Cleft Lip and Palate
Cleft lip and cleft palate are birth defects that occur when a baby's lip or mouth doesn't form properly during pregnancy. A cleft lip appears as a split or opening in the upper lip, ranging from a small notch to a complete separation extending into the nose. A cleft palate is an opening in the roof of the mouth (palate) that can involve the hard palate, soft palate, or both. These conditions can occur separately or together, and may be unilateral (affecting one side) or bilateral (affecting both sides). Clefts are among the most common birth defects worldwide, affecting approximately 1 in 700 babies. While they can cause challenges with feeding, speech, hearing, and dental development, modern treatment approaches involving a multidisciplinary team of specialists can address these issues effectively. With proper care, children born with cleft lip and/or palate typically achieve normal appearance, speech, and quality of life.
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What Causes It?
Genetic factors - Inherited genes from one or both parents can contribute to cleft formation.
Environmental influences during pregnancy - Various exposures may interact with genetic susceptibility.
Maternal smoking - Cigarette smoking during pregnancy increases risk significantly.
Alcohol consumption - Maternal alcohol use during pregnancy raises risk.
Certain medications - Anti-seizure drugs, acne medications containing isotretinoin, and some other drugs taken during pregnancy.
Insufficient maternal nutrition - Particularly deficiency of folic acid and other B vitamins.
Viral infections - Certain infections during early pregnancy may increase risk.
Maternal diabetes - Poorly controlled diabetes before and during pregnancy.
Maternal obesity - Higher body mass index associated with increased risk.
Advanced maternal age - Older maternal age may slightly increase risk.
Family history - Risk increases if parents or siblings have clefts.
Genetic syndromes - Clefts may be part of genetic syndromes like Van der Woude syndrome, Pierre Robin sequence, or velocardiofacial syndrome.
Male gender - Cleft lip with or without cleft palate is more common in males.
Female gender - Isolated cleft palate (without cleft lip) is more common in females.
In many cases, the exact cause remains unknown despite thorough investigation.
Signs & Symptoms
Physical characteristics:
Visible gap or split in the upper lip (cleft lip).
Opening in the roof of the mouth that may connect the mouth and nasal cavity (cleft palate).
Asymmetrical nose and/or nostril, particularly with unilateral cleft lip.
Dental abnormalities - Missing, extra, displaced, or malformed teeth.
Functional challenges:
Feeding difficulties - Problems creating suction for breastfeeding or bottle feeding.
Excessive air intake during feeding, leading to increased gas and spitting up.
Liquid or food coming through the nose during feeding (nasal regurgitation).
Speech problems - Delayed speech development, hypernasality (too much air through the nose).
Articulation difficulties, especially with certain consonants.
Hearing issues - Increased susceptibility to middle ear infections and hearing loss.
Eustachian tube dysfunction affecting middle ear ventilation.
Dental problems - Misaligned teeth and abnormal bite patterns.
Breathing issues - Possible airway obstruction, especially with associated conditions like Pierre Robin sequence.
Social and psychological impacts:
Potential challenges with self-image and social interactions, particularly during school years.
Impact on facial appearance varies depending on type and severity of cleft and quality of repair.
Associated conditions:
In some cases, clefts may be part of a syndrome with additional health issues.
How We Diagnose
Our specialists use advanced diagnostic methods to accurately identify and assess your condition
Prenatal Ultrasound
Many cleft lips can be detected during routine prenatal ultrasound examinations, typically during the second trimester (around 18-20 weeks). Cleft palate is more difficult to visualize on ultrasound and may not be detected before birth. 3D/4D ultrasound improves visualization of facial structures.
Physical Examination After Birth
Visual inspection and examination of the baby's mouth, lip, and palate by healthcare providers immediately after birth can confirm the presence of clefts. The examination determines whether the cleft affects the lip, palate, or both, and whether it is unilateral or bilateral.
Team Evaluation
Comprehensive assessment by a multidisciplinary cleft team, typically including a plastic surgeon, oral surgeon, otolaryngologist (ENT), speech-language pathologist, audiologist, orthodontist, and others. This team evaluates the extent of the cleft and develops a coordinated treatment plan.
Feeding Assessment
Evaluation by a feeding specialist, often a speech-language pathologist or nurse with expertise in cleft care, to assess feeding challenges and recommend appropriate techniques and specialized equipment.
Hearing Screening
Early and regular hearing tests to detect potential hearing loss related to middle ear fluid or infections, which are common in children with cleft palate.
Genetic Evaluation
May be recommended to determine if the cleft is associated with a genetic syndrome, particularly if there are other congenital anomalies present. This might include chromosome analysis, specific gene testing, or whole exome sequencing.
