Management of Cleft Lip and Palate.

This publication combines the work of 53 contributors of scientific and clinical papers from a symposium of the Educational Foundation of the American Society of Plastic and Reconstructive Surgeons held at Duke University Medical Center, April 12 through 14, 1973. The principal contributors are plastic surgeons, but other medical and allied professionals are represented. The book deals with management but has a substantial scientific base and contains an excellent bibliography. It has five parts: part 1, General Considerations Regarding Etiology and Management of the Cleft Lip and Palate"; part 2, "The Unilateral Cleft Lip"; part 3, "The Bilateral Cleft Lip"; part 4, "The Cleft Palate"; part 5, "Secondary Procedures in the Treatment of Cleft Lip and Palate Patients." Each section is comprehensive and instructive. There is a wide spectrum of material, from anesthetic management to repair of fistulas and maxillary orthodontia as well as speech therapy. Basic surgical techniques with

Introduction: Cleft management is an exhaustive process for the patient, the orthodontist, and the caregiver. In recent decades, a wide number of challenges have been addressed with the inclusion of various dental specialties for the detection, diagnosis, and treatment of orofacial clefts. The orthodontist plays a very pivotal role during the overall management of children with cleft lip and palate as they need to make critical decisions for when to intervene orthodontically and at what stage to set priorities for individual treatment goals. Objectives: The objectives of this study were to provide an in-depth review of the evolving role of various disciplines focusing on orthodontics in the management of cleft cases. Methods: A general search was carried out to identify the published data on cleft lip and cleft palate management on PubMed and Scopus until the 1st of June 2021 using keywords such as cleft lip, cleft palate, cleft orthodontics, naso-alveolar molding, and surgical cleft orthodontics. The related literature was then reviewed and analyzed. Results: With improvements in 3D modeling, CT scans of patients can be used to construct precise 3D models, and these can be utilized to demonstrate various clinical issues related to clefts. The orthodontist has a major role in the various stages and steps, follow-up, treatment care, and outcome assessment. With the advent of technological advancements and artificial intelligence, the role is only going to evolve and expand further in the management of the cleft lip and palate. Diagnostic techniques utilizing artificial intelligence to detect cleft during the prenatal period have also been tested and have been shown to have a high rate of accuracy. The evolution of distraction osteogenesis came into the limelight as a revolutionary modality for cleft treatment. Computer-assisted orthognathic surgery is a widely used modality for reshaping the osseous defects of the maxilla in patients with congenital clefts. With the development of additional modalities such as aligners, patients that need to undergo complex orthognathic surgeries can also be treated with aligners without compromising the outcomes. Conclusion: The cleft lip and palate can be managed by a multi-disciplinary team. Orthodontics has an important role in the overall management of a cleft affected individual as they must make critical decisions regarding orthodontic interventions as well as set priorities for each treatment goal. With the advent of technological advancements and artificial intelligence, the diagnosis and management of the cleft lip and palate have become simplified.

