What Is a Cleft Palate?
A cleft palate is a gap or opening in the roof of the mouth (palate) that forms when the tissue does not fully close during fetal development. A cleft can affect the hard palate (the bony front portion of the roof of the mouth), the soft palate (the muscular back portion), or both. Some children have a cleft that extends through the entire palate from front to back. A cleft palate can appear on one side (unilateral) or both sides (bilateral). In some cases, the opening is not visible at all. This is called a submucous cleft palate, where the muscles beneath the surface of the soft palate are split even though the lining of the mouth looks intact. Submucous cleft palate is often discovered later in childhood when a child develops speech problems.
A cleft palate can occur by itself or alongside a cleft lip, which is a split in the upper lip. The lip involvement can range from a small notch to a complete separation that extends into the nose. When a cleft lip and a cleft palate are both present, the condition is called cleft lip and palate. A lip-only cleft, without involvement of the palate, is a separate condition but is treated by the same surgical team. According to the CDC, cleft lip with or without cleft palate affects about 1 in 1,600 births in the United States. Cleft palate alone occurs in about 1 in 2,800 births. Together, lip and cleft palate conditions are among the most common birth differences seen in newborns.
The exact cause of a cleft lip or cleft palate is not always known. These conditions result from a combination of genetic and environmental factors during early pregnancy. Having a family history of clefting increases the likelihood, but many children born with a cleft have no family history. Certain medications taken during pregnancy, maternal diabetes, and smoking have been associated with a higher risk. If a cleft is detected before birth through ultrasound, your healthcare provider can refer you to a treatment team so care begins immediately after delivery.
How a Cleft Palate Affects Your Child
- Feeding: A baby with a cleft palate often has difficulty creating suction for breastfeeding or bottle-feeding. Specialized bottles and nipples can help until cleft palate repair. A child may need a feeding specialist in the first weeks of life.
- Speech: An unrepaired cleft palate allows air to escape through the nose during speech, causing a nasal quality. A child may have difficulty producing certain sounds, particularly pressure consonants. Early cleft palate repair and speech therapy help prevent long-term speech difficulties.
- Hearing: Children with a cleft palate have a higher risk of fluid buildup in the middle ear, which can affect hearing. Your child may need ear tubes (tympanostomy tubes) placed during early childhood. Regular hearing tests help catch problems early.
- Dental development: The cleft can affect how teeth grow in, leading to missing teeth, extra teeth, or teeth that come in at unusual angles. Children with cleft lip and palate almost always need orthodontic treatment. A pediatric dentist familiar with cleft care should be part of the team.
Types of Cleft Lip and Cleft Palate
Cleft lip and cleft palate can occur in several forms, and the type directly affects which surgeries your child will need and when. Understanding the specific type of cleft helps families prepare for the treatment ahead.
Unilateral Cleft Lip
A unilateral cleft lip is a split on one side of the upper lip. It can be incomplete (a partial notch that does not extend to the nose) or complete (a full separation that reaches into the nostril). This type may occur alone or together with a cleft palate. Surgical repair typically involves one procedure around 3 months of age, though some children need a lip revision later in childhood to refine the scar or improve symmetry.
Bilateral Cleft Lip
A bilateral cleft lip involves splits on both sides of the upper lip. This type is more complex to repair because the central portion of the lip (the prolabium) is often small and underdeveloped. Bilateral repair may be done in one or two stages, depending on the surgeon's approach and the severity of the cleft. Children with bilateral involvement of both the lip and palate often need more procedures overall than those with a unilateral cleft.
Cleft Palate Only
An isolated cleft palate occurs when the roof of the mouth does not close during fetal development, but the lip forms normally. The cleft may involve only the soft palate, only the hard palate, or both. This form is sometimes harder to detect at birth because the lip looks normal. Children with a palate-only cleft still need surgical repair and often require speech therapy, but they do not need lip repair.
