Cleft lip and palate

Overview

Board takeaway: Coordinate cleft-adjacent tooth treatment with the graft and orthodontic plan; prevent disease around scars and appliances.

The most common craniofacial anomaly. The pediatric dentist is part of a team that sequences surgery, orthodontics, bone grafting and dental care from birth to adulthood.

How does Cleft lip and palate affect dental management?

• Team: Coordinate with the cleft team: surgeon, orthodontist, speech, ENT, audiology, social work
• Before extraction: Assess restorability, infection, position, and the role of each cleft-adjacent tooth in the graft and orthodontic plan before extraction
• Anesthesia: Altered anatomy changes local anesthetic landmarks; the airway may be harder for sedation
• Prevention: Intensive prevention: fluoride, sealants, hygiene around scars and appliances

Exam pearl

What is Cleft lip and palate?

Congenital openings in the upper lip, the palate (roof of the mouth), or both, resulting from incomplete joining of facial tissues during fetal development.

What are the main systemic features of Cleft lip and palate?

• Frequency: About 1 in 700 births; cleft lip with or without palate more often in males; isolated cleft palate more often in females and more often syndromic
• Associated syndromes: Associated with Pierre Robin sequence, Van der Woude (lip pits), 22q11.2 deletion, Stickler and Treacher Collins
• Cause and history: Most cases are multifactorial.
• History: Review family history, maternal smoking or diabetes, and medication exposures without assigning causation in an individual child
• Function: Feeding difficulty, middle ear disease with hearing loss, velopharyngeal insufficiency and speech problems

What oral findings occur in Cleft lip and palate?

• Lateral incisor: Agenesis, peg shape or duplication of the maxillary lateral incisor next to the cleft (most often affected)
• Nearby teeth: Supernumerary teeth, ectopic and rotated teeth near the cleft; enamel hypoplasia
• Occlusion: Maxillary hypoplasia with anterior and posterior crossbites; Class III
• Disease risk: Higher caries risk; oronasal fistula

For Cleft lip and palate, why graft the alveolus before canine eruption?

• Canine eruption through graft stabilizes arch and supports adjacent teeth
• Graft closes oronasal fistula and supports alar base
• Grafting after eruption can leave less bone support and a poorer long-term tooth prognosis, but late grafting can still be appropriate

What is the cleft team treatment timeline?

• Infancy: assess airway, feeding, growth, hearing, and associated anomalies. Use specialized bottles and presurgical orthopedics or nasoalveolar molding when the team indicates them.
• Lip repair: ACPA describes surgery often within the first six months for a healthy infant; timing is individualized. The historical “rule of 10s” is not a universal eligibility requirement.
• Palate repair: ACPA describes repair commonly at 9–14 months, ideally by 18 months, with patient/family readiness and airway safety considered.
• Speech development: ongoing assessment and therapy; consider additional surgery for structural velopharyngeal insufficiency (VPI) after team evaluation, including airway risk.
• Alveolar graft: time from dental development and imaging, generally before eruption of the adjacent permanent tooth through the cleft; the relevant tooth may be a lateral incisor or canine.
• After growth: orthognathic surgery and rhinoplasty.

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Typical stages are infant airway and feeding support, individualized lip and palate repair, development-guided alveolar grafting, and definitive jaw surgery after growth. The cleft team and airway safety control timing.

Should you extract a badly malformed cleft-side lateral incisor in a 6-year-old, and how does the grafting plan affect that decision?

Do not extract it on appearance alone.

• Assessment: Assess infection, restorability, root position, periodontal support, and whether it contributes to the planned arch.
• Timing: Coordinate retention or extraction with the cleft orthodontist and surgeon so the timing supports graft healing and tooth eruption.
• When treatment is needed: An infected or hopeless tooth needs treatment; other extractions may be part of a deliberate orthodontic or grafting plan.

Sources

• Supplemental study guide: Pediatric Dental Study Guide: Cleft Lip and Palate
• Definition: CDC: Cleft lip and cleft palate
• Policy on the Management of Patients with Cleft Lip/Palate and Other Craniofacial Anomalies
• Management of the Developing Dentition and Occlusion in Pediatric Dentistry
• Supplemental clinical source: ACPA: Parameters of Care (2024), Cleft Surgery and Alveolar Bone Grafting