NAM appliance has been used, the surgical repair is much less than if it was not used.

This is because the palatal segments will be closer together after the use of the NAM appliance.

Cleft Palate repair is usually around 9-18 months of age

When the cleft palate involves only the back of the palate, this is where the soft palate is. It is called an incomplete soft palate. When the cleft runs the whole length of the palate from front to back, it is called a complete cleft palate. It is possible to only have a cleft lip, only have a cleft palate, or have both. 

Complete Cleft Palate

The surgery is done before speech development occurs so that the child can learn to speak with an intact palate. It is also done after cleft lip repair has been completed. It is performed under general anesthesia, just like the cleft lip repair surgery. It takes between 2 and 6 hours to complete.

The palate is closed in a 3-layer technique.

  1. First the inner layer towards the nose is closed,
  2. Then, the muscles of the palate are closed,
  3. Finally, the tissues in the mouth are closed.

By aligning and closing the muscles of the palate, speech, eating, swallowing, and hearing are improved. 

Why is this surgery important?

Prior to surgery, there is a communication between the mouth and the nose via the roof of the mouth. This surgery helps to close that communication. 

The reason this is important is because it:

  • Allows for formation of a watertight and airtight valve, which is necessary for normal speech 
  • Preserves facial growth
  • Allows for appropriate dental development! 

Tubes for the ears can also be inserted at this appointment.

It is important to remember!

A portion in the front of the palate will be left open to allow the jaw to grow. This will be repaired with the secondary alveolar bone graft. 

What’s normal:

  • More discomfort than cleft lip repair surgery
  • Nasal congestion
  • Staying in the hospital for 1-3 days
  • Stitches on palate that will dissolve over the next 2 weeks
  • Bloody drainage from nose & mouth
  • Swelling, bruising
  • Arm restraints for 2 weeks to make sure baby won’t disturb the site! 

Diet after repair: 

  • Only a cup can be used after the operation
    • A suction via a sippy cup or bottle can disturb the stitches in the mouth due to pressure
  • Mix baby food with fluid in the cup so it can be poured into the mouth
  • NO spoon for a week after surgery (varies from surgeon to surgeon)
  • After eating, always make sure to give child water to rid the mouth of debris 

What’s not normal

  • The baby refuses to eat
  • Fever over 100.4º F
  • Skin color changes
  • Excessive bleeding or foul-smelling odor from palate

For information on what to bring to the hospital for this surgery, see this post HERE. 

I hope you found this helpful. These are life-changing procedures for your little one, so while it may seem scary, it is so beneficial and helpful for them!

Thanks for visiting!

*photos courtesy of UCLA School of Dentistry
Orthognathic Surgery (Jaw Alignment)

Orthognathic Surgery (Jaw Alignment)

Posted on by The Cleft Dentist

 There was a special request to do a post on orthognathic surgery, or jaw alignment surgery, in cleft patients. So here we are! This can get pretty complicated, so I’m going to keep it as simple as possible! Let’s start with WHY this surgery is sometimes necessary for cleft patients.

It all started with the palate surgery…

The surgery that is done on the palate when the cleft patient is an infant leads to scar tissue forming on the upper jaw. Scar tissue is not as stretchy as normal tissue, so as the jaw tries to grow, the scar tissue pulls it back . At the same time, the lower jaw is growing normally. This leads to a discrepancy in size between the upper and lower jaws. 

Some say that a delayed approach to palatal closure significantly decreases the chance of the patient having to undergo this operation.

Also, the severity of the cleft determines whether or not this surgery will be done. This is mostly due to the fact that the more severe the cleft, the more surgeries there will be, leading to more scar tissue. 

The upper jaw ends up being smaller than the bottom jaw.

This is one of the reasons cleft patients need palatal expanders as part of their orthodontic treatment. 

Rapid Palatal Expander

What this looks like:

From the patient’s profile, the lower jaw is protruding out while the middle of the face looks sunken in. While the palatal expander helps to align the jaw from left to right, the jaw from front to back is still out of alignment. This is called an anterior crossbite, or Class III malocclusion. 

For some people, this can be fixed with braces, orthodontic rubber bands, and some tilting of the teeth. For others, the misalignment is too severe, and surgery is necessary. 

Why it’s important:

The dental malocclusion, or misalignment, can lead to speech and sleep obstruction issues.  It is also more difficult for the patient to eat with a misaligned jaw.

When it should be done:

The best time would be when the face is mature and before the patient finishes high school . This is between 14 to 16 in girls and 16 to 18 in boys. It is up to the patient and the doctors, though, when the surgery should be done.

It is preferable for the procedure to not be done until the secondary bone graft procedure is completed because there needs to be stability in the upper arch first. However, if a fistula remains, sometimes these procedures can be done at the same time. 

Let’s get into it, shall we? 

The procedure that is done is called a LeFort I osteotomy. The patient is being seen by the orthodontist at the time of surgery, who is responsible for creating an appliance that will guide the surgeon into the correct alignment of the jaws. The orthodontist knows how the bite should be, so the guide portrays how they would like the bite to be after the procedure. The guide is used by the oral surgeon during the operation to know where to place the jaw.

The upper jaw segment is separated during the surgery to allow it to be moved into the correct position. The incision is made right above the upper teeth. Bone is placed in the new space that is created. 

Le Fort I

Alternatively, there can be a device inserted into the upper jaw, and distraction can be done. What this means is the device will be adjusted,  and the maxilla will slowly go into place as the device is activated each time, moving bones apart. As the bone is “distracted” and moved forward into the right position, new bone forms, creating stability. This is usually done when the jaw discrepancy is more severe, and it takes about 6-8 weeks. The device is removed by the surgeon at this time. 

The main difference between the two procedures is that one is done slowly while the other is done in one surgery and one step. Also, with the distraction procedure, a bone graft is not necessary.

After the surgery

The jaw is  secured in place with metal plates and screws after the Le Fort I. A splint is used to hold the jaws in place for 6 weeks. You’ve probably heard of this as “jaws wired shut.” 

You will not be able to chew, so it’s important to make sure you get adequate nutrition through blended foods.

Try to aim for 2 or 3 nutrient-dense drinks per meal time. Avoid fizzy drinks, and try using a straw. That will help a lot. Good foods include milkshakes, smoothies, soups, juice, yogurt.

It is very important to use good oral hygiene still while healing. Use a small soft toothbrush to brush your teeth, and rinse your mouth with warm salt water.