Submucous Cleft Palate
A submucous cleft palate is a hidden form where the muscles of the soft palate are split underneath the mucous membrane lining. The surface of the palate may look normal, but the muscles do not function correctly. Signs include a bifid (split) uvula, a translucent zone in the midline of the soft palate, and a notch that can be felt at the back of the hard palate. This condition is often not diagnosed until a child develops speech difficulties, sometimes around ages 3-5. Not every child with a submucous cleft needs surgery. The care team will evaluate whether the cleft is affecting speech enough to warrant surgical repair.
Cleft Palate Surgery Timeline by Age
Cleft palate treatment is not a series of one-time fixes. It is a coordinated sequence of surgeries and therapies spread across childhood and sometimes into the late teenage years. The timing of each step depends on the child's growth, the type and severity of the cleft, and whether a cleft lip is also present. Your child may need anywhere from two to seven or more procedures before treatment is complete. Ongoing speech therapy and orthodontic care between surgical stages are also common.
Birth to 3 Months
If a cleft lip is present, cleft lip surgery (cheiloplasty) is typically performed around 3 months of age following the "rule of 10s" (10 weeks old, 10 pounds, hemoglobin of 10). The procedure closes the split in the upper lip and reconstructs the shape of the lip and nose. Before surgery, the focus is on feeding support, nutritional monitoring, and sometimes nasoalveolar molding (NAM), a device that helps shape the lip and nose tissue before the repair. For babies with both a cleft lip and cleft palate, lip repair comes first, and palate repair follows several months later.
9 to 18 Months: Palate Repair
The primary cleft palate repair (palatoplasty) is the most important surgery in the treatment timeline. This procedure closes the opening in the roof of the mouth and reconstructs the muscles of the soft palate so they can function properly for speech and swallowing. Most cleft teams schedule the cleft palate repair between 9 and 18 months of age. Repairing the palate before the child begins forming words gives the best chance for normal speech development. In children with a wider cleft, the surgeon may stage the repair into two separate procedures: one for the soft palate and a second for the hard palate.
Ages 5 to 8: Speech Surgery and Ear Tubes
About 20-30% of children need a secondary speech surgery (pharyngoplasty or pharyngeal flap) if the initial palate repair does not fully resolve nasal air escape during speech. A child may also need velopharyngeal surgery if the soft palate is too short to close against the back of the throat. Ongoing speech therapy is standard throughout this period. Your healthcare provider will monitor hearing at regular intervals, and ear tubes may be placed or replaced as needed to manage middle ear fluid and prevent hearing loss.
Ages 8 to 12: Bone Grafting
An alveolar bone graft fills the gap in the gum ridge (alveolar bone) where the cleft is. Bone is typically taken from the child's hip and packed into the cleft site. This surgery provides bone support for the permanent teeth to erupt and stabilizes the dental arch. It is timed to coincide with the eruption of the permanent canine teeth, usually between ages 8 and 12.
Teenage Years: Orthodontics and Possible Jaw Surgery
Orthodontic treatment with braces is nearly universal for children with a cleft lip, cleft palate, or both. The timing and duration depend on the child's dental development. Some teenagers with cleft palate develop an underbite because the upper jaw does not grow forward as much as the lower jaw. In these cases, a child may need orthognathic (jaw) surgery after growth is complete, typically around ages 16-19. A child may also benefit from a rhinoplasty (nose surgery) to improve nasal breathing and correct any residual deformity from the original cleft lip repair. For many families, these final procedures mark the completion of the treatment journey.
The Cleft Palate Team Approach
Cleft lip and palate treatment requires a coordinated team of specialists who work together from birth through late adolescence. A child born with a cleft lip, a cleft palate, or both will see multiple healthcare providers over the course of treatment. Most children are treated at a cleft palate or craniofacial center affiliated with a hospital or university medical center.
The core team typically includes an oral and maxillofacial surgeon or plastic surgeon (who performs the cleft palate repair and cleft lip surgery), an orthodontist (who manages tooth alignment and jaw growth), a speech-language pathologist (who monitors and treats speech issues related to the cleft), an otolaryngologist or ENT (who manages ear and hearing concerns), and a pediatric dentist (who provides routine dental care adapted for the cleft). A feeding specialist is often part of the team during infancy, especially before palate repair.
