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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}}
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| {{Editor Help}}
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| ==Overview==
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| {{Infobox_Disease | | {{Infobox_Disease |
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| | eMedicineTopic = 2679
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| | MeshID = | | | MeshID = |
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| {{SI}} | | {{Cleft lip and palate}} |
| '''Cleft lip''' and '''cleft palate''', which can also occur together as '''cleft lip and palate''' are variations of a type of clefting [[congenital deformity]] caused by abnormal facial development during [[gestation]]. This type of deformity is sometimes referred to as a ''cleft''. A '''[[cleft]]''' is a sub-division in the body's natural structure, regularly formed before birth. A cleft lip or palate can be successfully treated with [[surgery]] soon after [[birth]]. Cleft lips or palates occur in somewhere between one in 600-800 births.
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| | | == [[Cleft lip and palate overview|Overview]] == |
| The term '''hare lip''' is sometimes used colloquially to describe the condition because of the resemblance of a hare's lip. The Chinese word for cleft lip is ''tuchun'' (兔唇), literally "harelip."
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| ==Cleft lip==
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| If only skin tissue is affected one speaks of cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or continues into the nose (complete cleft). Lip cleft can occur as one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial [[nasal processes]] (formation of the primary palate).
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| <center>
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| <gallery>
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| image:CleftLip1.svg|Unilateral incomplete
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| Image:Cleft lip unilateral complete (left side).svg|Unilateral complete
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| image:CleftLip3.png|Bilateral complete
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| </gallery>
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| </center>
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| A mild form of a cleft lip is a '''microform cleft'''. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases [[Orbicularis oris muscle|muscle tissue in the lip]] underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a [[craniofacial team]] as soon as possible to determine the severeness of the cleft.
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| The actor Joaquin Phoenix is an example of a person with a microform cleft that did not require surgery.
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| <center>
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| <gallery>
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| Image:Cleftbefore.jpg|3 months old boy before going into surgery to have his unilateral incomplete cleft lip repaired.
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| Image:Cleftafter.jpg|The same boy, 1 month after the surgery.
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| Image:Cleftafter2years.jpg|Again the same boy, age 1.5 years old. Note how the scar gets less visible with age.
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| </gallery>
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| </center>
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| == Cleft palate ==
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| '''Cleft palate''' is a condition in which the two plates of the [[skull]] that form the [[hard palate]] (roof of the mouth) are not completely joined. The [[soft palate]] is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide.<ref>{{cite web |url=http://www.wrongdiagnosis.com/c/cleft_palate/stats-country.htm |title=Statistics by country for cleft palate |accessdate=2007-04-24 |work=WrongDiagnosis.com }}</ref>
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| Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the [[Palatine uvula|uvula]] is usually split.It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes (formation of the [[secondary palate]]).
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| The hole in the roof of the mouth caused by a cleft connects the mouth directly to the [[nasal cavity]].
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| Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant.
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| <center>
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| <gallery>
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| image:Cleftpalate3.png|Incomplete cleft palate
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| image:Cleftpalate1.png|Unilateral complete lip and palate
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| image:Cleftpalate2.png|Bilateral complete lip and palate
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| </gallery>
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| </center>
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| A direct result of an open connection between the [[oral cavity]] and [[nasal cavity]] is '''velopharyngeal insufficiency''' ([[velopharyngeal inadequacy|VPI]]). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal [[voice]] [[resonance]] and nasal emissions.<ref name="Sloan">{{cite journal |author=Sloan GM |title=Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art |journal=Cleft Palate Craniofac. J. |volume=37 |issue=2 |pages=112-22 |year=2000 |pmid=10749049 |doi=}}</ref> Secondary effects of VPI include speech [[articulation]] errors (e.g., [[distortions]], substitutions, and omissions) and compensatory misarticulations (e.g., glottal stops and posterior nasal fricatives).<ref>Hill, J.S. (2001). Velopharyngeal insufficiency: An update on diagnostic and surgical techniques. Current Opinion in Otolaryngology and Head and Neck Surgery, 9, 365-368.</ref>. Possible treatment options include [[speech therapy]], prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and [[Pharyngeal flap surgery|surgical procedures]].<ref name="Sloan" />
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| ==Prevalence among racial groups==
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| {{main|Clefting prevalence in different cultures}}
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| [[Prevalence]] rates reported for live births for Cleft lip with or without Cleft Palate (CL +/- P) and Cleft Palate alone (CPO) varies within different [[racial]] groups. | |
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| The highest prevalence [[rates]] for (CL +/- P) are reported for [[Native Americans in the United States|Native Americans]] and [[Asians]]. [[Africans]] have the lowest prevalence rates.
