From child to adult patient
Treatment for a cleft lip and palate (CLP) or a craniofacial syndrome does not end with the conclusion of paediatric care. Growth of the facial skeleton — particularly the upper jaw (maxilla) — is often restricted in cleft patients by scar tissue from the early lip and palate repairs. This so-called secondary maxillary hypoplasia often only becomes fully visible towards the end of growth and can no longer be corrected with braces alone.
For many people, a new phase of care therefore begins in early adulthood: orthognathic (jaw realignment) surgery. Depending on individual findings, this may be combined with nose correction, residual speech issues (velopharyngeal insufficiency, VPI) and dental/prosthetic rehabilitation of the former cleft area.
Many consequences of craniofacial conditions can still be treated in adulthood – for example facial asymmetries, jaw-joint and bite problems, obstructive sleep apnoea or aesthetic concerns. Whether surgery is advisable and feasible depends on the individual findings and is assessed by an interdisciplinary specialist centre.
Which operation, and when? The road into adulthood
The timing of jaw surgery depends on completion of facial skeletal growth — usually from around age 16 in women and around age 18 in men, confirmed by serial radiographs (lateral cephalogram, hand-wrist X-ray). In craniofacial syndromes with pronounced midface hypoplasia (Crouzon, Apert, Pfeiffer syndrome), a first major procedure may already be necessary in childhood or adolescence — definitive fine correction then follows after growth is complete.
Orthodontic preparation
Decompensation of tooth position (compensatory tilting is reversed) so that the true skeletal discrepancy becomes visible and surgically correctable. Close coordination between orthodontics and maxillofacial surgery.
3D surgical planning
CBCT/CT-based virtual planning, fabrication of patient-specific splints or cutting guides. For combined findings, the sequence of upper- and lower-jaw correction, nasal correction, and any VPI surgery is determined by the interdisciplinary team.
Le Fort I osteotomy ± BSSO
Advancement of the upper jaw to compensate for scar-related maxillary hypoplasia, combined where necessary with a lower jaw osteotomy (BSSO) for a bimaxillary correction of the bite.
Le Fort III distraction (often earlier) + Le Fort I in adulthood
In Crouzon, Apert or Pfeiffer syndrome, the entire midface is often advanced in childhood/adolescence using distraction osteogenesis (functional indication: obstructive sleep apnoea, corneal exposure). A residual correction of the upper jaw after growth completion is then possible, usually to a lesser extent.
Septorhinoplasty, VPI surgery, dental implants
Only after the jaw position has been stabilised are nose shape, speech function and dental rehabilitation of the cleft area finally corrected — an earlier nose correction would be altered again by the later jaw movement.
Le Fort I osteotomy and bimaxillary correction (BSSO)
The Le Fort I osteotomy completely separates the upper jaw (maxilla) above the tooth roots from the rest of the facial skeleton and repositions it in a new, three-dimensionally planned position — typically forward and/or downward to compensate for the cleft-related underdevelopment. Where there is a combined over-/underbite, the lower jaw is additionally repositioned by a bilateral sagittal split osteotomy (BSSO) — known as bimaxillary surgery.
Indication
Skeletal Class III relationships due to an underdeveloped upper jaw, transverse and vertical discrepancies, anterior open bite, aesthetic midface concavity.
Procedure
Inpatient procedure under general anaesthesia, fixation with titanium plates/screws, usually intraoral access without visible facial scars. Post-operative swelling over 1–2 weeks.
Cleft-specific considerations
Scar tissue from previous lip and palate repair can limit blood supply and the achievable advancement. For large discrepancies, distraction osteogenesis may be more appropriate than a single-stage advancement.
Velopharyngeal function
Advancing the upper jaw can increase the velopharyngeal distance and worsen or unmask a pre-existing VPI — pre-operative speech assessment is therefore part of the planning.
Le Fort III distraction for syndromic midface hypoplasia
In syndromes with premature fusion of the skull sutures (craniosynostoses such as Crouzon, Apert or Pfeiffer syndrome), the entire midface lags behind in growth while the lower jaw continues to grow normally. The result is pronounced midface retrusion with bulging eyes (exorbitism), narrowing of the upper airway up to obstructive sleep apnoea, and a skeletal Class III profile.