Other team members may include a geneticist, psychologist, social worker, audiologist, and nurse coordinator. Each healthcare provider on the team plays a specific role in managing the long-term needs of children with cleft lip and cleft palate. The American Cleft Palate-Craniofacial Association (ACPA) sets standards for cleft teams and maintains a directory of approved teams across the United States. Families can use the ACPA directory to find a qualified team near them.
What to Expect During Palate Repair Surgery
The primary cleft palate repair is performed under general anesthesia and typically takes 2-3 hours. The surgeon closes the cleft by rearranging the tissue and muscles of the palate. Several surgical techniques are used for cleft palate repair, including the Furlow double-opposing Z-plasty (often preferred for soft palate clefts) and the two-flap palatoplasty (commonly used when the hard palate is involved). The surgeon selects the technique based on the width, location, and extent of the cleft.
During surgery, the surgeon repositions the muscles of the soft palate so they can work together to close off the nasal passage during speech and swallowing. In a normal palate, the soft palate lifts to seal the nose from the mouth when a person speaks or eats. In a child with a cleft, these muscles are attached in the wrong position. The muscular reconstruction performed during cleft palate repair is a critical part of the procedure and directly affects long-term speech outcomes.
Most children stay in the hospital for 1-2 nights after cleft palate surgery. Parents can expect the child to be fussy, have some nasal congestion, and need pain medication for the first few days. Your child may have arm restraints (called "no-nos") to prevent them from putting fingers or objects into their mouth. Your healthcare provider will review post-operative care instructions, including feeding guidelines, pain management, and what to watch for during the first two weeks of recovery.
Recovery After Cleft Palate Surgery
The initial recovery period after cleft palate repair lasts about 2-4 weeks. During the first two weeks, the child is restricted to liquids and soft foods to protect the surgical site. No hard, crunchy, or sharp foods are allowed. A child may resist eating at first because of mouth pain, but it is important to maintain fluid intake. Most cleft teams provide specific feeding instructions, including the use of a syringe or special cup rather than a regular bottle or sippy cup with a hard spout.
Pain is usually manageable with prescribed medication for the first 3-5 days, then over-the-counter children's pain relievers. Swelling inside the mouth is normal and resolves within 1-2 weeks. A foul smell from the mouth is common during healing and does not usually indicate infection.
Activity is restricted for about two weeks to three weeks after surgery. Nothing should be placed in the mouth (no pacifiers, no fingers, no hard-spouted cups) to avoid disrupting the repair. Most children return to their normal energy level within a week, though dietary restrictions continue for 2-4 weeks. Your child may return to daycare or other activities once your healthcare provider confirms the surgical site is healing properly. A follow-up appointment is typically scheduled one to two weeks after surgery to check healing and address any concerns.
Cost and Insurance Coverage
The total cost of cleft lip and cleft palate treatment over childhood can range from $50,000 to $100,000 or more when all surgeries, orthodontics, speech therapy, and related care are included. A single cleft palate repair typically costs $10,000 to $30,000, depending on the hospital, surgeon, and geographic location. If cleft lip surgery is also needed, that adds additional cost. Bone grafting, jaw surgery, and rhinoplasty each carry separate fees as well.
The good news is that cleft palate surgery is considered medically necessary by virtually all insurance providers. Private insurance, Medicaid, and the Children's Health Insurance Program (CHIP) cover cleft palate surgery and most related treatments. Many states have specific mandates requiring insurers to cover cleft palate care, including orthodontic treatment that is part of the cleft treatment plan.
If insurance is a barrier, organizations like Smile Train and Operation Smile provide funding for cleft treatment. Hospital social workers on cleft teams can help families identify resources. Costs vary by location, provider, and the complexity of the child's case.
The Role of Speech Therapy in Cleft Palate Treatment
Speech therapy is one of the most important parts of treatment after palate repair. A cleft palate affects how a child learns to produce sounds, and even after a successful repair, many children need professional guidance to develop clear, age-appropriate speech.