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| * Native Americans: 3.74/1000
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| *[[Japanese people|Japanese]]: 0.82/1000 to 3.36/1000
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| *[[Han Chinese|Chinese]]: 1.45/1000 to 4.04/1000
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| *[[Caucasian race|Caucasians]]: 1.43/1000 to 1.86/1000
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| *[[Latin Americans]]: 1.04/1000
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| *Africans: 0.18/1000 to 1.67/1000
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| Rate of occurrence of CPO is similar for Caucasians, Africans, North American natives and Asians.
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| Prevalence of “cleft [[uvula]]” has varied from .02% to 18.8% with the highest numbers found among [[Chippewa]] and [[Navajo people|Navajo]] and the lowest generally in Africans.
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| ==Causes of cleft==
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| During the first six to eight weeks of pregnancy, the shape of the embryo's head is formed. Five primitive tissue lobes grow:
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| :'''a)''' one from the top of the head down towards the future upper lip;
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| :'''b-c)''' two from the cheeks, which meet the first lobe to form the upper lip;
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| :'''d-e)''' and just below, two additional lobes grow from each side, which form the chin and lower lip;
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| If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face).
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| The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These back portions are called palatal shelves, which grow towards each other until they fuse in the middle.<ref>Dudas et al. (2007): Palatal fusion – Where do the midline cells go? A review on cleft palate, a major human birth defect. Acta Histochemica, Volume 109, Issue 1, 1 March 2007, [http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7CW7-4KV3XM1-1&_user=10&_coverDate=03%2F01%2F2007&_rdoc=2&_fmt=full&_orig=browse&_srch=doc-info(%23toc%2318099%232007%23998909998%23643280%23FLA%23display%23Volume)&_cdi=18099&_sort=d&_docanchor=&_ct=9&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=17601b1e25589fa0a31f100e2deef522 Pages 1-14]</ref> This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two shelves, and the way they are glued together, are quite complex and obscure despite intensive scientific research.<ref>{{cite journal |author=Dudas M, Li WY, Kim J, Yang A, Kaartinen V |title=Palatal fusion - where do the midline cells go? A review on cleft palate, a major human birth defect |journal=Acta Histochem. |volume=109 |issue=1 |pages=1-14 |year=2007 |pmid=16962647 |doi=10.1016/j.acthis.2006.05.009}}</ref>
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| The cause of cleft lip and cleft palate formation can be genetic in nature. A specific gene that increases threefold the occurrence of these deformities has been identified in 2004 as reported by the BBC.<ref>{{cite web |url=http://news.bbc.co.uk/1/hi/health/3577784.stm |title=BBC NEWS | Health | Cleft palate genetic clue found |accessdate=2007-07-01 |format= |work=}}</ref>
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| Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. Scientists have investigated seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids- which are members of the vitamin A family; [[anticonvulsant]] drugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and illegal drugs (cocaine, crack cocaine, heroin, etc.) as [[teratogen]]s that increase the possibility of clefting.
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| If a person is born with a cleft, the chances of that person having a child with a cleft, given no other obvious factor, rises to 1 in 14. Research continues to investigate the extent to which [[Folic acid]] can reduce the incidence of clefting.
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| In some cases, cleft palate is caused by syndromes which also cause other problems. [[Stickler's Syndrome]] can cause cleft lip and palate, joint pain, and [[myopia]]. [[Loeys-Dietz syndrome]] can cause cleft palate or [[bifid uvula]], [[hypertelorism]], and [[aortic aneurysm]]. Cleft lip/palate may be present in [[Patau’s Syndrome]] (trisomy 13). Many clefts run in families, even though there does not seem to be any identifiable syndrome present.