The Le Fort III osteotomy with distraction osteogenesis separates the entire midface (frontal bone–orbit–cheek–nose–maxilla complex) as one unit and gradually advances it over several weeks using internal or external (halo-type) distractors. Unlike the Le Fort I osteotomy for isolated cleft lip and palate, here the surgical goal is not only the bite but also airway width and protection of the eyes.
First Le Fort III or monobloc distraction
A functional indication (airway, corneal protection) may require advancement before growth is complete — with the understanding that remaining growth potential may partially relapse the correction.
Definitive Le Fort I residual correction
Fine-tuning of occlusion and midface projection after growth is complete, usually to a smaller extent than the primary procedure. Combination with BSSO of the lower jaw depending on findings.
Surgically assisted rapid palatal expansion (SARPE)
Many people with cleft lip and palate have a transverse underdevelopment of the upper jaw — the maxilla is too narrow compared with the mandible, often with a unilateral or bilateral crossbite. During growth, the upper jaw can still be widened orthodontically with a palatal expansion appliance (e.g. Hyrax). After growth is complete, however, the palatal suture has fused — a purely orthodontic expansion would mainly tip the teeth rather than widen the bone.
In adults, expansion is therefore surgically assisted: in surgically assisted rapid palatal expansion (SARPE), the palatal suture and the lateral bony connections of the upper jaw are surgically separated (osteotomy); the maxilla is then slowly and gradually widened using a transpalatal distraction screw. The method is also referred to as surgical palatal expansion.
Indication
Transverse maxillary hypoplasia after growth completion, unilateral or bilateral crossbite, lack of space before a planned Le Fort I osteotomy.
Procedure
Osteotomy of the palatal suture and lateral maxillary walls, activation of the distraction screw starting after a few days (approx. 0.5 mm/day), retention period of several months for bony consolidation.
Cleft-specific considerations
Scarred palatal tissue from previous cleft surgery can make distraction more difficult and increase the risk of asymmetric expansion — careful pre-operative planning and, if necessary, slower activation are important.
Combination
SARPE can be performed as a standalone procedure or as a preparatory step before a Le Fort I osteotomy, if both corrections are planned together.
Septorhinoplasty: correcting the cleft nose
Cleft lip and palate typically also affects nasal shape: the nostril on the cleft side is often flattened and displaced laterally, the nasal septum is usually deviated, and the nasal tip can appear asymmetric. Initial corrections are often made as part of the primary lip repair or during school age — however, a definitive septorhinoplasty is usually performed only after nasal growth is complete and after any jaw surgery, since the latter changes the position of the nasal base.
Functional goal
Correction of septal deviation to improve nasal breathing — often combined with septoplasty and, if needed, correction of the inferior turbinates.
Aesthetic goal
Symmetrising the nostrils, straightening the nasal dorsum, re-projecting the nasal tip — taking into account the cartilage and soft-tissue characteristics typical of cleft noses.
Timing
Usually after growth is complete and — if planned — after orthognathic surgery, since this affects the nasal base and therefore the surgical outcome.
Technique
Often an open rhinoplasty technique with cartilage grafts (e.g. from the septum or ear) to reconstruct the alar cartilage on the cleft side and stabilise the nasal tip.
VPI surgery in adulthood
Some adult patients with cleft lip and palate continue to have residual velopharyngeal insufficiency (VPI) — usually known since childhood, but sometimes only noticeable in adulthood, for example when professional demands (speaking professions, singing) require a clearer voice, or when a Le Fort I advancement unmasks a previously compensated VPI.
The surgical principles are the same as in childhood (pharyngeal flap, velopharyngoplasty or palate lengthening) — but in adults, particular attention must be paid to the risk of post-operative obstructive sleep apnoea (OSA), as a pharyngeal flap narrows the airway. A sleep medicine assessment before and, if needed, after the procedure is therefore recommended.
Dental implants and secondary cleft reconstruction
One or more teeth (usually the lateral incisor) are often missing in the area of the former alveolar cleft, and the alveolar ridge is frequently reduced in width and height following the alveolar bone grafting (alveolar cleft osteoplasty, usually with bone from the iliac crest) performed in childhood. In adulthood, several options are available for definitive dental rehabilitation.
| Option | Requirement | Note |
|---|---|---|
| Single-tooth implant | Sufficient bone volume in the cleft area, usually present after childhood alveolar bone grafting | Most common solution for a missing lateral incisor; technically demanding due to soft-tissue conditions |
| Secondary bone augmentation | Insufficient bone volume, e.g. after resorption of the graft | Renewed bone grafting before implantation, often planned together with orthognathic surgery |
| Orthodontic space closure | Small gap, favourable tooth position | Alternative to an implant — the neighbouring tooth is moved orthodontically into the gap |
| Bridge / removable denture | Implant not possible or not desired | Conventional prosthetic solution, possibly as an interim option |
Timing matters: implants are usually placed after completion of any planned orthognathic surgery, since the position of the upper jaw changes during that surgery. Repair of residual oronasal fistulae (small connections between the mouth and nasal cavity in the former cleft area) is usually carried out in the same surgical step as the jaw surgery.