After 6 weeks, start chewing slowly again. It will take a bit of time for it to feel normal again.

It will also be difficult to speak. Be patient, and bring a pen and paper with you everywhere! 

Complications

The side effects include:

  • numbness in the face
  • infection
  • instability of jaw
  • nasal blockage
  • loss of teeth
  • jaw returns to how it was before surgery
    • this is more common with Le Fort I

The most common side effect by far is experiencing temporary numbness in the face.  There are many nerves in this region of the face, so the surgery may affect some of those nerves. This is what causes the temporary numbness.

My story

I was lucky enough that I was part of the group of cleft patients who did not require orthognathic surgery. My Class III malocclusion (lower teeth in front of upper teeth) was corrected with braces and orthodontic rubber bands. My teeth were also tilted to be in front of my lower teeth.

I am so grateful for this, but I do remember when the orthodontist said “Let’s try to do this with just rubber bands, but if it doesn’t work, we will need to do jaw surgery.” Thankfully, I was diligent with my bands, and the surgery was not necessary.

I know this is one of the tougher surgeries for cleft patients, but the outcome is great and life-changing. 

Thanks for reading. Let me know if you have any questions!!

Packing for the Hospital

Packing for the Hospital

Posted on by The Cleft Dentist

A very popular question from parents is always: What should I bring to the hospital for my baby’s surgery?  

Great question!

You want your baby to be as comfortable as possible, and you want to be as comfortable as possible too! I know my mom always slept in the chair next to me each time I had surgery, and she always had a bag full of important things to make me feel better. 

*Side note>>for older children who have long hair, consider putting his or her hair in a braid since they are going to be laying on their backs for quite a while!

I want to address the 2 important surgeries early on in the baby’s life for this post.  I hope this can help you parents out there who are wondering what the heck to bring for this hospital visit!

I’ve included links and pictures of some amazon products I recommend. 

Let’s start with the Cleft Lip Repair surgery. 

Cleft Lip Repair Surgery- What to Bring

  1. Long sleeve t-shirt for baby that is slightly larger than normal
    • This will be for after the surgery> It will go under the “no-no’s”
    Click to Shop

  2. Favorite stuffed animal or blankie 
    • They might let your child hold this during the surgery!
  3. Sweatpants or leg warmers for baby to wear under gown

    Click to Shop
  4. Shirts should be zip up or snap up- NOTHING OVER THE HEAD (see above)
  5. Toys that can still be used with arm restraints on

    Click to Shop
  6. iPad for TV shows 
  7. A list of medications 
  8. The normal formula or breast milk you usually use & bottles
    • You may want to bring bottle washing supplies since you may be there for a couple of days
  9. Ziploc bags, wipes, antibacterial wipes, tissues 
  10. Bibs 
  11. Infant carrier and stroller
    • If you have a wrap, bring that too. Baby will want to be held after the surgery
  12. For you: 
    • Lots of snacks
    • Toiletries
    • Warm blanket
    • Sandals/Slippers
    • Dark clothing (because there will be blood from your baby’s drool)
    • Headache medicine
    • Phone charger
  13. Camera 

Cleft Palate Repair Surgery- What to Bring

  1. Shirts that are zip up or snap up
  2. Favorite stuffed animal or blankie
  3. Sweatpants or leg warmers to wear under the hospital gown
  4. Toys
  5. iPad for TV shows 
  6. List of Medications
  7. Squeeze pouches of applesauce, fruit, etc.
    Click to Shop

  8. Ziploc bags, wipes, antibacterial wipes, tissues
  9. Bibs 
  10. Infant carrier and stroller 
    • If you have a wrap, bring that too. Baby will want to be held after the surgery 
  11. Sippy cup that does not require suction

    Click to Shop
  12. For you:
    • Lots of snacks
    • Toiletries
    • Warm blanket
    • Sandals/Slippers
    • Dark clothing (because there will be blood from your baby’s drool)
    • Headache medicine
    • Phone charger
  13. Camera 

The most important thing…

Remember to take care of yourself, and bring necessities for you, too! Your baby will be doing lots of sleeping, so make sure you have something to entertain yourself. And definitely do not forget food for yourself! You will probably overpack, but as long as you have the things listed above, you should be great.

Don’t forget:

If you are calm, your baby will be calm too. 

 

I hope this helped! Feel free to comment below if anything in addition to this list was helpful for you.

Thank you, and good luck!

Cleft Lip Repair

Cleft Lip Repair

Posted on by The Cleft Dentist

Since we discussed the NAM appliance last week, it seemed appropriate to do this next post on cleft lip repair. It’s what comes after the NAM appliance is finished, which is around 3 months of age.

How a cleft lip forms

A cleft lip forms during the 6th week in utero due to failure of the lip fusing properly. During this time, facial structures are coming together in utero, and if that is interrupted, a cleft lip can occur. A cleft lip can be due to many reasons, some of which are discussed HERE.

It is actually the second most common embryonic deformity. It occurs in approximately 1 in 700 births. Cleft lip occurs more commonly in males, and a unilateral (cleft on one side) cleft lip occurs more commonly than bilateral cleft lips (occurring on both sides).

Unilateral
Bilateral

The cleft can either be a small, incomplete cleft, or it can extend into the floor of the nose and involve part of the upper jaw.

The lip needs to be repaired:

To prevent future problems with hearing, breathing, eating, speaking, and it also improves the patient’s physical appearance.

Most children are able to lead a healthy, happy life after cleft repair.

How has the NAM helped us get here?

The NAM appliance has reduced the size of the cleft, which will allow for a better esthetic outcome from the lip surgery. The surgeon doesn’t have to do as much “pulling” to connect the lip together.

Is it OK if we didn’t do the NAM, though?

Of course it is! The outcome will still be great. I didn’t have a NAM appliance when I was young, either.

The Surgery

At 3 months old, the baby will go under general anesthesia to have the cleft lip repair, so the baby will be completely asleep.  The baby will also receive local anesthetic after the general anesthesia has done its job in order to minimize bleeding and provide numbing to the surgical area.

The surgery usually takes between 2 and 6 hours, and the child will stay overnight for at least 1 day.

Young children usually get general anesthesia through a mask that covers the nose and mouth. A particular flavor can even be chosen for the scent. The good news is the baby will have no shots or needles while awake! An IV will be placed in the arm or leg to deliver medication only after the child is asleep.