Development of the Palate. Moore K, Persaud T. In: The Developing Human. 5th ed. Philadelphia, Pa: WB Saunders Co; 1993The Oral Cavity: Cleft Lip and Palate. Tinanoff N. In: Behrman R, Kliegman R, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:1532The Multidisciplinary Evaluation and Management of Cleft Lip and Palate. Robin N, Baty H, Franklin J, et al. South Med J. 2006;99:1111–1120Craniofacial, Cleft Palate. Witt PF. eMedicine Specialties, Plastic Surgery, Craniofacial. 2006. Available at: http://www.emedicine.com/plastic/TOPIC519.HTMCleft Lip/Cleft Palate. Healthinfo. Children's Hospital, St. Louis. 2007. Available at: http://www.stlouischildrens.org/tabid/88/itemid/2526/Cleft-Lip–Cleft-Palate.aspxCleft Palate Foundation Website. Available at: http://www.cleftline.org/Feeding Your Baby With a Cleft Palate Video. Moses M, Alexander ME. New Orleans, La: Cleft & Craniofacial Team of New Orleans. Available at: http://www.neworleanscleftteam.org/videos.htmlCleft palate (CP) is a relatively common birth defect throughout the world. However, it is important to distinguish between cleft palate alone (CPA) and cleft lip with or without cleft palate (CLP), two distinct birth defects that have different causes, incidences, and sex and racial predilections. For example, in the Caucasian population, the incidence of CLP is about 1 in 750 births and that of CPA is about 1 in 2,500. CLP is more common in males; CPA is more common in females. The distribution of CPA varies slightly in different ethnic groups, but is significantly different for CLP, which is most common in Native Americans (1 in 230 to 1,000) and Asians (1 in 400 to 850) and least common in African Americans (1 in 1,300 to 5,000).The incidence of concurrent genetic disorders is increased for children who have CLP and even higher in those born having CPA. More than 200 genetic syndromes have CLP as a feature; a larger number of syndromes feature CPA. Any newborn who has CLP or CPA should be evaluated by a geneticist for the presence of additional congenital anomalies; complete pregnancy, birth, and family histories should be obtained; and a physical examination should be performed. Identifying whether a cleft is isolated or part of a syndrome is essential in guiding the evaluation for additional associated anomalies, providing anticipatory guidance for the family, and performing genetic counseling. The recurrence risk for the family of a child who has isolated CLP is about 4% and for the family of a child who has isolated CPA is about 2%. These numbers are increased if more than one child is born with a clefting defect, if a parent also is affected, and as the severity of the clefting defect increases. If the CLP or CPA is part of a genetic syndrome, the recurrence risk depends on the inheritance pattern of the syndrome.Clefting defects occur early in embryologic life, generally between the 6th and 9th weeks of gestation. The primary palate begins to form at about 35 days, complete lip development occurs by the 6th week, and palatal fusion follows. Cleft lip occurs when there is interruption or hypoplasia of the mesenchymal layer, which causes a failure of fusion of the medial nasal process, maxillary process, and lateral nasal process. Clefts of the lip can be unilateral or bilateral and can vary from a small notch in the border of the lip to complete separation at the philtral column and extension to the border of the nose.Cleft palate occurs when the palatal shelves fail to fuse. Clefts of the palate also can be unilateral or bilateral and can vary in severity from a submucous cleft to clefts involving both the primary (anterior to the incisive fossa) and secondary (posterior to the incisive fossa) palates. Although clefting defects generally are multifactorial traits caused by an interplay between genetic and environmental factors, some clefts result from mutations in single genes (TBX22, IRF6, MSX1), some are part of chromosomal aneuploidy or deletion syndromes (trisomy 13, velocardiofacial syndrome), and others result from teratogens (anticonvulsants).An important type of clefting defect to recognize in the neonatal period is Pierre Robin sequence (PRS), which includes micrognathia (small mandible), a retropositioned tongue, and a U-shaped cleft palate. The initial embryologic event is believed to be failure of the mandible to grow properly, leading to positioning of the tongue in the back of the pharynx, which blocks the ability of the palatal shelves to fuse properly. Affected children often experience severe respiratory distress, leading to a mortality rate as high as 30% and requiring interventions ranging from prone positioning to allow the tongue to fall forward out of the airway to intubation and tracheostomy. Children who have PRS require careful monitoring, particularly in the first 1 to 4 weeks after birth. Over time, the lower jaw generally “catches up” in growth, but sometimes surgical intervention is required for jaw expansion. PRS generally occurs as an isolated birth defect, but may be part of syndromes such as trisomy 18 or Stickler syndrome.Regardless of the cause, the child who has a cleft and his or her family face many challenges. Initially, difficulty in feeding and growth may be encountered, followed by recurrent ear infections and sometimes hearing loss, dysfunctional speech and communication, and social struggles because of the child's appearance, not to mention the physical and emotional strain encountered because of the medical and surgical interventions needed to treat these birth defects.Because of the complexity of the sequelae of CP, comprehensive multidisciplinary care for affected children is necessary and generally should be provided by a CP team, consisting of a pediatric geneticist, plastic surgeon, otolaryngologist, dentist, oromaxillofacial surgeon, orthodontist, prosthodontist, audiologist, speech and language pathologist, and social worker. It is vital for this team to work together to balance the many factors important in managing the care of a child who has a cleft.An important initial concern to parents of a newborn who has a cleft is how to feed their baby. Although many new parents find feeding their babies challenging, feeding can be particularly difficult for the baby who has a cleft. Parents have the added concern that the baby must gain weight before the cleft can be repaired.Several techniques can help in feeding a baby who has a cleft. Babies who have a cleft lip but an intact palate generally are able