I received a request…
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Let’s talk Speech: 
Patients who are born with only cleft lip will have little to no struggle with speech. They will mostly only have the same challenges as those without a cleft lip.
The palate has 2 components- the hard palate, which is toward the front, and the soft palate, which is toward the back. A cleft palate means the palate is open into the nasal cavity, and when the opening is not closed properly, speech can be hypernasal 
. This can be corrected with surgery, but it still affects speech for cleft babies. The other reason for speech delay is because the middle ear is affected in cleft patients, so this can cause a speech delay since children learn to speak by hearing sounds they make. Therefore, an audiologist and a speech therapist are very important for speech development 
.
So this post goes out to patients with cleft palates
As you know from my Timeline of Events post, speech evaluation and therapy should begin around 18 months of age.
However, evaluation can even begin at birth to look at:
- mental development
- motor development
- hearing
- relationship between mother & baby
- how to use toys and how to speak to a baby
- ALSO>>> the speech therapist can offer advice to the parents regarding a nurturing environment
An important note to consider…
There remains controversy over whether the hard palate (more toward the front of the mouth) should be repaired early (at 12 months) or late (at 36 months). The benefit of late hard palate closure is undisturbed facial growth for the baby. However, in a study comparing patients with early and late hard palate closure, the patients with early closure performed significantly better with speech than those with late closure.² 
Speech therapy
Begins once a month after the palatoplasty (cleft palate repair).¹
What the speech therapist is looking at here: 
- swallowing
- hearing
- articulation development
If issues continue by the age of 4: 
- the frequency of speech therapy will increase to once a week
- here, it is important to further evaluate the soft palate (back of the top of the mouth) because there may have been complications with its closure
- further surgeries may need to be considered at this point to adjust the closure of the palate
When to see the dentist:
One goal of palatal closure is to make sure the jaws and teeth grow into the right places.
A key for successful speech development and cleft treatment is to see a Craniofacial Orthodontist around 12 months of age. Orthodontists assess facial development as part of their treatment, so seeing one early enough can help determine any future surgeries that may be needed. Also, the orthodontist can consult with the speech therapist about facial development and how it is affecting the patient’s speech. 
Another benefit of seeing a craniofacial orthodontist early is that as soon as teeth start coming in, the doctor can start aligning the teeth correctly. Establishing a dental home early in treatment is extremely important. The orthodontist and the surgeon will work closely together to make sure the jaws are aligned properly, which will help tremendously with speech. 
As shown in my Timeline of Events post, an alveolar bone graft occurs around age 10. This will also help the permanent teeth develop into the proper places and serve as stability for the gums. 
A maxillofacial prosthodontist for speech later in life…
When speech issues are still prevalent for the adult cleft palate patient, even after palatal repair, there is still another option. 
Maxillofacial prosthodontists can make a speech bulb, which sometimes is the only option for improving speech after further surgical interventions have not been successful. The use of a speech bulb involves some preparations on teeth to help hold the speech bulb in place. It is removable, with an extension on the back of the prosthesis to aid in closing the back of the palate. Also, if there has been no cleft palate closure, due to any reason, the speech bulb can close the communication between the nose and the mouth.³ 
My story:
I like to share my personal experience with these topics so you can get to know me better, and also so you can ask me questions about my personal journey if you’d like. 
This part for me is not as exciting because I was part of the group of cleft palate babies that had late palatal closure of the hard palate at the age of 4. I did have an obturator up until that time. I took speech lessons until I was about 6 years old. I don’t remember much about my speech therapy because it was so early in life, but I do remember it being very casual and not traumatic at all. Speech was always something I struggled with, especially with “r” and “s” sounds, but my doctors said it sounded very good for a cleft palate patient. I do not wear a speech bulb now either, so my closure was adequate. 
Since my personal history on this one was not as involved, I’ll share with you a case I did during my residency of a 16-year-old girl requiring a speech bulb. 
Case report:
The history of this patient: She was born with a unilateral cleft lip + palate. She had undergone palatal closure, orthodontics, bone grafts, and nose repair previously. To replace her missing teeth, she had a fixed bridge.
Her speech still sounded hypernasal, regardless of the surgical procedures, so a speech bulb was indicated. Treatment was done in the following sequence:
- Upper & lower impressions were made
- Teeth were evaluated on the cast for areas to wrap a clasp in order to hold the prosthesis in place
- Since there were no areas to engage a clasp, dental material, called composite, needed to be added to the molars (this is painless and does not require any anesthesia)
- New upper impression was made after addition of composite
- Clasps were bent to go around teeth and underneath composite that was added
- Extension was added to reach the back of the mouth
- Acrylic was mixed and formed on cast
- Acrylic was trimmed and polished
- The patient came in and acrylic was adjusted as necessary
- Wax was added to the metal extension to simulate a bulb, and the correct size was obtained based on trial & error with the wax
- Once the final form of the wax was created, it was converted into acrylic
- Every 2 weeks, the patient would come back in, and wax would be added and then converted, if necessary
The purpose of the speech bulb is that it helps to close off any remaining space due to insufficient muscle from the cleft. By closing the space, speech is improved and does not sound hypernasal.
Please see photos below! And please feel free to post comments on this post. Thank you! 
¹Willadsen, E. , Boers, M. , Schöps, A. , Kisling‐Møller, M. , Nielsen, J. B., Jørgensen, L. D., Andersen, M. , Bolund, S. and Andersen, H. S. (2018), Influence of timing of delayed hard palate closure on articulation skills in 3‐year‐old Danish children with unilateral cleft lip and palate. International Journal of Language & Communication Disorders, 53: 130-143.
²OGATA, Y. The Speech Therapy of Cleft Palate Patients as an Oral Rehabilitation. Journal of Dentistry Indonesia, North America, 4, Oct. 2015. Available at: <http://www.jdentistry.ui.ac.id/index.php/JDI/article/view/758/658>. Date accessed: 20 Mar. 2018.
³Mohammed M. (2006). Prosthetic Speech Appliances for Patients with Cleft Palate. In: Berkowitz S. (eds) Cleft Lip and Palate. Springer, Berlin, Heidelberg.