The actual surgery requires an incision of one side of the cleft and then that skin is rotated to join the other part of the lip. The other part of the lip also has an incision to completely release it from underlying bone to allow the surgeon to move the lip to where he or she would like for it to go.

The baby will have stitches on the lip and base of the nose (depending on the type of cleft).

After the surgery

The child will wake up in the recovery room with an IV still in the arm or leg. Also, there will be a set of arm restraints called “no-no’s” to make sure the baby won’t bend his or her arms at the elbow and touch the face. These will need to stay on for 2 weeks.

Sometimes, nasal retainers will be used and placed in the nostrils to help shape the nose. These could stay in place for up to 3 months.

Nasal stents in place

The baby will stay in the hospital until the baby is able to drink fluids. The IV will then be removed, and the baby can go home! If any sutures need to be removed because they are not dissolvable, this will be done 1 week after the surgery.

Home Care

  • Only liquids until stitches are removed
  • Gentle cleansing of stitches with cotton swabs & diluted hydrogen peroxide
  • Gently massage area & avoid sunlight
  • No-no’s stay on for at least 2 weeks
    • remove them every 2-4 hours to make sure they are not too tight
  • Raise baby’s head slightly while sleeping to help with swelling
  • Clean the sutures after each time the baby eats
  • Vaseline can be placed on the stitches after cleaning
  • Most importantly: Remember that the baby crying will not harm the stitches!
What’s normal:
  • Bleeding from lip for up to 24 hours from surgery
  • Swelling
  • Difficulty feeding the baby
    • the baby needs to get used to his or her new mouth!
    • plus, there may be some soreness and swelling causing discomfort
  • Redness & firmness 4-6 weeks after surgery
What’s not normal:
  • Fever
  • Trouble breathing or skin color changes
  • Continuous bleeding or bad smell coming from stitches
  • Signs of dehydration
  • Movement of the nasal stents

My story

I didn’t have a NAM appliance when I was young because they didn’t exist yet!

I had my lip repair done when I was 3 months old. My parents kept my “no-no’s” for a really long time in the basement. I remember seeing them when I was about 10 and thinking they looked so small!!

My mom always told me it was very difficult to feed me after my lip repair. She said only 2 people were able to successfully feed me, which were my grandmother and her.  They would use medicine cups to drip fluids into my mouth. Imagine how tedious that must have been!

My lip repair was successful, and I went on to have many nose reconstructions, and when I was 21, I had a second lip reconstruction where my plastic surgeon was able to smooth over some of the scar tissue on the inside of my lip. It felt so amazing to not feel “bumps” on the inside of my lip.

I’ve never had any issues with my lip, and most patients don’t. After repair of the lip, patients can function normally in terms of anything to do with the lip. The challenging aspects are the palate, bone defect, and nasal defects.

Thanks so much for reading today. As always, let me know if you have a request for the next post!!

The Cleft Dentist™


http://www.surgeryencyclopedia.com/Ce-Fi/Cleft-Lip-Repair.html

http://www.chp.edu/our-services/plastic-surgery/patient-procedures/cleft-lip-repair

https://www.aboutkidshealth.ca/Article?contentid=33&language=English
*photos courtesy of UCLA
NAM Appliance

NAM Appliance

Posted on by The Cleft Dentist

We have a special post today because it is something that is very interesting to me for 2 reasons: 

  1. I never had the chance to experience a NAM appliance myself when I was a baby.
  2. I’m fascinated by the appliance, and I did a research paper on it in dental school!

Nowadays, it is very typical for a cleft baby to either have a NAM appliance or the Latham appliance prior to closure of the lip. While it is not absolutely necessary to have these appliances, it does help tremendously with the surgical result. In this post, we will be focusing on just the NAM appliance.

I will also be interviewing my husband towards the end of this post because he is currently working on a cleft baby, and he made a NAM appliance for the little one!  He is a maxillofacial prosthodontist fellow at UCLA.

What NAM stands for…

Nasoalveolar Molding

  • Naso= nose 
  • Alveolar= bone 

So literally, it means it helps to shape the nose and the segments of the palate on either side of the cleft (bone).

What it does

A cleft lip + palate creates a large defect in the lip and palate, often causing the nose to be off-center, especially in a unilateral cleft lip + palate. The reason for this is because due to the location of the cleft, there is no bone in the area to support the structure of the nose. Therefore, the bridge of the nose is pushed to the side.  In a bilateral cleft lip + palate, the nose may be centered, but it is often wide and flat.

NAM does not involve surgery! It is a device that helps shape the gums, lips, and nose in both unilateral and bilateral clefts. It gradually creates pressure to shape the facial structures and reduce the size of the cleft.  After that, the lip is surgically repaired.

The NAM appliance needs to be cleaned daily.  It is taken out of the mouth by the parent or caregiver and rinsed with toothpaste, toothbrush, and warm water before replacing the tapes.

Why it is so great! 

It usually requires the child to have less surgeries to repair the cleft than in the past. Reducing the size of the cleft with the NAM appliance allows for a thinner scar and helps the surgeon achieve a better shape of the nose. Quite often, the NAM can help prevent future surgeries that were once required for a cleft child. 

What it looks like

It is clear acrylic, and it looks like a retainer that fits over the entirety of the baby’s upper jaw.

NAM appliance

There is a button that comes out the front of the mouth where the cleft is through the lip.  Rubber bands are placed around the button on either side and pulled to create tension. Tape is then used to hold the appliance in place by taping the rubber bands to the cheeks. 

Button that rubber bands go around

When the cleft in the gums is reduced to about 1/4″, the nasal portion is added to the appliance. This is a projection that extends up into the nostril coming out of the front of the appliance and helps to remodel the nose from a flat shape to a more rounded shape. 

