Overview and definition
Cleft palate is a congenital structural malformation—not a neoplasm or acquired disease—arising from failure of fusion of the palatal shelves of the maxillary processes between roughly 8 and 12 weeks of gestation.[1] It may be isolated (secondary palate only, posterior to the incisive foramen) or occur as part of cleft lip and palate, which also involves the primary palate (lip and alveolus).[1][2] Isolated cleft palate and cleft lip with/without cleft palate are regarded as distinct entities with overlapping radiologic appearances.[3] Severity ranges from a submucous cleft or bifid uvula to complete clefting of the soft and hard palate.[2] Classification systems include Veau and the anatomically descriptive LAHSHAL palindrome (lip, alveolus, hard palate, soft palate), the latter favored for recording side, site, and completeness.[4][5] More than 300 syndromes are associated, most commonly Pierre Robin sequence, van der Woude, velocardiofacial, Stickler, Treacher Collins, and Goldenhar syndromes.[2]
Radiographic findings
Recognition: In dental practice, cleft palate is usually a known clinical diagnosis, but its bony correlates are encountered on routine imaging. Clefts involving the primary palate (cleft lip and palate) produce the alveolar findings typical of dental imaging; isolated clefts of the secondary palate are seldom evident on panoramic images and are best shown on CBCT/CT as a midline defect of the hard palate and nasal floor. On panoramic radiographs the alveolar/palatal cleft appears as a radiolucent cleavage near the lateral incisor–canine region, and interpretation is complicated by cervical spine overlap and the narrow image layer, which can mimic cysts, tumors, or the normal fossa between alveolar yokes.[6] Distinguishing cleft alveolus with versus without cleft palate on panoramic films is difficult even for experienced observers, because the key discriminator—cleft extension posterior to the incisive foramen—is best resolved on cross-sectional imaging.[6]
Cross-sectional imaging: Cone-beam CT is the preferred modality for defining cleft shape, size, volume, nasal-floor involvement, and bone support of adjacent teeth, and low-dose, restricted field-of-view protocols are recommended given repeated lifetime exposures.[7] Systematic 3D reporting characterizes cleft location, dimensions at nasal floor, mid-alveolus, and crest, and graft integration after alveolar bone grafting.[8] Expected associated findings include missing or supernumerary teeth, oronasal fistulas, and maxillary growth restriction.[3]
Management and prognosis
Interpretation centers on confirming cleft extent and documenting dentoalveolar sequelae rather than treating the finding as a pathologic lesion.[3][8] Red flags warranting correlation include previously undocumented clefting, submucous cleft with velopharyngeal insufficiency, and associated anomalies suggesting a syndrome.[2] Care is best delivered by an ACPA-recognized multidisciplinary cleft/craniofacial team; the primary clinician's role is appropriate referral and longitudinal coordination.[9] Primary palatoplasty is generally performed between 6 and 14 months, with timing still debated; the TOPS randomized trial found better velopharyngeal function at 5 years with repair at 6 versus 12 months.[10] Alveolar bone grafting is typically timed to adjacent canine root development, around 9–12 years.[11]