Additional Imaging
In some cases, CT scans or MRI may be used to better visualize the anatomy of complex clefts or associated craniofacial abnormalities, particularly when planning surgical intervention.
Treatment Options
Personalized treatment plans tailored to your specific needs and condition
Specialized Feeding Techniques
Immediate assistance after birth to establish adequate nutrition, which is critical for growth and surgical readiness. This may include specialized bottles and nipples designed for babies with clefts, positioning techniques, and feeding strategies that compensate for difficulties with suction. A feeding specialist provides guidance tailored to the baby's specific challenges.
Pre-surgical Orthopedics/Nasoalveolar Molding
For some infants, particularly those with wide clefts, devices similar to retainers may be used before surgery to align the parts of the lip and gum ridge, bringing them closer together. This can improve surgical outcomes and final appearance. Nasoalveolar molding (NAM) specifically helps shape the nose and align the maxillary segments before cleft lip repair.
Cleft Lip Repair Surgery
Surgical closure of the cleft lip, typically performed when the baby is around 3-6 months old and has reached certain health and weight milestones. Various surgical techniques may be used depending on the cleft's characteristics, with the goals of creating a functional and natural-appearing lip, symmetrical nose, and minimal visible scarring.
Cleft Palate Repair Surgery
Surgical closure of the roof of the mouth, usually performed when the child is 9-18 months old, before significant speech development. The surgery aims to create a functional palate that allows for normal speech development, proper feeding, and appropriate separation between the nasal and oral cavities, while allowing for normal facial growth.
Ear Tubes (Myringotomy Tubes)
Tiny tubes surgically placed in the eardrums to ventilate the middle ear and prevent fluid accumulation. Children with cleft palate often have dysfunction of the Eustachian tubes, which normally ventilate the middle ear, leading to frequent ear infections and potential hearing loss. These tubes are often placed during the palate repair or as a separate procedure.
Speech Therapy
Ongoing assessment and therapy by a speech-language pathologist specialized in cleft care. Therapy addresses articulation errors, resonance problems (hypernasality), and other speech issues related to the cleft. Early intervention helps maximize speech development and minimize the need for secondary surgeries for speech improvement.
Dental and Orthodontic Treatment
Specialized dental care to address missing, malformed, or misaligned teeth common in children with clefts. This includes regular dental checkups, orthodontic treatment (braces), and potentially bone grafting to the gum ridge (alveolar bone graft) around ages 6-9 to support permanent tooth eruption and provide stability for the dental arch.
Secondary Surgeries
Additional procedures that may be needed as the child grows, potentially including velopharyngeal procedures for speech (if the palate doesn't function properly during speech), revision of lip and nose for improved appearance, jaw surgery (orthognathic surgery) during teenage years to correct growth discrepancies, and rhinoplasty after facial growth is complete.
Home Remedies
Specialized Feeding Techniques
Use recommended specialized bottles and nipples designed for babies with clefts. Position baby in a more upright position (at least 45 degrees) during feeding to reduce nasal regurgitation and ear infections. Take frequent burping breaks, as babies with clefts often swallow more air. Be patient with feedings, which may take longer than with non-affected babies.
Oral Hygiene Care
Begin oral care early, even before teeth erupt, by gently cleaning the gums with a soft, damp cloth after feedings. Once teeth appear, brush with an appropriately-sized soft toothbrush and the recommended amount of fluoride toothpaste. Pay special attention to teeth adjacent to the cleft site, which may be more vulnerable to decay.
Scar Management
After lip repair, follow your surgeon's instructions for scar care, which may include gentle massage with recommended ointments, sun protection, and potentially silicone gel sheets. Consistent care during the first year after surgery, when the scar is actively remodeling, can significantly improve the final appearance.
Speech Practice
Engage in activities recommended by your speech-language pathologist to reinforce therapy goals at home. These might include specific sound practice, blowing games to strengthen oral muscles, or exercises to reduce nasal air emission. Make these activities playful and incorporate them into daily routines rather than creating separate "practice sessions."
Ear Care and Monitoring
Watch for signs of ear infections (tugging at ears, irritability, fever) and seek prompt treatment. If ear tubes are placed, follow care guidelines, which typically include keeping water out of the ears during baths and swimming with special precautions or earplugs.
Supportive Feeding Environment
Create a calm, positive atmosphere during mealtimes. As your child transitions to solid foods, be aware that they may have difficulties with certain textures or feeding methods due to palatal differences or previous feeding challenges. Introduce new foods and textures gradually, and consult feeding specialists if difficulties persist.