How it works 

  1. A dental impression is made of the newborn’s upper jaw by a dentist

    Impression
  2. The NAM appliance is made and inserted into the baby’s mouth
  3. The rubber bands are applied, and tape is placed on the baby’s cheeks
    • This creates pressure upward and backward. It is perfectly NORMAL for the eyes to droop down and the skin to be irritated by the tape. The eyes will return to normal once NAM is finished, and the doctor actually uses the skin irritation as an indication that you are correctly using the appliance at all times!
    • Tape is replaced daily by the parent
    • If the appliance is not sturdy in the mouth, replace the tape and pull more tension on the rubber bands 

      Tape & Rubber Bands around knob
  4. Adjustments are made to the NAM on a weekly basis by adding to the acrylic on the inside surface
    • Each time the baby comes in, more material is added to the area of the cleft to continue creating pressure. The pressure helps to redirect the growth of the face and palate as the child grows. Each adjustment is very small. 
  5. When the cleft is reduced to about 1/4″, the nasal portion is added to shape the nose
    Nasal Portion in nose

    Nasal Portion added
  6. By the time the baby is ready for surgery, the cleft has been reduced significantly, which makes for easier surgical repair 

Benefits 

  • Helps to create suction by closing the cleft while appliance is in place (easier for feeding)

  • Weekly checkups are always nice to have to make sure the baby is progressing well!
  • Speech will be much better due to smaller cleft
  • Minimal scarring
  • More rounded nose
  • Fewer future surgeries 

Interview with Dr. Paul Canallatos

At what age does the NAM appliance start?

It is ideal to start within the first 6 weeks of life.

Does the baby need to wear the appliance all the time?

The baby should wear the prosthesis at all times, including feeding. It can be removed temporarily for hygiene, but it is ideal to have it worn as much as possible to allow the molding to take place.

Does it hurt the baby?

It does not hurt the baby, but it is uncomfortable for a couple of days after an adjustment is made- much like a patient is sore after getting an adjustment at the orthodontist.

How does the baby eat with the appliance in?

The baby is able to be fed via a bottle the same way as without the prosthesis. The baby can sometimes even eat better with the prosthesis in after a while.

How long does the baby need to wear the appliance before surgery?

It is ideal to have the prosthesis worn up until the 3-month period before the first surgery, which is the lip surgery.

How do you make the impression of the baby’s mouth?

The impression is made with a putty material that is very viscous so the patient will not breathe in the material. While making an impression, we make sure there is plenty of room for the baby to breathe. The patient cries during the impression because it is something new, but it does not hurt. Crying is a good thing because we know we have a clean airway then!

Let us know if you have any other questions!

 *pictures provided by UCLA
Frequently Asked Questions: dental-related

Frequently Asked Questions: dental-related

Posted on by The Cleft Dentist

You guys asked some great questions!   The questions I received were all dental questions, so I will be doing another post on non-dental FAQs as well! I did my best here to answer your questions, especially the ones that were asked the most. I’ll be happy to add to this post if any other questions come up as you’re browsing.

This blog is completely for you guys, so I hope these answers help! Let’s dive in!

My son’s adult front tooth grew in sideways. When and how will that get fixed?

This is actually pretty common in cleft patients for the teeth to grow in sideways next to the cleft. The reason for this is that teeth like to migrate and grow towards SPACE. Wherever there is room, the teeth tend to go. Most of the time, this will happen when the corresponding baby tooth is still in the mouth. The adult tooth will grow toward the space of the cleft because it can sense there is room for it to grow! The tooth will be fixed during orthodontia. Braces will move the teeth into their proper positions around the age of 11-14. This is done after the bone graft procedure.

My daughter is 1 month old. How many teeth can I expect in the coming months?

4-7 months: The first teeth will most likely be the two lower front teeth, but teeth can also begin appearing around 3 months old.

8-12 months: The front top teeth will appear around this time. In cleft patients, both front top teeth may not erupt due to the cleft being in this area. That is normal.

9-16 months: Next, the front top teeth next to the central incisors will erupt. Again, in cleft patients, this may not erupt because there is no bone in this area. That is also normal. Next, the lower lateral incisors will erupt (the teeth next to the central incisors).

13-19 months: The molars will erupt.

16-23 months: Canines will erupt.

23-33 months: Second molars will erupt.

Do not worry too much if the teeth do not arrive during these time frames. Especially with cleft patients, there can be delayed eruption of the teeth. The teeth will erupt when they are ready!

What is the average lifespan of dental implants? Do you usually have to get them redone?

Dental implants can last decades if you take good care of them. They are always placed with the intent of having them last even your lifetime. The best way to take care of them is to make sure you are flossing around them, and also, I highly recommend a Waterpik.  The implants do not normally need to be replaced unless an infection develops around them, bone loss, or periodontal disease affects them. What is more likely to occur is that as you get older, you will notice the teeth with implants on them will appear shorter than the teeth next to them. This is because your face grows, but the implants stay in one spot. If this is bothersome to you, only the crown will need to be replaced…not the implant!

My baby has a gum notch. What procedures could be involved?

I’m assuming that by “gum notch” you mean a defect in the bone where the cleft is. Possible procedures include bone grafting, orthodontics, and others, depending on the type of cleft your child has. A good post to look at is the Timeline of Events one.  This should help!

Does having a gum notch mean her teeth will become rotten?

No! Having a cleft does not predispose patients to having rotten teeth. Having a cleft merely means there will be some difficulties with teeth, such as later eruption or no eruption at all in the area of the cleft. This does not mean cleft patients will definitely lose teeth. Most cleft patients just don’t have their front adult teeth, and THESE options can be explored if that is the case. As long as you take care of your teeth, you will not lose them!

My 3-year-old son has a transparent spot on his front tooth. Is there anything I can do for his future teeth?

This sounds to me like it is just a thin spot of enamel. If it’s just one spot, it does not sound alarming. Sometimes, there can be the opposite effect where there is a white spot. These spots are not worrisome at all. The enamel is weaker in these areas, so just keep an eye on these for any appearance of a cavity. As for the future teeth, this can happen in any of those teeth as well and are not related to the baby teeth. It may happen in the adult teeth, or it may not happen, but there is no way to prevent it. Just make sure to do proper hygiene to reduce the risk of cavities!

Are clefts associated with weak tooth enamel or something that would predispose to decay? Should I be concerned about his adult teeth?

Clefts are not associated with weak tooth enamel. One interesting characteristic of cleft patients though is that we are mouth breathers much of the time because we do not breathe well through our noses. This can create a dry environment in the mouth, which can lead to decay. This is because saliva has certain elements in it that protect the teeth from harmful bacteria. The way to prevent decay is proper hygiene and also drinking water to keep the mouth salivating will help!

 My baby has gum notch. What is the procedure for the gum notch?

Again, I’m assuming here the gum notch means a defect in the bone where the cleft is. This area will remain as is until about the age of 10, when the fistula is finally closed with the bone graft. I explain all about the bone graft in THIS POST.

Will babies with clefts suffer with teething?

Yes! Just like any other baby, though. That part is completely normal.