Funding in adulthood: IV (disability insurance) and KVG (health insurance)
Cleft lip and palate is one of the congenital conditions ("Geburtsgebrechen") recognised by the Swiss disability insurance (IV) under the Ordinance on Congenital Conditions (GgV-EDI). The IV generally covers medical measures for congenital conditions up to the completed age of 20. Operations that were started or bindingly planned before this date can, under certain conditions, still be billed through the IV afterwards — this should be clarified early with the responsible IV office.
IV congenital condition cover
Jaw surgery and ENT/speech therapy measures related to cleft lip and palate are generally covered by the IV as a congenital condition — usually without deductible or co-payment.
Planning before the 20th birthday
If surgery is foreseeably needed, early registration with the IV office and surgical planning before completing the 20th year of age helps secure cost coverage.
Health insurance (KVG)
After the 20th birthday, the mandatory health insurance generally applies. Medically indicated jaw surgery (e.g. for functionally relevant dysgnathia) is usually a mandatory KVG benefit — pre-authorisation before the procedure is recommended.
Dental services
Implants and dentures in the cleft area may, depending on findings, fall under congenital-condition dental treatment — again, clarification and application should ideally happen before the 20th birthday; later needs are assessed individually by the IV or health insurer.
FAQ: Adults with cleft lip and palate
Is it normal to need surgery again in adulthood?
Yes. Because upper jaw growth in many cleft patients is not complete until after puberty, the definitive jaw surgery is deliberately planned for that point — even if several operations already took place in childhood.
What is orthognathic surgery?
Orthognathic surgery is a procedure in which the upper and/or lower jaw is surgically separated from the rest of the skull and repositioned into a new, functionally and aesthetically more favourable position. In cleft lip and palate this usually involves the upper jaw (Le Fort I osteotomy).
When is the right time for jaw surgery?
Usually after facial growth is complete — around age 16 for women and around age 18 for men, confirmed by repeated X-rays. In syndromic forms with functional urgency (e.g. airway problems), earlier procedures may be necessary.
What is the difference between Le Fort I and Le Fort III surgery?
The Le Fort I osteotomy repositions only the tooth-bearing part of the upper jaw and primarily corrects the bite. The Le Fort III osteotomy repositions the entire midface including the eye sockets and nose — it is used in syndromic midface hypoplasia (e.g. Crouzon, Apert syndrome).
What is surgically assisted rapid palatal expansion (SARPE)?
SARPE is a procedure to widen an upper jaw that is too narrow in adults, in which the fused palatal suture is surgically released and then gradually widened using a distraction screw. It is often necessary in adults because purely orthodontic expansion is no longer possible after growth is complete.
Will jaw surgery affect my speech?
Advancing the upper jaw can change the velopharyngeal distance and reveal a previously compensated velopharyngeal insufficiency (VPI). A speech therapy and, if necessary, ENT assessment before surgery is therefore part of careful planning.
Can my nose be corrected at the same time?
Yes, by septorhinoplasty. This is usually performed only after any planned jaw surgery, since that changes the position of the nasal base and would otherwise affect the rhinoplasty result.
What happens to the gap in the cleft area?
The gap (usually in place of the lateral incisor) is often restored with a dental implant — provided there is sufficient bone volume, usually present thanks to alveolar bone grafting performed in childhood. Implants are usually placed after completion of any planned jaw surgery.
Who pays for treatment in adulthood?
Up to the 20th birthday, the IV (disability insurance) generally covers measures related to the recognised congenital condition of cleft lip and palate; the exact scope should be clarified with the IV in each case. After that, the mandatory health insurance (KVG) generally applies for medically indicated procedures. Early planning before the 20th birthday often secures the more favourable IV coverage.
Questions about treatment in adulthood?
Our network connects you with experienced craniofacial teams in Switzerland — for a specialist assessment, even if your last treatment was years ago.