to breast- or bottle-feed. There may be some difficulty in creating a seal from the lip around the breast or bottle, but holding the baby in an upright “football” position or adjusting the breast to help tuck the cleft into the breast tissue usually can help the baby feed successfully.Infants who have a CP have a connection between the mouth and the nose and, therefore, have difficulty creating sufficient suction in the mouth to complete a feeding without tiring. Often they are unable to obtain enough nutrition by breastfeeding alone. Mothers should be encouraged to try breastfeeding, but if weight gain is poor, supplementation with a bottle, ideally using pumped human milk, will be needed. However, bottle-feeding also may present a challenge. Infants who have CP often need small, frequent feedings, particularly in the beginning. Babies should be positioned relatively upright, so a limited amount of milk escapes through the nose, although this occurrence generally is not harmful to the baby.Because babies who have CP often swallow more air than do other babies, they should be burped two to three times during a feeding, with the bottle positioned as upright as possible to avoid air in the nipple, or fed with an angled bottle. However, parents should be cautioned not to stop for too long in the middle of the feeding to burp the baby or the infant may lose interest in completing the feeding.Several special types of nipples and feeders can help babies who have CP. Using a cross-cut nipple and cutting the cross-cut hole at the tip of the nipple larger with a scalpel or small scissor allows the baby to get more milk without having to increase suction. Feedings generally should be limited to about 30 minutes, and if the baby takes longer to feed, the size of the hole should be increased to allow greater milk flow. The hole can be enlarged slightly after each feeding until the baby coughs or chokes during the feeding, indicating that the hole is too large. The parent should dispose of this nipple and use a new one, cross-cutting the hole to the largest size that did not cause coughing.Many parents find it helpful to use soft, squeezable bottles, which allow them to provide the force for giving a mouthful of milk to the baby, rather than having the baby suck to provide the force. Several companies make feeders specifically for infants who have CP, using specially cut nipples and compressible bottles. Pediatricians should consult the CP team for recommendations of specific types and brands of nipples and bottles suited best to the needs of a particular patient.A cleft lip generally is repaired surgically between the ages of 10 and 12 weeks, according to the “rule of tens”–10 pounds, 10 weeks old, and hemoglobin of 10.0 g/dL (100.0 g/L). A cleft palate usually is repaired between 6 and 12 months of age. Such early repair provides the benefit of better speech outcome, but poses the risk of impairing maxillary growth. Several techniques are used in CP repair, depending on the characteristics of the cleft and experience of the surgeon, with the Furlow double-opposing Z-plasty being the most common. As they get older, children may need revisions of a cleft lip or palate repair, along with alveolar grafting or rhinoplasty to repair a nasal deformity associated with the cleft lip.Most children who have CP experience problems with middle ear disease. Probably because of anomalies of the insertion of the tensor and levator veli palatini muscles into the eustachian tube, affected children are unable to open and ventilate the middle ear adequately. If left untreated, chronic serous otitis media can lead to hearing impairment, which might impair speech and learning, so myringotomy tubes often are inserted at the time of palatoplasty. Children who have CP must have frequent hearing evaluations throughout childhood.After CP repair, about 10% to 20% of patients experience velopharyngeal insufficiency, a phenomenon in which the soft palate cannot form a tight closure with the pharynx, causing air to escape through the nose rather than being directed through the mouth during speech. This effect manifests as audible nasal air escape and as hypernasal resonance during speech, particularly when making the s, z, sh, f, p, and b sounds. Affected children may develop maladaptive compensatory articulation errors for these sounds, making their speech more difficult to understand. Children who have CP also may have speech problems caused by dental malocclusion from the cleft or from fistula formation after surgery. Fistulas can develop between the oral and nasal cavities, leading to air escape during speech and to regurgitation of food or liquids through the nose. Surgical correction of velopharyngeal insufficiency, fistula, or other structural anomalies generally is necessary before speech therapy, an integral part of treatment for the child who has CP, can be successful.Many patients have an osseous defect of the maxillary alveolar bone, requiring a bone graft, which generally is performed between 6 and 8 years of age. About 25% of children who have CLP have residual jaw deformities after their cleft repairs and may need a maxillary advancement (LeFort I procedure), orthodontic treatment, or palatal expanders. Children who have CLP may be missing their lateral incisors in the area of the alveolar cleft and often have poorly formed teeth or teeth that lack enamel. Good dental hygiene is important from the time the first tooth erupts because healthy teeth stimulate and retain alveolar bone, which is important for lip support and function.Clefting deformities are relatively common birth defects and have a multifactorial inheritance pattern. Children who have clefts and their families can anticipate difficulties with feeding, speech and hearing, dentition, and cosmesis. With care from a multidisciplinary CP team, however, they can receive appropriate help and compassion to get through the challenging early years.Comment: Centers that provide coordinated team care for children who have clefting and other craniofacial deformities are ideal for meeting the multitude of issues confronting the affected child and family. Not all of us have ready access to such centers for our patients, and our responsibility becomes appreciating the following issues: feeding, hearing and speech, dental and orthodontal problems, the need for genetic counseling, and emotional needs. We must do our best to provide, beyond surgical repair, the full spectrum of services needed.