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| ==Treatment== | | == [[Cleft lip and palate pathophysiology|Pathophysiology]] == |
| Cleft lip and palate is very treatable, however the kind of treatment depends on the type and severity of the cleft. | |
| Most children with a form of clefting are monitored by a ''cleft palate team'' or ''craniofacial team'' through young adulthood. Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as [[deciduous teeth]] are replaced by [[permanent teeth]], thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.
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| ===Cleft lip treatment=== | | == [[Cleft lip and palate causes|Causes]] == |
| Within the first 2-3 months after birth, [[surgery]] is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, the often preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10 g haemoglobin). If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the ''Millard procedure'' pioneered by Ralph Millard.
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| Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of [[muscle]]s required to purse the lips run through the upper lip. In order to restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the [[philtrum]]) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.
| | == [[Cleft lip and palate epidemiology and demographics|Epidemiology and Demographics]] == |
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| D. Ralph Millard pioneered the technique of rotation-advancement
| | == [[Cleft lip and palate risk factors|Risk Factors]] == |
| procedure for cleft lip repair, performing the first procedure at a
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| [[MASH|Mobile Army Surgical Hospital]] unit in Korea.<ref>{{cite web |url=http://calder.med.miami.edu/Ralph_Millard/biography.html |title=Biography and Personal Archive |accessdate=2007-07-01 |format= |work=}} at miami.edu</ref> This technique is the standard used to repair unilateral cleft lip all over the world. | |
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| ===Cleft palate treatment=== | | == [[Cleft lip and palate natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| [[Image:Repairedcleftpalate.JPG|150px|thumb|left|A repaired cleft palate on a 64-year-old Hispanic female.]]
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| Often a cleft palate is temporarily closed using a [[palatal obturator]]. The obturator is a prosthetic device made to fit the roof of the mouth covering the gap.
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| Cleft palate can also be corrected by [[surgery]], usually performed between 9 and 18 months. Approximately 20-25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the [[Latham appliance]]. The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip and/or palate repair.
| | == Diagnosis == |
| | [[Cleft lip and palate history and symptoms|History and Symptoms]] | [[Cleft lip and palate physical examination|Physical Examination]] |
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| If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patients own chin, rib or hip.
| | == Treatment == |
| | | [[Cleft lip and palate surgery|Surgery]] | [[Cleft lip and palate psychosocial issues|Psychosocial Issues]] | [[Cleft lip and palate primary prevention|Primary Prevention]] | [[Arthrogyropsis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cleft lip and palate future or investigational therapies|Future or Investigational Therapies]] |
| ===Speech and hearing treatments=== | |
| A [[tympanostomy tube]] is often inserted into the [[eardrum]] to aerate the [[middle ear]]. This is often beneficial for the hearing ability of the child.
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| Speech problems are usually treated by a [[speech and language pathology|speech-language pathologist]]. In some cases [[pharyngeal flap surgery]] is performed to regulate the airflow during speech and reduce nasal sounds.
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| ===Sample treatment schedule===
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| Note that each individual patient's schedule is treated on a case-by-case basis and can vary per hospital. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases this is usually one procedure (for example lip repair) in other cases this it is an ongoing therapy (for example speech therapy).
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| <center>
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| {| class="wikitable" width="90%"
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| | <p align="right">age
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| | <center>0 m</center>
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| | <center>3 m</center>
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| | <center>6 m</center>
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| | <center>9 m</center>
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| | <center>1 y </center>
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| | <center>2 y </center>
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| | <center>3 y </center>
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| | <center>4 y </center>
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| | <center>5 y </center>
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| | <center>6 y </center>
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| | <center>7 y </center>
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| | <center>8 y </center>
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| | <center>9 y </center>
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| | <center>10 y</center>
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| | <center>11 y</center>
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| | <center>12 y</center>
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| | <center>13 y</center>
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| | <center>14 y</center>
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| | <center>15 y</center>
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| | <center>16 y</center>
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| | <center>17 y</center>
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| | <center>18 y</center>
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| | [[Palatal obturator]]
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| | bgColor="#009900" |
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| | bgColor="#009900" |
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| | Repair cleft lip
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| | Repair [[soft palate]]
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| | Repair [[hard palate]]
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| | [[Tympanostomy tube]]
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| | [[Speech therapy]]/[[Pharyngeal flap surgery|Pharyngeal surgery]]
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| </center>
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| === Craniofacial team ===
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| {{Main article|Craniofacial team}}
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| A craniofacial team is routinely used to treat this condition. The majority of hospitals still use craniofacial teams; yet others are making a shift towards dedicated cleft lip and palate programs. While craniofacial teams are widely knowledgeable about all aspects of craniofacial conditions, dedicated cleft lip and palate teams are able to dedicate many of their efforts to being on the cutting edge of new advances in cleft lip and palate care.