Some skin on the upper lip is joined with the gum notch on my baby. How will it be normal?

This sounds like the frenulum attachment. This is just a muscle attachment that occurs in people without clefts too. It is not a bad thing, but it could pull on the muscle between the 2 front teeth if not removed, leading to a space between the two front teeth. It can be cut at any age, if you would like.

Will having a cleft of the soft palate only cause any tooth problems?

Usually there are no tooth problems with clefts of the soft palate. The only tooth problems are the ones that those without cleft palate would experience!

Does having a cleft lip & palate mean they will need a palate expander down the road?

Usually, a palatal expander is a good idea because due to the surgeries of the palate, the scar tissue pulls on the teeth and jaw and constricts the upper jaw. The constriction causes an inaccuracy in the bite of the cleft patient. An expander will help expand the palate to achieve more space in the arch to make up for the constriction that has occurred.

My cleft child has a tooth coming through her palate. Will this cause any issues with her palate repair?

This is actually very common in cleft patients. It would only cause an issue with palate repair if it is in the way of where tissue in the palate will be taken to do the repair. Usually, the tooth will be extracted at time of palate repair, especially if it is so far from the rest of the teeth that there is no way orthodontia could fix it.

Where can I find an orthodontist for my cleft child? 

Search for “craniofacial orthodontist” in your area!

What is your take on snap-in dentures, and are there any problems with them?

Snap-in dentures are absolutely wonderful. They are actually considered the gold standard for dentures on the lower jaw. Two implants are sufficient for snapping in the denture, and they help to hold the denture in one spot! This is especially helpful if you don’t have much bone in the lower jaw from wearing dentures for so long. The dentist just needs to make sure you have enough bone for implant placement! Snap-in dentures are not necessary in the upper jaw, unless there is some abnormality in the maxilla. The most common complication with these dentures are that the little buttons on the inside of the denture where the implants snap in actually wear over time, so they need to be replaced. Another common complication is the denture may break in half between the two snaps. These complications are nothing though compared to how your life will be changed for the better!

Is it common to miss other teeth not in cleft areas?

Yes, but this is unrelated to the cleft. People will commonly miss lateral incisors or premolars.

Is it common to have a frenulum connecting a cleft child’s upper lip to the gums in the area of the cleft?

This is also not cleft related, but can happen in cleft patients as often as it does in non-cleft patients. Please refer to question above regarding frenulum!

Does an expander cause a fistula in the cleft area?

No! The upper jaw in a cleft patient is usually constricted because of scar tissue pulling on the jaw from previous surgeries. This constriction will make the fistula appear smaller. As the palate is expanded, the fistula will appear larger. An expander just draws more attention to a fistula that was already there!  Also, a fistula is left in the cleft area until the bone grafting procedure is done, which is usually right after palatal expansion.

How many hours in dental school are spent learning about cleft-related issues? What is the knowledge-base of an average dentist regarding clefts?

Honestly, not much. We learn about what it involves and how it develops in the womb. We don’t learn about specifics in treating cleft patients. So, an average general dentist knows what a cleft lip & palate is, knows which teeth are affected, and in general, knows what steps need to be done to repair the cleft. However, specialists, including oral surgeons, orthodontists, pediatric dentists, and prosthodontists, all have a strong knowledge-base regarding clefts. We treat these patients during our residencies as well, so we know how to deal with cleft patients in detail. A  toddler will be treated by oral surgeons, pediatric dentists, and a maxillofacial prosthodontist. Young children will be treated by oral surgeons, pediatric dentists, and an orthodontist. Adults will be treated by a prosthodontist, oral surgeon, and a general dentist can also treat an adult with a cleft.

 

That was fun!  Thank you so much for submitting your questions! Please feel free to submit follow-up questions in the comments section, below.

 

What I Ate: the post-surgical soft food diet

What I Ate: the post-surgical soft food diet

Posted on by The Cleft Dentist

It is so important to make sure you have a well-balance diet, even though it may seem so limited with soft foods. You'll see how easy it is to get creative with what you can eat! It is ESSENTIAL to increase your protein intake to help with tissue healing.

Wednesday, March 28th

Day of Surgery

 

Post-surgery:                    

Image result for pressed juicery freeze chocolate & vanilla swirl

Pressed Juicery ice cream:

Vanilla Almond & Chocolate Almond- made of only almonds, dates, vanilla, and sea salt

 

Snack:

Mug Cake

Chocolate Mug Cake:

  • 1 scoop Protein Powder
  • 1 tbsp coconut flour
  • splash vanilla extract
  • 1/4 tsp baking powder
  • 1/4 cup milk (any you like)

You can either microwave this for 1 minute or eat as is. I like to eat as is. It tastes like cake batter!

 

Dinner:

Crockpot Sweet Potato Lentils

Crockpot Sweet Potato Lentils:  Serves 6

  • 3 large sweet potatoes
  • 3 cups vegetable broth
  • 1 onion, minced
  • 2 tsp coriander, 2 tsp garam masala, 2 tsp chili powder
  • 1/2 tsp salt
  • 1.5 cups uncooked red lentils
  • 2 cups milk (any you like)
  • 1 cup water

Cook on LOW for 6 hours. This is great for the day of surgery, so you can just throw it all in a crockpot and not worry about it for later!

 

Thursday, March 29th

Day after surgery

 

Breakfast:

Rebbl

Rebbl Turmeric Golden- Milk:

Turmeric is great to have post-surgery because it helps with INFLAMMATION. I added some protein powder to this to make sure it was well-balanced.

You can buy this at Whole Foods or on Amazon.

 

Snack:

Mug Cake

Chocolate Mug Cake: recipe can be found above

 

Lunch:

Smoothie Bowl

Green Smoothie Bowl:

  • 1 cup spinach
  • 1 scoop protein powder
  • 1/2 frozen banana
  • 1 tbsp. peanut butter
  • 1/2 cup strawberries

Topped with: 1 tsp honey, 1 tsp tahini

Blend altogether!

 I like smoothie bowls because it feels more substantial than just drinking a smoothie. Plus, remember, no straws during this time! It's perfect to top it off with soft foods, and then it feels more like a meal.

Snack:

Banana Bread

Soft Banana Bread*:

  • 3 medium ripe bananas
  • 1/2 cup creamy almond butter
  • 2 eggs
  • 1 tbsp. honey
  • splash vanilla extract
  • 1/3 cup coconut flour
  • 1/2 tsp baking powder
  • sprinkle cinnamon

Bake at 350º for 30-40 minutes. Topped with honey and creamy peanut butter.