Introduction: This national survey on the management of cleft lip and palate (CLP) in India is the first of its kind. Objective: To collect basic data on the management of patients with CLP in India for further evaluation. Materials and Methods: A proforma was designed and sent to all the surgeons treating CLP in India. It was publicized through internet, emails, post and through personal communication. Subjects: 293 cleft surgeons representing 112 centers responded to the questionnaire. Most of the forms were filled up by personal interview. Results: The cleft workload of the participating centers is between 10 and 2000 surgeries annually. These centers collectively perform 32,500–34,700 primary and secondary cleft surgeries every year. The responses were analyzed using Microsoft excel and 112 as the sample size. Most surgeons are repairing cleft lip between 3-6 months and cleft palate between 6 months to 1 year. Millard and Tennison repairs form the mainstay of lip repair. Multiple techniques are used for palate repair. Presurgical orthopedics, lip adhesion, nasendoscopy, speech therapy, video-fluoroscopy and orthognathic surgery were not always available and in some cases not availed of even when available. Conclusion: Management of CLP differs in India. Primary surgical practices are almost similar to other studies. There is a lack of interdisciplinary approach in majority of the centers, and hence, there is a need for better interaction amongst the specialists. A more comprehensive study with an improved questionnaire would be desirable.

Introduction:This national survey on the management of cleft lip and palate (CLP) in India is the first of its kind.Objective:To collect basic data on the management of patients with CLP in India for further evaluation.Materials and Methods:A proforma was designed and sent to all the surgeons treating CLP in India. It was publicized through internet, emails, post and through personal communication.Subjects:293 cleft surgeons representing 112 centers responded to the questionnaire. Most of the forms were filled up by personal interview.Results:The cleft workload of the participating centers is between 10 and 2000 surgeries annually. These centers collectively perform 32,500–34,700 primary and secondary cleft surgeries every year. The responses were analyzed using Microsoft excel and 112 as the sample size. Most surgeons are repairing cleft lip between 3-6 months and cleft palate between 6 months to 1 year. Millard and Tennison repairs form the mainstay of lip repair. Multiple techniques are used for palate repair. Presurgical orthopedics, lip adhesion, nasendoscopy, speech therapy, video-fluoroscopy and orthognathic surgery were not always available and in some cases not availed of even when available.Conclusion:Management of CLP differs in India. Primary surgical practices are almost similar to other studies. There is a lack of interdisciplinary approach in majority of the centers, and hence, there is a need for better interaction amongst the specialists. A more comprehensive study with an improved questionnaire would be desirable.

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

Cleft lip and cleft palate (orofacial cleft) are facial and oral malformations that occur very early in pregnancy. A cleft lip and cleft palate, known technically as an orofacial cleft, is actually a group of various conditions that involve a ‘cleft” on the patient’s face. Clefting results when there is not enough tissue in the mouth or lip area, and the tissue that is available does not join together properly. Cleft lip and cleft palate can occur on one or both sides of the mouth. Because the lip and the palate develop separately, it is possible to have a cleft lip without a cleft palate, a cleft palate without a cleft lip, or both together. Children with a cleft lip with or without a cleft palate or a cleft palate alone often have problems with feeding and speaking clearly and can have ear infections. They also might have hearing problems and problems with their teeth. Cleft lip with or without cleft palate, can be diagnosed during pregnancy by a routine ultrasound. They can also be diagnosed after the baby is born, especially cleft palate. Treatment with orofacial clefts can vary depending on the severity of the cleft; the child’s age and needs; and the presence of associated syndromes or other birth defects, or both.

