The Road to Intelligible Speech: Surgical Interventions from Birth to Early Adulthood for the Child Born with Cleft Lip and Palate

The second edition of Evaluation and Management of Cleft Lip and Palate: A Developmental Perspective is designed to be a concise roadmap for the speech-language pathologist (SLP) and other professionals who provide services for the child born with oral clefts. To provide effective services, a clear understanding of the various surgical interventions that a child goes through from birth to early adulthood is essential. In this article, I review the timing and types of surgeries that are typically done in the United States when a child is born with non-syndromic cleft lip and palate (CLP). I also provide information to help guide the SLP when a specific surgery has not yet occurred.

Early Surgeries

A child born with complete CLP, either unilateral or bilateral, has structural defects that will require at least three surgeries by early school age. The lip is repaired first, followed by the hard and soft palate, and then the alveolar ridge. I need to alert the reader, however, that there is no consensus across surgeons and centers regarding actual timing and some surgeries may be combined.

Lip Repair. Lip surgery is typically done by 2 to 3 months of age based on the “rule of 10s.” This rule, adopted in the early 1960s, is meant to ensure safety of the infant during surgery by waiting until the infant is 10 weeks of age, weighs 10 pounds, and has a hemoglobin level of 10 grams per deciliter. Lip repair may occur later than 3 months if parents opt for pre-surgical orthopedic appliances such as nasoalveolar molding (NAM). In such cases, lip repair may be delayed until the oral appliance has aligned maxillary segments. It should also be noted that some centers have abandoned the rule of 10s when an infant is healthy and do early lip repair, often within the first month of life.

Palate Repair. A single-stage repair of both the hard and soft palates is typically done when the infant is 9 to 12 months of age. The timing for this surgery is motivated by concerns for facial growth that may be impeded by tissue scarring if surgery is done earlier. In addition, natural growth of the infant reduces the width of the palatal cleft to some extent, making the surgery somewhat easier at older ages. As SLPs are well aware, infants begin canonical babbling by 6 months of age. Most infants born with cleft palate, therefore, will have restricted consonant inventories during babbling—often only nasal consonants— until the palate is repaired. Recent research has shown that even following palate repair, emergence of oral pressure consonants may take up to 6 months or longer for some infants (Zajac et al., 2021). Factors such as age at palate repair and middle ear status (hearing) may further influence the onset of oral pressure consonants. Of interest, palate repair is done at 6 months of age in many European centers. A recent randomized clinical trial reported better velopharyngeal function at 5 years of age—without significant midface hypoplasia—when palate surgery was done at 6 versus 12 months of age (Gamble et al., 2023). Perhaps surgeons in the United States will follow suit and start to repair the palate at earlier ages.  

Later Surgeries

Alveolar Bone Graft. It must be emphasized that neither lip nor palate surgery by design attempts to repair the alveolar bone defect. This is done in a procedure called alveolar bone grafting (ABG) when the child achieves mixed dentition at the approximate age of 8 to 10 years. This delay in repairing the alveolar ridge is also motivated by concerns regarding scarring and facial growth. Typically, ABG is done by taking bone from the hip of the child to fill the alveolar cleft and then closing the soft tissue gap. Often, orthodontic expansion of the maxillary arch is done prior to ABG. It must be mentioned that some centers will do soft tissue repair of the alveolar cleft at earlier ages, often at time of lip repair. This procedure, called gingivoperiosteoplasty (GPP), does not involve bone grafting. GPP is somewhat controversial as it may impede facial growth and still require actual bone grafting at a later age.

SLPs need to be aware that some school-age children with CLP who they see for evaluation and/or therapy may not yet have undergone orthodontics and ABG. These children may exhibit passive nasal air emission and even hypernasality depending on the size of the residual alveolar clefts. In addition, these children may be prone to obligatory distortion of sibilants due to several anterior oral anomalies including missing teeth, ectopic teeth, anterior cross bite (under bite), and posterior cross bite. If these children are not readily stimulable for improved articulation, then speech therapy should not be initiated until the underlying structural anomalies are corrected via orthodontics and surgery.

Maxillary Advancement. This surgery is typically done at skeletal maturity (mid-teens or later) on an elective basis when there is significant midface deficiency and Class III malocclusion (under bite). The surgery will move the maxilla forward to improve facial esthetics and establish normal occlusion with the lower jaw. Adolescents and young adults with CLP who have significant under bite often exhibit dental or inter-dental sibilant distortions. Although we tell patients that maxillary advancement in theory should improve articulation, there is limited empirical information to support this claim. In addition, patients with repaired CLP have increased risk of developing hypernasal resonance following maxillary advancement. In some cases, additional palatal surgery or the use of obturator appliances are needed to resolve the adverse effects of the maxillary advancement on velopharyngeal function.

The road to intelligible speech includes multiple surgeries for the child born with non-syndromic cleft lip and palate. In our textbook, we hope to provide the SLP and other professionals with the information needed to understand this journey and provide effective services.

References

Gamble, C., Persson, C., Willadsen, E., Albery, L., Soegaard Andersen, H., Zattoni Antoneli, M., ... & Shaw, W. (2023). Timing of primary surgery for cleft palate. New England Journal of Medicine, 389(9), 795– 807.

Zajac, D. J., Vallino, L. D., Baylis, A. L., Adatorwovor, R., Preisser, J. S., & Vivaldi, D. (2021). Emergence of prevocalic stop consonants in children with repaired cleft palate. Journal of Speech, Language, and Hearing Research, 64(1), 30–39.

Zajac, D. J., & Vallino-Napoli, L. D. (2026). Evaluation and management of cleft lip and palate: A developmental perspective (2nd edition). Plural Publishing.