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| Many of the top pediatric hospitals are developing their own CLP clinics in order to provide patients with comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child throughout their cleft lip and palate treatment (which is ongoing) allows for the best outcomes in every aspect of a child's care. While the individual approach can yield significant results, current trends indicate that team based care leads to better outcomes for CLP patients. .<ref>{{cite web |url=http://www.widesmiles.org/cleftlinks/WS-359.html|author=Joanne Green |title=The Importance of a Multi-Disciplinary Approach |accessdate=2007-10-15 |format= |work=}}</ref>
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| A complete listing of craniofacial teams is available through the [http://www.cleftline.org Cleft Palate Foundation]
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| ==Complications==
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| [[Image:Habermanfeeding.jpg|thumb|left|A baby being fed using the Haberman Feeder. The upright sitting position allows [[Earth's gravity|gravity]] to help the baby swallow the milk more easily]]
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| Cleft may cause problems with feeding, ear disease, speech and socialization. | |
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| Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby's nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the [[Haberman Feeder]], or by using a combination of nipples and bottle inserts commonly used with other infants. A large hole, crosscut, or slit in the nipple, a protruding nipple and pressure applied to the bottle insert by the caregiver's hand can result in controllable flow to the infant without the stigma caused by specialized equipment.
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| Individuals with cleft also face many middle ear infections which can eventually lead to total hearing loss. The eustacian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self cleaning.
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| Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist. Bonding with the infant, socializing with family and community may be interrupted by the unexpected appearance, unusual speech and the surgical interventions necessary. Support for the parents as well as for the child can be pivotal.(see Psychosocial issues)
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| <BR clear=all>
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| ==Psychosocial issues==
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| Having a cleft palate does not inevitably lead to a psychosocial problem. Most children who have their cleft lips repaired early have a happy youth and a healthy social life. However, it is important to remember that adolescents with cleft palate are at an elevated risk for developing psychosocial problems especially those relating to self concept, peer relationships, and appearance. It is important for parents to be aware of the psychosocial challenges their adolescents may face and to know where to turn if problems arise.
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| A cleft palate may impact an individual’s [[self-esteem]], [[social skills]], and [[behavior]]. There is a large amount of research dedicated to the [[social development|psychosocial development]] of individuals with cleft palate. Self-concept may be adversely affected by the presence of a cleft palate. Research has shown that during the early preschool years (ages 3-5), children with cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions with other children increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and speech abnormalities, if present. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft palate.<ref>Tobiasen, J.M. (1984) Psychosocial correlated of congenital facial clefts: a conceptualization and model. Cleft Palate Journal, 21, 131-139.</ref> Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers. Yet these children were similar to their peers in regard to “how well they liked themselves.”