*Recipe from Rachl Mansfield

 This bread is seriously so soft and delicious. Be careful with your toppings and make sure they are smooth and soft enough to do minimal chewing and easy to swallow.

Dinner:

Roasted Red Pepper Soup

 

Creamy Roasted Red Pepper Soup:

Recipe can be found HERE

You already know how I feel about this recipe. It's SO good. It's also surprisingly filling, so one bowl of this one, and you are set! Make sure you give it a good blend so there are no surprises when you're eating.

Hope you got some new ideas!

I just wanted to show 2 days of a soft food diet. You can get really creative with it! If you do not want to use protein powder, or the child is too young for the protein powder, I would suggest using yogurt, oats, hemp seeds, or flax seeds as a substitution.

Feel free to leave me a comment below with any questions you have or any other suggestions you'd like to know for some soft-food recipes. I have many more! I'll be posting them periodically in the Recipes section of the blog.

Also, healing has been going well! I'm still sticking to a soft-food diet to not disturb the implants. I'm also taking Osteoven supplements to help with bone formation!

What do you want to know about next? Visit my Requests page, and drop me a comment!

 

My Dental Implant Surgery!

My Dental Implant Surgery!

Posted on by The Cleft Dentist

It’s done!

I had 2 dental implants placed yesterday, Wednesday, March 28th. My bone graft surgery was on November 22, 2017. 4-6 months is a good amount of time to have dental implants placed after a block graft in order to prevent the bone from disintegrating. Remember, the only reason bone is there is to support teeth. Dental implants act like the root of a tooth, so if a dental implant is there, it will stabilize the bone and give the reason for the bone to be there!

The implants I had placed were of the Straumann brand. I like this brand the most because I like the surface of the implants, and the components of the implant are easier to work with. But really, any brand is doable.

The day of:

My surgery was scheduled for 12 PM, so I arrived at the surgery center at 11 AM. I was brought back into the pre-op area where I met with the anesthesiologist and nurses.  I had not eaten anything yet that day, so I was so hungry!

Before the surgery

 

I was so nervous….

Even after all of the surgeries and knowing a 3D x-ray had been taken, so there was definitely bone in there, I was STILL nervous. So…reminder to you: It is totally normal to be nervous. And also, the older you get, you will feel more calm because you know what’s coming, but you’ll also feel nervous because you know what’s coming. Just make sure you have someone with you who can tell you jokes and keep your mind distracted, just like my husband did. It helped so much.  And it doesn’t hurt to make sure you have your meal planned for when you leave the hospital…it gives you something to look forward to.

I was sedated…

I chose to be sedated for this surgery instead of doing general anesthesia. This is because a dental implant surgery is not very serious, and sedation is easier on the stomach and recovery aspect. Dental implants can even be placed with just local anesthesia (like a shot you get at the dentist for a filling), but I wanted to not be aware of what was going on so my nerves could be down.

This involves just an IV, and medication is inserted through the IV, and before you know it, you are sedated and unaware of what is going on. When I woke up, the first thing I asked was,

“Are they in?”

And thankfully, I received a laugh and a yes! I was so happy. I felt a little groggy waking up, but it honestly just felt like I was waking up from a long sleep. It took about 15 minutes for me to be fully alert. My lip was very numb still, and I had some pain at the surgical site. I was given pain medication, some water, and I changed into my clothes, which always feels good! Within an hour, I was discharged and feeling pretty normal. My lip was numb for about 1.5 hours after the surgery, so I had to be careful with eating anything to avoid biting my lip!

Implants- picture taken an hour after surgery

After leaving the hospital with my husband, we went straight to Pressed Juicery for a healthy ice cream . This has become a tradition for my family to always get ice cream or a milkshake to eat with a spoon on the way home from the hospital.

I will be sharing a “What I Ate” post so you can see how creative you can actually get with soft foods!!

For now, let’s talk about some things that are normal and things that aren’t, so you know what to look out for.

Instructions:

  1. No straws for 1 week after surgery
  2. Only SOFT foods allowed for 1 week
  3. For 24 hours: no driving, alcohol, bending over, sudden movements
  4. No strenuous activity- only walking for 1 week and then can add small activities like yoga after 1 week. Activity can resume after 2 weeks
  5. Keep surgical area elevated to avoid swelling
  6. No direct pressure on surgical area
  7. No hot foods for 1 week
  8. Brush your teeth still!!! Just be careful around surgical area
  9. Use Peridex (chlorhexidine) prescribed by your doctor two times a day, and no eating or drinking for a half hour after swishing
    • Make sure you really do use the chlorhexidine as indicated because it is ESSENTIAL to helping repair tissues
  10. No aggressive spitting for 1 week
  11. You can shower today! Do it! It will make you feel better

What is normal:

  1. Some blood coming from the surgical area
  2. Some swelling in the surgical area
  3. Slight pain in the surgical area
  4. Feeling tired or exhausted the day of surgery and the day following surgery
  5. Some nausea the day of surgery
  6. You might see some screws in your mouth where the implants were placed. This is COMPLETELY normal. If you don’t see them the next day after surgery, don’t freak out! Your tissue might be healing over them. That is okay!

What is not normal:

  1. Difficulty breathing, headache, vision issues
  2. Persistent dizziness
  3. Persistent nausea or vomiting
  4. Pain that does not go away after a few days, pus coming from the surgical area (green, yellow)
  5. Temperature greater than 101.5

Look out for my “What I Ate” post. It’s very important to maintain a healthy diet while healing, and make sure you’re not just eating sugary foods. A well-balanced diet will help the healing process!

Thank you all for your support and well wishes for my surgery. It did go well, and I will continue to update you on this post as I heal!

Bone Grafts in Cleft Patients

Bone Grafts in Cleft Patients

Posted on by The Cleft Dentist

The most important part of cleft treatment

In my opinion, the secondary alveolar bone graft is the most important aspect of treatment for the cleft patient.

The bone graft closes the final communication between the nose and mouth, and it helps to stabilize the jawbone. Having an interruption in the jawbone, due to the cleft, can cause lack of stability and collapse of the arch. The teeth next to the area lacking bone will begin to migrate and tilt toward that area. Think of it like completing a circle. Having a cleft makes for a break in the circle, and the bone graft fills in the last portion of the circle and stabilizes everything .