Cleft lip and palate are relatively frequent craniofacial alterations caused by the lack of union of the frontonasal processes with the maxillary processes during the first weeks of intrauterine life. This study evaluated the sociodemographic factors associated with the level of knowledge about management of cleft lip and palate (CLP) patients in Peruvian dental students. This analytical, observational, cross-sectional and prospective study evaluated 191 dental students belonging to two branches of a private Peruvian university (one branch in the capital city and the other in a province), from September to November 2022. A validated questionnaire of 14 closed multiple-choice questions was used. A logit model was used to evaluate the influence of the variables: sex, age, academic year of study, marital status, relationship with CLP persons, place of origin and area of residence, on the level of knowledge of the students considering a significance level of p<0.05. Of the total, 77%, 22.5% and 0.5% presented a poor, fair and good level of knowledge, respectively, on the dental management of the patient with cleft lip and palate. In addition, those who lived in urban areas were 2.8 times more likely to have poor knowledge about the dental management of patients with CLP, compared to those who lived in non-urban areas (OR = 2.83; 95% CI: 1.26-6.33). Finally, sex, age, marital status, place of origin, academic year of studies and relationship with CLP persons were not considered influential factors (p>0.05). Most of the students showed a poor level of knowledge about the dental management of patients with cleft lip and palate, a risk factor being that the students live in an urban area. It is recommended that educational authorities include selected topics on CLP in subjects related to infant, child and adolescent care.

Congenital cleft lip and palate is the most commonly found craniofacial defect. The most common problem in an infant with cleft lip and palate is the difficulty in feeding due to communication between oral and nasal cavity. Difficulty in feeding leads to inadequate nutrition and affects the health of the infant. Feeding problems should be assessed and intervened as early as possible, as they are important aspect of the multidisciplinary team approach in the management of cleft lip and palate. Feeding obturator restores this gap and assists in feeding as well as helps in reduction of airway problems, regurgitations, and frequent infections. This clinical report describes a technique of fabrication of a feeding appliance in a 4 hours old neonate with veau type III cleft lip and palate. Keywords: Cleft lip; cleft palate; obturator; feeding appliance; feeding obturator; Veau Type III cleft lip and palate

This is volume 8 of symposia organized by the Educational Foundation of the American Society of Plastic and Reconstructive Surgeons held at Duke University Medical Center, April 12 to 14, 1973. The authors have clearly been selected because of their particular contributions or views on matters of current debate in the field of cleft lip and palate. The majority of contributors are plastic surgeons with other representatives from the fields of orthodontics, speech, anatomy, otolaryngology, and psychology. The subject is subdivided into sections on general considerations in etiology and management, unilateral cleft lip, bilateral cleft lip, cleft palate, and secondary procedures in the treatment of cleft lip and palate patients. Otologic problems, the physiology of speech, the correction of velopharyngeal insufficiency, and the timing and use of orthodontic and bone grafting procedures are included in the section on cleft palate. The various techniques of surgical repair of unilateral and bilateral

Cleft lip and palate is one of the most common craniofacial anomalies of humans. A child born with cleft lip and palate may experience difficulties while feeding due to lack of seal of the oral cavity due to incomplete facial and palatal structures. Difficulty in feeding leads to inadequate nutrition and affects the health of the infant. Feeding difficulties should be assessed and intervened as early as possible, as they are an important aspect of the multidisciplinary team approach in the management of cleft lip and palate. Feeding appliance is a favorable feeding option in these infants as it creates a separation between oral and nasal cavities and thus helps in creating a negative intraoral pressure during suckling. This case report represents a fabrication of feeding appliance for a 2-day-old neonate born with cleft lip and palate, using copper wire as a retainer for the appliance.

Background: Sufficient knowledge and awareness of cleft lip and palate deformity is required to identify and manage at the condition at the earliest. Objectives: This study was conducted to assess the awareness and knowledge of medical students on cleft lip and palate. To assess the understanding of the possible causative factors of cleft lip and palate among the same population. Materials and Methods: A cross sectional study was carried out among 128 medical students attending a tertiary care hospital in south India. This was performed through a researcher administered questionnaire which contained queries regarding risk factors and management. Results: A total of 89.1% of the subjects were aware of the term cleft lip and palate with the majority being females. Though they were not well informed regarding the treatment procedures, and timings. The results were then interpreted in table formats for better understanding of the level of education on the topic. Conclusion: There is a general lacking of experience in the diagnosis and management of cleft lip and palate among medical students which should be addressed to ensure timely cure and quality of life of the patients.

