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The Surgical and Orthodontic Roadmap for CLA

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The treatment roadmap for Cleft Lip and Alveolus (CLA) involves staged procedures synchronized with a child's growth. It typically begins with infant orthopedics (NAM) and lip repair at 3-6 months, followed by an alveolar bone graft between ages 8-12, and concludes with standard orthodontics.

Key Takeaways

  • • Treatment for Cleft Lip and Alveolus (CLA) happens in planned stages coordinated with a child's natural growth and dental development.
  • • Nasoalveolar molding (NAM) in the first weeks of life helps shape the nose and narrow the gum gap, allowing for a better surgical repair.
  • • The primary lip repair surgery typically takes place when the infant is 3 to 6 months old.
  • • A secondary alveolar bone graft is usually performed between ages 8 and 12 to provide a solid foundation for permanent teeth to emerge.
  • • Children with CLA rarely need major jaw realignment surgery as teenagers because their upper jaw usually grows normally.

Managing a diagnosis of Cleft Lip and Alveolus (CLA) involves a well-coordinated roadmap of surgical and orthodontic care. Because the palate (roof of the mouth) is intact, the journey for a child with CLA is often more straightforward than for children with a combined cleft lip and palate [1][2]. Treatment is delivered in “stages” that follow your child’s natural growth and dental development [1].

Stage 1: The First Weeks (Infancy)

The journey often begins before the first surgery with Presurgical Infant Orthopedics (PSIO), most commonly Nasoalveolar Molding (NAM) [3].

  • The Goal: To gently guide the gum segments closer together and shape the nose [4].
  • The Benefit: By narrowing the gap in the lip and gumline, NAM allows the surgeon to perform a more aesthetic, “tension-free” repair [5].
  • Timing: This process works best when started in the first 1-2 weeks of life while the baby’s cartilage is still very pliable [6].

Stage 2: The First Surgery (3 to 6 Months)

The primary surgery to repair the lip (cheiloplasty) typically occurs between 3 and 6 months of age [1][7].

  • Lip Repair: The surgeon joins the separated muscle and skin of the lip to create a natural appearance and function [5].
  • Gingivoperiosteoplasty (GPP): In some cases, if the gum segments have been brought very close together by NAM, the surgeon may perform a GPP at the same time as the lip repair [8]. This procedure uses the body’s own healing tissue to encourage bone to bridge the gap in the gumline, potentially reducing the need for a later bone graft [9].

Stage 3: The “Gold Standard” Bone Graft (Ages 8 to 12)

If a gap remains in the gumline, your child will need a Secondary Alveolar Bone Graft (SABG) [1].

  • Why it’s done: The bone graft provides a solid foundation for adult teeth (especially the permanent canine) to grow into [10]. Without this bridge of bone, teeth near the cleft may not have enough support to erupt properly [11].
  • The “Gold Standard”: Surgeons typically use a small amount of the child’s own bone, usually harvested from the iliac crest (the hip bone) [1][12]. This bone is highly effective at “taking” and becoming a permanent part of the jaw [13].
  • Timing: This is ideally done during “mixed dentition”—the stage when a child has both baby and adult teeth—before the permanent canine tooth comes through the gum [14][15].

Stage 4: Orthodontics (Childhood and Adolescence)

Orthodontic care is a constant thread throughout your child’s roadmap.

  • Phase 1: Braces or expanders may be used around age 7-9 to prepare the jaw for the bone graft [1].
  • Phase 2: After the permanent teeth have erupted, a second phase of braces ensures the teeth are properly aligned for a healthy bite and smile [16].

Looking Ahead: Why CLA is Unique

One of the most encouraging aspects of a CLA diagnosis is the long-term outlook for the jaw. Children with CLA have a significantly lower need for orthognathic surgery (major jaw-realignment surgery) as teenagers compared to those with a cleft palate [17][2].

Because the roof of the mouth was never affected, the upper jaw typically grows much more normally [18]. This means that for most children with CLA, the journey concludes with standard orthodontics rather than the complex jaw surgeries often required for more severe cleft types [2].

Frequently Asked Questions

When does a baby with CLA have their first lip repair surgery?
The primary surgery to repair the lip, called a cheiloplasty, typically occurs between 3 and 6 months of age. In some cases, the surgeon may also repair the gumline gap during this same procedure.
What is Nasoalveolar Molding (NAM) and when does it start?
NAM is a presurgical orthodontic treatment that gently guides the baby's gum segments closer together and shapes the nose before surgery. It is most effective when started in the first one to two weeks of life while the infant's cartilage is still highly pliable.
Why does a child with CLA need an alveolar bone graft?
A bone graft provides a solid foundation for adult teeth, especially the permanent canines, to erupt properly. Without this bridge of bone, the permanent teeth near the cleft may lack the support needed to grow into a healthy position.
Will my child need major jaw surgery when they are older?
Because the roof of the mouth is intact in CLA, the upper jaw usually grows normally. This means children with CLA have a significantly lower need for major jaw-realignment surgery as teenagers compared to children with a cleft palate, and typically only require standard braces.
When will my child start seeing an orthodontist?
Orthodontic care is involved throughout the treatment roadmap. An orthodontist may provide NAM during infancy, use expanders or braces around age 7 to 9 to prepare for a bone graft, and apply a final set of braces after permanent teeth erupt.