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| The relationship between parental attitudes and a child’s self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children.<ref>{{cite journal |author=Pope AW, Ward J |title=Self-perceived facial appearance and psychosocial adjustment in preadolescents with craniofacial anomalies |journal=Cleft Palate Craniofac. J. |volume=34 |issue=5 |pages=396-401 |year=1997 |pmid=9345606 |doi=}}</ref> Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences.<ref>{{cite web |url=http://cleftline.org |title=Cleft Palate Foundation |accessdate=2007-07-01 |format= |work=}}</ref>
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| As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft palate will deal with the typical challenges faced by most of their peers including issues related to self esteem, dating, and social acceptance.<ref>{{cite journal |author=Snyder HT, Bilboul MJ, Pope AW |title=Psychosocial adjustment in adolescents with craniofacial anomalies: a comparison of parent and self-reports |journal=Cleft Palate Craniofac. J. |volume=42 |issue=5 |pages=548-55 |year=2005 |pmid=16149838 |doi=10.1597/04-078R.1}}</ref><ref>{{cite journal |author=Endriga MC, Kapp-Simon KA |title=Psychological issues in craniofacial care: state of the art |journal=Cleft Palate Craniofac. J. |volume=36 |issue=1 |pages=3-11 |year=1999 |pmid=10067755 |doi=}}</ref><ref name="PopeSynder">Pope, A.W. & Snyder, H.T. (2004). Psychosocial adjustment in children and adolescents with a craniofacial anomaly: Age and sex patterns. The Cleft Palate-Craniofacial Journal, 42, 4.</ref> Adolescents, however, view appearance as the most important characteristic above intelligence and humor.<ref>Prokohorov, A.V., Perry, C.L., Kelder, S.H., & Klepp, K.I. (1993). Lifestyle values of adolescents: Results from the Minnesota Heart Health Youth Program. Adolescence, 28.</ref> This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Males typically deal with issues relating to withdrawal, attention, thought, and [[internalizing]] problems and may possibly develop anxiousness-depression and aggressive behaviors.<ref name="PopeSynder" /> Females are more likely to develop problems relating to self concept and appearance. Individuals with cleft palate often deal with threats to their [[Quality of life]] for multiple reasons including: unsuccessful social relationships, deviance in social appearance, and multiple surgeries. Individuals with cleft palate often have lower QOL scores than their peers. Psychosocial functioning of individuals with cleft palate often improves after surgery, but does not last due to unrealistic expectations of surgery.
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| ==Controversy==
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| In some countries cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform [[abortion]] beyond the legal [[fetal]] age limit, even though the [[fetus]] is not in jeopardy of life or limb. Some [[human rights]] activists contend this practice of "cosmetic murder" amounts to [[eugenics]]. A [[United Kingdom|British]] clergywoman, [[Joanna Jepson]], who suffered from a congenital jaw deformity herself (not a cleft lip or palate as is sometimes reported), has started legal action to stop the practice in the [[UK]] as reported by CNN<ref>{{cite web |url=http://www.cnn.com/2003/WORLD/europe/12/01/uk.curate.abortion/index.html |title=CNN.com - Priest challenges late abortion - Dec. 1, 2003 |accessdate=2007-07-01 |format= |work=}}</ref> and the BBC.<ref>{{cite web |url=http://news.bbc.co.uk/1/hi/england/hereford/worcs/3680162.stm |title=BBC NEWS | England | Hereford/Worcs | CPS examines late abortion case |accessdate=2007-07-01 |format= |work=}}</ref> Note that in the UK, an abortion could never be justified under the 1967 Abortion Act on the basis that a cleft lip and palate is not considered a serious handicap.
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| ==References==
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| {{Reflist|2}}
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| | ==Case Studies== |
| | :[[Cleft lip and palate case study one|Case #1]] |
| ==See also== | | ==See also== |
| ===Treatment/aids=== | | ===Treatment/aids=== |
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| * [[Popliteal pterygium syndrome]] | | * [[Popliteal pterygium syndrome]] |
| * [[Van der Woude syndrome]] | | * [[Van der Woude syndrome]] |
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| ===General Support Discussion Boards===
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| *[http://www.cleftadvocate.org/ftfc.html cleftAdvocate's Family-to-Family Connection Listserv]
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| *[http://www.aboutcleft.com/ aboutcleft - International Discussion Boards]
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| *[http://www.faceforward.org.uk/ Face Forward - The UK's Number One Discussion Boards]
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| ===Organisations=== | | ===Organisations=== |
| * [[Cleft lip and palate organisations|List of Cleft lip & palate organizations]] | | * [[Cleft lip and palate organisations|List of Cleft lip & palate organizations]] |
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| {{SIB}}
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| {{Congenital malformations and deformations of digestive system}} | | {{Congenital malformations and deformations of digestive system}} |
| {{Cleft lip and palate}} | | {{Cleft lip and palate}} |