Management of cleft lip and palate has been well characterized in pediatric patients, but limited data exist regarding the long-term functional outcomes of cleft patients once they reach adulthood. An institutional, cross-sectional survey of adult patients with a history of cleft lip and/or palate was performed. The survey recorded patient characteristics, concerns, and barriers to care. Patient-reported outcome measures were assessed using the Nasal Obstruction Symptom Evaluation Scale, Epworth Sleepiness Scale, Mandibular Function Impairment Questionnaire, and the CLEFT-Q Speech Modules. A total of 63 patients (18.2%) participated in the survey. The mean patient age was 43.7 years (median: 41y, range: 19-93y), and the most common diagnosis was cleft lip and palate (51%) followed by isolated cleft palate (35%) and isolated cleft lip (14%). A subset of patients scored with moderate to severe dysfunction on each outcome measure including the Nasal Obstruction Symptom Evaluation Instrument (59%), Epworth Sleepiness Scale (7%), and Mandibular Function Impairment Questionnaire (13%). Respondent scores on the CLEFT-Q Speech modules demonstrated a bimodal distribution with lower scores in a significant subset of patients with cleft palate and cleft lip and palate. Many respondents (41%) were interested in clinical evaluation but cited barriers to seeking treatment including financial barriers (35%) or lack awareness of clinical options (27%). Many cleft patients have persistent needs or concerns in adulthood, especially regarding speech and nasal breathing. Systemic barriers pose challenges to these patients undergoing clinical evaluation.

Introduction:With advancement of medical services in developed countries and awareness among the patients, it is rare to find an adult with an unoperated cleft lip and palate. However, the scenario is totally different in developing countries. Working as a part of a team in developing country, where co-coordinated team work is primitive, resources to provide treatment are very thin, public awareness of availability of treatment for this anomaly is minimal, the age of patients reaching for primary treatment varies from few days to late forties. Though the aim and aspiration is to provide holistic multidisciplinary care, the priority is getting treatment for all cleft patients. In such situation, the management of cleft lip and palate demands changes of approach, techniques and philosophy.Aims and Objectives:The deformed anatomy especially the facial bones and dentition is described. Due to well established deformities, the approach for management is individualized. The procedures and modification of procedures has been described.Results and Outcome:The outcome of the primary repair is adults certainly have less than satisfactory outcome for obvious reasons. The expected outcome and expectation of patients and families following primary surgeries in cleft lip and palate has been discussed. Though all adult patients got some improvement in speech after palate repair, achieving normal speech was difficult. The naso-labial appearance was not perfect, but well accepted by the patients and families. There are many psychosocial problems in these patients, the objective evaluation could not be done due to too many variables. However, primary repair of cleft lip and palate is justified and beneficial for the patients.

Introduction: With advancement of medical services in developed countries and awareness among the patients, it is rare to find an adult with an unoperated cleft lip and palate. However, the scenario is totally different in developing countries. Working as a part of a team in developing country, where co-coordinated team work is primitive, resources to provide treatment are very thin, public awareness of availability of treatment for this anomaly is minimal, the age of patients reaching for primary treatment varies from few days to late forties. Though the aim and aspiration is to provide holistic multidisciplinary care, the priority is getting treatment for all cleft patients. In such situation, the management of cleft lip and palate demands changes of approach, techniques and philosophy. Aims and Objectives: The deformed anatomy especially the facial bones and dentition is described. Due to well established deformities, the approach for management is individualized. The procedures and modification of procedures has been described. Results and Outcome: The outcome of the primary repair is adults certainly have less than satisfactory outcome for obvious reasons. The expected outcome and expectation of patients and families following primary surgeries in cleft lip and palate has been discussed. Though all adult patients got some improvement in speech after palate repair, achieving normal speech was difficult. The naso-labial appearance was not perfect, but well accepted by the patients and families. There are many psychosocial problems in these patients, the objective evaluation could not be done due to too many variables. However, primary repair of cleft lip and palate is justified and beneficial for the patients.