When should this treatment be done?

This treatment should be done around the ages of 8 to 10. The reason for this timing is because we want to complete this treatment prior to eruption of the canine, which is next to the cleft area. Again, this helps to create arch stability before eruption of permanent canine teeth next to the cleft.

Where does the bone come from?

The bone is usually taken from the hip. This is called an autograft because it is a graft that is taken from your own bone. An autograft is considered standard of care because there is less risk for transmission of disease and should be accepted better since it comes from the patient instead of an outside source. The only down side is that you can experience pain for a bit while the donor site is healing .

Another option would be allograft bone, meaning it comes from a bone bank that collects cadaver bone. The bone is cleaned and disinfected through many processes, but there is always the slight chance of disease transmission. Also, this type of bone does not have all of the cells that are present in autografts to encourage bone growth .

What can go wrong?¹

  1. Sutures can come undone, exposing the bone graft
    • once the bone graft is exposed, the part of the bone that is exposed is now dead and will come out either as one piece or in tiny pieces
  2. Eruption of the canine within the bone graft
  3. Infection of the graft site
  4. Harm to teeth next to bone graft site
  5. Complete failure of the bone graft, leading to communication between nose and mouth

It is, unfortunately, not uncommon for these grafts to fail. The surgeon is essentially placing bone into a hole that is not supported by structures around it. Also, there is a lack of blood supply to these regions because of scar tissue. Scar tissue is the result of the surgeries done to repair the cleft defect.

What happens if it does fail?

Don’t lose hope! When you read my story below, you will feel better about this. There are so many options that you can do in case of failure. And thanks to prosthodontists, they can be some pretty great options. Ready? Let’s go!

  1. Try again
    • This is what most people do who have a failure. Yes, it stinks, but why not keep trying?
  2. If you are an adult, and you really don’t want to try anymore, an obturator is a great option
    • Obturators will replace the missing teeth AND cover the hole where the communication exists
  3. Complete orthodontic treatment, and try again
    • This would mean the next attempt would be in the early to mid- teenage years
  4. Leave the defect as is, and replace missing teeth with a bridge or removable partial denture

And what if it succeeds?

I like the way you think!

  1. Proceed with all of the steps outlined in Timeline of Events
  2. Replace missing teeth once orthodontic treatment is completed

My story

I had an iliac crest graft in 1998, which failed. An iliac crest graft involves bone being taken from the hip. I remember feeling tiny granules of bone in my mouth as the stitches had opened up. I had another iliac crest graft in 2002, which also failed. I continued with my orthodontic treatment and proceeded to have the final surgeries involved with clefts, including nose and lip revisions.

Finally, in 2009, my last bone graft was successful, meaning an adequate volume of bone remained in place, but it was not taken from my hip. It had been cadaver bone and was covered by a metal mesh material to protect it and hold it in place. I had been freaking out the week after the surgery, so afraid it was going to fail like the others did. I remember going to my surgeon’s office almost every day (my poor mother), just so he could make sure it looked good. He looked right at me and said,

“It’s not going to fail”

That was all I needed. I didn’t go back until I actually had a follow-up scheduled, and the bone graft had been successful. Never underestimate the power of positive thinking. I swear it works!

About 5 months later, I had 2 dental implants placed where the bone graft had been. It had been planned, as explained in my Dental Implants post, so the implants were placed exactly where they needed to go. 

However, there was a slight complication. I could not wear my retainers made by my orthodontist while I was healing because they would not fit over the newly built up gingiva. I did not know what to do, but everyone said the most important thing was to have the bone graft heal. Ultimately, my teeth had moved and shifted because of not wearing the retainers. I had to undergo orthodontics again once I was done healing from the bone graft.

This is very important!!!

Please do not make the same mistake I did. Please make sure you go to a prosthodontist during the process so that the prosthodontist can figure these things out FOR you. Having someone like a prosthodontist on my team would have helped with maintaining the teeth in their positions and also giving me something to wear while healing to replace my missing teeth.

3 months later, I had my implants restored with crowns, and I had never been happier in my life.

This sounds like a pretty good ending!

Unfortunately, it didn’t end there. For 10 years, it was great. My confidence had soared, I made amazing friends, and I met the most wonderful man who is now my husband. You can read about what happened to my implants HERE. Long story short, I developed an aggressive infection, and they were failing.

In November 2017, I agreed to have another surgery…. 10 years after I thought I was done for good. I found an oral surgeon at UCLA who specializes in craniofacial patients, and he is also a plastic surgeon. Amazing!! He removed my implants and did a bone graft, taken from my hip, under general anesthesia. I was swollen and in a fair amount of pain for about 3 days.

After a week, the swelling had gone down, and my hip pain was almost gone.

However, a new problem came up at my 3 week follow-up. The sutures had loosened, and the bone graft was exposed. I kept the area very clean and rinsed with chlorhexidine 3 times a day. Chlorhexidine is controversial because while it does keep the area very clean, it also prevents tissue from growing. My surgeon had warned me that either a large amount of bone is going to come out or just the outside layer of bone will loosen after some time. I couldn’t handle this. More bad news, more complications, the possibility of more surgery. I had follow-ups every 2 weeks, and nothing was changing, which was actually a good sign. But I wanted something to happen so we could move on to the next step.

 

 

 

 

1 month post-op

Finally, I stopped using chlorhexidine, and the tissue began to grow over the bone. It continued to grow.

2 months post-op

 

At my 3 month follow-up, a tiny sliver of bone was loose, and there was beautiful tissue underneath. This was the best situation we could have asked for!

3 months post-op

 

I had a CBCT taken, and a guide was made for proper placement of the implants. My husband, who is also a prosthodontist, planned the implants and designed the surgical guide. He also made retainers for me and a flipper for me to wear during healing.

What’s next?

On Wednesday, March 28th, I’m having 2 new dental implants placed. I’m SO nervous that when the surgeon sees the bone, it won’t be good enough for the implants.  But, I have to remember, positive thinking goes a long way!

I’m going to update you about everything so you’ll understand the ins and outs of dental implant surgery. Here we go! Wish me luck. 

¹G. De Riu, V. Lai, M. Congiu, A. Tullio. Secondary bone grafting of alveolar cleft. Minerva Stomatol. 2004 Oct; 53(10): 571–579.
Speech & Dental Case Report

Speech & Dental Case Report

Posted on by The Cleft Dentist

I received a request…

This post is for a special fan of the site, and she made the request for this topic to be addressed last week. So if you have a special request for a topic, please fill out the form at the bottom of the page, or click on the tab at the top of the page.

