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. It can involve the hard palate (the bony front portion), the soft palate (the muscular back portion), or both. A cleft palate can occur on one side (unilateral) or both sides (bilateral).
Cleft palate can occur by itself or alongside a cleft lip, which is a split in the upper lip. When both are present, the condition is called cleft lip and palate. 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.
The exact cause is not always known. Cleft palate results from a combination of genetic and environmental factors during early pregnancy. Having a family history of clefting increases the likelihood, but many children with cleft palate have no family history.
How a Cleft Palate Affects Your Child
- Feeding: Babies with a cleft palate often have difficulty creating suction for breastfeeding or bottle-feeding. Specialized bottles and nipples can help until surgical repair.
- Speech: An unrepaired cleft palate allows air to escape through the nose during speech, causing a nasal quality and making certain sounds difficult to produce.
- Hearing: Children with cleft palate have a higher risk of fluid buildup in the middle ear, which can affect hearing. Many need ear tubes (tympanostomy tubes) placed during early childhood.
- Dental development: The cleft can affect how teeth grow in, leading to missing teeth, extra teeth, or teeth that come in at unusual angles. Orthodontic treatment is almost always needed.
Cleft Palate Surgery Timeline by Age
Cleft palate treatment is not a single surgery. It is a series of procedures and therapies spread across childhood and sometimes into the late teenage years. The timing of each step is based on the child's growth and development.
Birth to 3 Months
If a cleft lip is present, lip repair surgery (cheiloplasty) is typically performed around 3 months of age following the "rule of 10s" (10 weeks old, 10 pounds, hemoglobin of 10). 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 repair.
9 to 18 Months: Palate Repair
The primary palate repair (palatoplasty) is the most important surgery in the cleft treatment timeline. It closes the opening in the roof of the mouth and reconstructs the muscles of the soft palate so they can function properly for speech. Most cleft teams schedule this surgery between 9 and 18 months of age. Repairing the palate before the child begins forming words gives the best chance for normal speech development.
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. Ongoing speech therapy is standard throughout this period. Ear tubes may be placed or replaced as needed to manage middle ear fluid.
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 cleft palate. 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, orthognathic (jaw) surgery may be recommended after growth is complete, typically around ages 16-19. A rhinoplasty (nose surgery) may also be performed to improve nasal breathing and appearance.
The Cleft Palate Team Approach
Cleft palate treatment requires a coordinated team of specialists who work together from birth through late adolescence. Most children are treated at a cleft palate or craniofacial center affiliated with a hospital or university.
The core team typically includes an oral and maxillofacial surgeon or plastic surgeon (who performs the surgeries), an orthodontist (who manages tooth alignment and jaw growth), a speech-language pathologist (who monitors and treats speech issues), an otolaryngologist or ENT (who manages ear and hearing concerns), and a pediatric dentist (who provides routine dental care adapted for the cleft).
Other team members may include a geneticist, psychologist, social worker, and feeding specialist. The American Cleft Palate-Craniofacial Association (ACPA) sets standards for cleft teams and maintains a directory of approved teams across the United States.
What to Expect During Palate Repair Surgery
The primary palatoplasty 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 exist, including the Furlow double-opposing Z-plasty and the two-flap palatoplasty. The surgeon selects the technique based on the width and location 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. This muscular reconstruction is a critical part of the procedure and directly affects speech outcomes.
Most children stay in the hospital for 1-2 nights after surgery. Parents can expect the child to be fussy, have some nasal congestion, and need pain medication for the first few days.
Recovery After Cleft Palate Surgery
The initial recovery period lasts about 2-4 weeks. During this time, the child is restricted to liquids and soft foods to protect the surgical repair. No hard, crunchy, or sharp foods are allowed. 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 2-3 weeks. 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. A follow-up appointment is typically scheduled 1-2 weeks after surgery to check healing.
Cost and Insurance Coverage
The total cost of 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. The primary palatoplasty alone typically costs $10,000 to $30,000, depending on the hospital, surgeon, and geographic location.
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.
When to See an Oral Surgeon for Cleft Palate Care
If your child is born with a cleft palate, your pediatrician will typically refer you to a cleft palate team early, often within the first few weeks of life. The oral and maxillofacial surgeon or plastic surgeon on the team will evaluate your child and discuss the surgical plan.
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. Early involvement with a cleft team leads to better outcomes in feeding, speech, and dental development. Learn more about oral surgery on our oral surgery specialty page.
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