A speech-language pathologist (SLP) with experience in cleft lip and palate will begin evaluating your child's speech development early, sometimes before the first birthday. The SLP monitors babbling patterns, sound production, and language milestones. After palate repair, formal speech therapy usually begins around age 2-3, when the child is actively building vocabulary and learning to form sentences.
Common speech issues after cleft palate repair include hypernasality (too much air escaping through the nose), compensatory articulation (where the child learns to produce sounds in the throat instead of the mouth), and difficulty with pressure consonants such as "p," "b," "t," and "d." Some children achieve normal speech with therapy alone, while others need additional surgery on the soft palate or pharynx to improve velopharyngeal function.
Parents play an important role in speech development between sessions. Your speech therapist can give you specific activities to practice at home. Consistency between professional sessions and home practice leads to the best outcomes.
When to See an Oral Surgeon for Cleft Palate Care
If your child is born with a cleft palate, a cleft lip, or both, your pediatrician or healthcare provider will typically refer you to a cleft palate team within the first few weeks of life. A lip cleft is often identified at birth or even before birth through prenatal ultrasound. A cleft palate alone may not be visible and is sometimes discovered during the newborn examination when a provider checks the roof of the mouth. The oral and maxillofacial surgeon or plastic surgeon on the team will evaluate your child and discuss the surgical plan for lip and cleft palate repair.
If you have not been connected with a cleft team, ask your pediatrician for a referral or contact the ACPA for a list of approved cleft palate teams in your area. Families dealing with a cleft lip and palate diagnosis for the first time often have questions about timing, surgical options, and what their child's life will look like long-term. Early involvement with a cleft team leads to better outcomes in feeding, speech, and dental development. Most children born with a cleft lip and cleft palate go on to live full, healthy lives with proper treatment. Learn more about oral surgery on our oral surgery specialty page.
Feeding Challenges Before and After Cleft Palate Surgery
Feeding is one of the first concerns parents face after a cleft lip or cleft palate diagnosis. A baby with an opening in the palate cannot create adequate suction for standard breastfeeding or bottle-feeding because the gap allows air and liquid to pass between the mouth and the nasal cavity.
Specialized bottles such as the Haberman feeder, Pigeon bottle, or Dr. Brown's Specialty Feeding System are designed for babies with a cleft. These bottles use a one-way valve or squeezable chamber so the baby does not need to generate suction. A feeding specialist on the care team can help parents find the right equipment and technique within the first days of life.
After palate repair, feeding restrictions protect the surgical site during healing. For the first two weeks after surgery, most teams recommend only liquids and very soft pureed foods given by syringe or open cup. No bottles, sippy cups with hard spouts, straws, or utensils should be placed in the child's mouth during this period. Your child may resist eating because of mouth soreness, but small frequent feedings help maintain nutrition and hydration.
As the palate heals over the following two weeks, softer table foods can gradually be reintroduced. Most children return to a normal diet by four to six weeks after surgery. Your healthcare provider will give you a specific timeline based on how your child's healing is progressing.
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Search Oral Surgeons in Your AreaLong-Term Follow-Up and Outcomes
Children born with a cleft lip and palate need long-term follow-up that extends from infancy through early adulthood. Regular appointments with the treatment team allow specialists to monitor growth, speech development, hearing, dental alignment, and psychosocial well-being at each stage.
During childhood, visits are typically scheduled at least once a year, with more frequent appointments during periods of active treatment such as orthodontics or bone grafting. Each specialist evaluates the child from their own area of expertise, and the team meets to coordinate the treatment plan. This team-based approach helps avoid gaps in care and ensures each procedure is timed correctly.
The long-term outlook for children with cleft lip and palate is excellent when treatment begins early and follows a coordinated plan. Most children achieve understandable speech, a functional bite, and a natural appearance. Studies show that children who receive care from an organized team have better outcomes than those who receive fragmented care from individual providers. Emotional and social support is also part of long-term care, as some children and teenagers may experience self-consciousness about scars or speech differences. A psychologist or counselor can help families navigate these challenges.