Let’s talk Speech: 

Patients who are born with only cleft lip will have little to no struggle with speech. They will mostly only have the same challenges  as those without a cleft lip.

The palate has 2 components- the hard palate, which is toward the front, and the soft palate, which is toward the back. A cleft palate means the palate is open into the nasal cavity, and when the opening is not closed properly, speech can be hypernasal .  This can be corrected with surgery, but it still affects speech for cleft babies. The other reason for speech delay is because the middle ear is affected in cleft patients, so this can cause a speech delay since children learn to speak by hearing sounds they make. Therefore, an audiologist and a speech therapist are very important for speech development .

So this post goes out to patients with cleft palates

As you know from my Timeline of Events post, speech evaluation and therapy should begin around 18 months of age.

However, evaluation can even begin at birth to look at:

  • mental development
  • motor development
  • hearing
  • relationship between mother & baby
  • how to use toys and how to speak to a baby
  • ALSO>>> the speech therapist can offer advice to the parents regarding a nurturing environment 

An important note to consider…

There remains controversy over whether the hard palate (more toward the front of the mouth) should be repaired early (at 12 months) or late (at 36 months). The benefit of late hard palate closure is undisturbed facial growth for the baby. However, in a study comparing patients with early and late hard palate closure, the patients with early closure performed significantly better with speech than those with late closure.² 

Speech therapy

Begins once a month after the palatoplasty (cleft palate repair).¹

What the speech therapist is looking at here: 

  • swallowing
  • hearing
  • articulation development

If issues continue by the age of 4: 

  • the frequency of speech therapy will increase to once a week
  • here, it is important to further evaluate the soft palate (back of the top of the mouth) because there may have been complications with its closure
    • further surgeries may need to be considered at this point to adjust the closure of the palate

When to see the dentist:

One goal of palatal closure is to make sure the jaws and teeth grow into the right places.

A key for successful speech development and cleft treatment is to see a Craniofacial Orthodontist around 12 months of age. Orthodontists assess facial development as part of their treatment, so seeing one early enough can help determine any future surgeries that may be needed. Also, the orthodontist can consult with the speech therapist about facial development and how it is affecting the patient’s speech. 

Another benefit of seeing a craniofacial orthodontist early is that as soon as teeth start coming in, the doctor can start aligning the teeth correctly. Establishing a dental home early in treatment is extremely important. The orthodontist and the surgeon will work closely together to make sure the jaws are aligned properly, which will help tremendously with speech. 

As shown in my Timeline of Events post, an alveolar bone graft occurs around age 10. This will also help the permanent teeth develop into the proper places and serve as stability for the gums. 

A maxillofacial prosthodontist for speech later in life…

When speech issues are still prevalent for the adult cleft palate patient, even after palatal repair, there is still another option. 

Maxillofacial prosthodontists can make a speech bulb, which sometimes is the only option for improving speech after further surgical interventions have not been successful. The use of a speech bulb involves some preparations on teeth to help hold the speech bulb in place. It is removable, with an extension on the back of the prosthesis to aid in closing the back of the palate. Also, if there has been no cleft palate closure, due to any reason, the speech bulb can close the communication between the nose and the mouth.³ 

 

My story:

I like to share my personal experience with these topics so you can get to know me better, and also so you can ask me questions about my personal journey if you’d like. 

This part for me is not as exciting because I was part of the group of cleft palate babies that had late palatal closure of the hard palate at the age of 4. I did have an obturator up until that time. I took speech lessons until I was about 6 years old. I don’t remember much about my speech therapy because it was so early in life, but I do remember it being very casual and not traumatic at all. Speech was always something I struggled with, especially with “r”  and “s” sounds, but my doctors said it sounded very good for a cleft palate patient. I do not wear a speech bulb now either, so my closure was adequate. 

My obturators from before my palatal closure

Since my personal history on this one was not as involved, I’ll share with you a case I did during my residency of a 16-year-old girl requiring a speech bulb. 

Case report:

The history of this patient: She was born with a unilateral cleft lip + palate. She had undergone palatal closure, orthodontics, bone grafts, and nose repair previously. To replace her missing teeth, she had a fixed bridge.

Her speech still sounded hypernasal, regardless of the surgical procedures, so a speech bulb was indicated. Treatment was done in the following sequence:

  1. Upper & lower impressions were made
  2. Teeth were evaluated on the cast for areas to wrap a clasp in order to hold the prosthesis in place
  3. Since there were no areas to engage a clasp, dental material, called composite, needed to be added to the molars (this is painless and does not require any anesthesia)
  4. New upper impression was made after addition of composite
  5. Clasps were bent to go around teeth and underneath composite that was added
  6.  Extension was added to reach the back of the mouth
  7. Acrylic was mixed and formed on cast
  8. Acrylic was trimmed and polished
  9. The patient came in and acrylic was adjusted as necessary
  10. Wax was added to the metal extension to simulate a bulb, and the correct size was obtained based on trial & error with the wax
  11. Once the final form of the wax was created, it was converted into acrylic
  12. Every 2 weeks, the patient would come back in, and wax would be added and then converted, if necessary

The purpose of the speech bulb is that it helps to close off any remaining space due to insufficient muscle from the cleft. By closing the space, speech is improved and does not sound hypernasal.

Please see photos below! And please feel free to post comments on this post. Thank you! 

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¹Willadsen, E. , Boers, M. , Schöps, A. , Kisling‐Møller, M. , Nielsen, J. B., Jørgensen, L. D., Andersen, M. , Bolund, S. and Andersen, H. S. (2018), Influence of timing of delayed hard palate closure on articulation skills in 3‐year‐old Danish children with unilateral cleft lip and palate. International Journal of Language & Communication Disorders, 53: 130-143. 

²OGATA, Y. The Speech Therapy of Cleft Palate Patients as an Oral Rehabilitation. Journal of Dentistry Indonesia, North America, 4, Oct. 2015. Available at: <http://www.jdentistry.ui.ac.id/index.php/JDI/article/view/758/658>. Date accessed: 20 Mar. 2018. 

³Mohammed M. (2006). Prosthetic Speech Appliances for Patients with Cleft Palate. In: Berkowitz S. (eds) Cleft Lip and Palate. Springer, Berlin, Heidelberg.