Age-Appropriate Explanations
As children grow, provide simple, honest explanations about their cleft appropriate to their developmental level. Practice with your child how to respond to questions or comments from others. Focus on building overall self-esteem and confidence beyond physical appearance.
Support Network
Connect with other families of children with clefts through support groups, either in-person or online. These connections provide emotional support, practical advice, and a sense of community with others who understand the unique journey of raising a child with a cleft.
Prevention Tips
Attend all scheduled appointments with your cleft team, typically every 6-12 months during childhood.
Follow through with recommended imaging studies, hearing tests, and speech evaluations to monitor progress.
Maintain excellent oral hygiene with regular brushing, flossing, and dental check-ups, as children with clefts have higher risk of dental problems.
Be vigilant about treating ear infections promptly and follow recommendations regarding ear tubes and hearing tests.
Practice speech activities at home as recommended by your speech-language pathologist.
Maintain proper nutrition to support growth and healing, especially before and after surgical procedures.
For infants with unrepaired palates, position on the back for sleep (as recommended for all infants) but consider tilting the crib mattress slightly to reduce nasal regurgitation.
After surgery, follow wound care instructions carefully and watch for signs of infection or complications.
Protect healing lip scars from sun exposure with sunscreen and/or physical coverage.
For women who have had a child with a cleft or have a family history of clefts, consult with a genetic counselor before future pregnancies.
During subsequent pregnancies, prenatal care should include adequate folic acid supplementation and avoidance of known risk factors like smoking and alcohol.
Consider psychological support if your child experiences social or emotional challenges related to their cleft.
Advocate for your child in school settings if speech or appearance issues lead to social or academic challenges.
Keep a well-organized medical record documenting all procedures, team recommendations, and progress.
Surgical Solutions
Advanced surgical procedures performed by our expert specialists
Primary Cleft Lip Repair
Surgical closure of the cleft in the lip, typically performed around 3-6 months of age when the baby is at a safe weight for anesthesia. For unilateral (one-sided) clefts, techniques like Millard rotation-advancement or Fisher repair create a functional lip with a natural-looking Cupid's bow and minimal visible scarring. Bilateral (two-sided) clefts require different approaches to reconstruct the central portion of the lip and reposition the premaxilla (central portion of the upper jaw). This surgery also includes initial reshaping of the nose, which is typically distorted by the cleft.
Primary Cleft Palate Repair
Closure of the opening in the roof of the mouth, usually performed between 9-18 months of age before significant speech development. The surgery involves rearranging the tissues of the hard and soft palate to create a functional barrier between the mouth and nose. Common techniques include the Furlow double-opposing Z-plasty, von Langenbeck procedure, or two-flap palatoplasty. The goals are to create a palate that functions properly for speech, feeding, and middle ear ventilation while minimizing impact on facial growth.
Alveolar Bone Graft
Surgical placement of bone tissue (usually harvested from the hip) into the gum ridge where the cleft affects the dental arch, typically performed around ages 6-9 when the permanent canine teeth are developing. This procedure stabilizes the maxilla (upper jaw), provides support for teeth adjacent to the cleft, allows teeth to erupt properly, and supports the base of the nose. The timing is critical to match the child's dental development.
Velopharyngeal Insufficiency Correction
Secondary surgeries to address persistent speech problems related to inadequate closure between the soft palate and back of the throat during speech (velopharyngeal insufficiency). Options include pharyngeal flap, sphincter pharyngoplasty, or palatal re-repair, depending on the specific pattern of dysfunction. These procedures aim to reduce hypernasality and nasal air emission during speech while avoiding airway obstruction during sleep.
Lip and Nose Revision
Secondary procedures to refine the appearance of the lip and nose after primary repair, addressing issues like lip notching, irregular scarring, or nasal asymmetry. These are typically performed in the preschool years (around age 4-5) when the child is becoming socially aware but before school entry, or during teenage years when facial growth is more complete.
Orthognathic (Jaw) Surgery
Correction of skeletal discrepancies in jaw growth that often occur in children with clefts, particularly midface deficiency (underdevelopment of the upper jaw). Usually performed after puberty when facial growth is complete, this procedure repositions the upper jaw, lower jaw, or both to improve bite function, facial proportions, and appearance. Often coordinated with orthodontic treatment before and after surgery.
Definitive Rhinoplasty
The final surgical refinement of the nose, addressing both aesthetic and functional concerns specific to cleft-affected noses, such as asymmetry, tip projection, and airway obstruction. This is typically performed when facial growth is complete, usually in late adolescence or early adulthood. It requires specialized techniques different from standard rhinoplasty due to the unique anatomy of cleft noses.
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