Questions for Your Doctor

  • • What is the specific age you recommend for my child's primary lip repair?
  • • Is my baby a candidate for Nasoalveolar Molding (NAM), and when do we need to start that process?
  • • Will a Gingivoperiosteoplasty (GPP) be performed during the initial lip surgery, or are we planning for a bone graft later?
  • • When will we start seeing the orthodontist for the first time?
  • • How will you monitor the development of the permanent teeth to decide the best time for the alveolar bone graft?

Questions for You

  • • How do I feel about the surgical timeline? Do I have enough support at home for the recovery periods?
  • • Am I comfortable with the specialized cleaning and care required for orthodontic appliances or NAM?
  • • What are my main concerns about the bone graft procedure, and what do I need to know to feel more prepared as my child gets older?

Want personalized information?

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References

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    Archives of craniofacial surgery 2022; (23(2)):53-58 doi:10.7181/acfs.2022.00115.

    PMID: 35526839
  2. 2

    Outcome of Patients with Complete Cleft Lip and Alveolus: 20-Year Follow-Up.

    Hattori Y, Pai BC, Saito T, et al.

    Plastic and reconstructive surgery 2025; (155(4)):746e-757e doi:10.1097/PRS.0000000000011622.

    PMID: 38991117
  3. 3

    Defining biomechanical principles in pre-surgical infant orthopedics in a real cleft finite element model.

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    International journal of oral and maxillofacial surgery 2025; (54(10)):904-913 doi:10.1016/j.ijom.2024.08.041.

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    PMID: 32165093
  5. 5

    Initial experiences with NAM-assisted primary repair of the BCLP deformity.

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    Special care in dentistry : official publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry 2017; (37(6)):304-308 doi:10.1111/scd.12252.

    PMID: 29194721
  6. 6

    Presurgical Nasoalveolar Molding and Columella Lengthening for Early Unilateral Cleft Lip and Palate Rehabilitation: A Comprehensive Clinical Case Report.

    Taori KP, Niranjane P, Kamble R

    International journal of clinical pediatric dentistry 2024; (17(8)):955-961 doi:10.5005/jp-journals-10005-2899.

    PMID: 39372347
  7. 7

    Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery.

    Sitzman TJ, Carle AC, Lundberg JN, et al.

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2020; (57(2)):198-207 doi:10.1177/1055665619880056.

    PMID: 31597471
  8. 8

    Skoog Primary Periosteoplasty versus Secondary Alveolar Bone Grafting in Unilateral Cleft Lip and Alveolus: Long-Term Effects on Alveolar Bone Formation and Maxillary Growth.

    Jabbari F, Hakelius MM, Thor ALI, et al.

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    PMID: 28027239
  9. 9

    NAM Therapy-Evidence-Based Results.

    Esenlik E, Gibson T, Kassam S, et al.

    The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2020; (57(4)):529-531 doi:10.1177/1055665619899752.

    PMID: 31960709
  10. 10

    Tooth movement toward alveolar bone grafting with rhBMP-2 in a child with unilateral cleft lip and palate: Case report with long-term follow-up.

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    International orthodontics 2024; (22(3)):100898 doi:10.1016/j.ortho.2024.100898.

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  11. 11

    Evaluation of Secondary Alveolar Bone Grafting for Unilateral Complete Cleft Alveolus: A Retrospective Cone Beam Computed Tomography-Based Study.

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    Facial plastic surgery & aesthetic medicine 2024; (26(5)):564-570 doi:10.1089/fpsam.2023.0257.

    PMID: 38621184
  12. 12

    Cleft Lip and Palate and Alveolar Bone Grafting in the United Kingdom: A Brief Overview for Non-specialists.

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    PMID: 26901609
  13. 13

    Management of Alveolar Cleft Defect by Iliac Crest Secondary Bone Grafting: A Case Report.

    Vemagiri CT, Damera S, Pamidi VRC, Pampana SG

    International journal of clinical pediatric dentistry 2022; (15(4)):472-474 doi:10.5005/jp-journals-10005-2405.

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  14. 14

    Secondary Alveolar Bone Grafting in Patients with Unilateral and Bilateral Complete Cleft Lip and Palate: A Single-Institution Outcomes Evaluation Using Three-Dimensional Cone Beam Computed Tomography.

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    Plastic and reconstructive surgery 2022; (149(6)):1404-1411 doi:10.1097/PRS.0000000000009142.

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  15. 15

    Association between the timing of secondary alveolar bone grafting and maxillary permanent central incisor development in unilateral cleft lip and palate.

    Saka A, Nishizawa C, Matsushita Y, et al.

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  16. 16

    Orthodontic burden of care for patients with a cleft lip and/or palate.

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  17. 17

    Need for orthognathic surgery in cleft patients from Northern Finland.

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  18. 18

    The Effects of Gingivoperiosteoplasty and Cleft Palate Repair on Facial Growth.

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This timeline provides a general overview of surgical and orthodontic treatments for Cleft Lip and Alveolus. Always consult your child's cleft care team for a personalized treatment plan and specific timing recommendations.

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