The Orofacial Exam

First step to assessing clefts.

The orofacial exam constitutes an essential part of the broader clinical speech evaluation for children with cleft lip and palate. The goal of the exam is to identify any structural, oral-motor or sensory deviations that might explain the presenting speech disorder. The findings help to determine if the problem should be treated with speech therapy or requires further surgery or other physical management.

"We're looking for any abnormal structures or structural relationships, any movement problems with the tongue and lips, for example, or any reduced sensory areas within the immediate extra and intraoral structures," said Judith Trost-Cardamone, PhD, CCC-SLP, professor in the Department of Communication Disorders and Sciences at California State University at Northridge.

In cleft lip and palate, the orfacial exam focuses on the oral and oropharyngeal structures, while also examining the oral-motor and oral-sensory components.

"Our focus is on structural deviations that may be underlying the speech disorder we hear because cleft lip and palate is really a structurally-based disorder. That early structural deviation leaves the child in a position of using broken equipment in the earliest stages of speech learning," Dr. Trost-Cardamone told ADVANCE. Without early speech assessment and monitoring, children with clefts have a high risk of developing cleft-type speech patterns that may persist even after the cleft has been repaired by surgery.

Young children with palatal clefts may be delayed in their early speech development, but most eventually catch up to their typically developing peers by their third birthday. Some children who are using pharyngeal and glottal productions into the preschool and school- age years may need a second surgery to ensure that speech therapy is effective. Others may be candidates for speech therapy only.

"We have to be very careful in our assessments and make sure that the child truly needs the second surgery," she said. "All the surgery provides is the physical ability for adequate velopharyngeal closure."

Surgery will not correct any learned misarticulations that have entered the phonological system. These will persist even after an adequate velopharyngeal closure mechanism has been provided. Children with these issues often require more long-term speech therapy.

During an orofacial exam, speech-language pathologists should examine the lips, nose and teeth. They should make note of missing or extra teeth (supernumerary) or teeth that erupted in the wrong place (ectopic teeth). These problems can lead to distorted speech sounds because they may force the child to make sounds in different places in the mouth.

For example, if there is an ectopic tooth in the middle of the hard palate, the tongue might try to avoid that area, slightly shifting placement for the target sound resulting in backed or retracted placement. Likewise, malocclusion, which occurs when the upper and lower jaws don't come together properly, can contribute to speech sound distortions or substitutions.

"If we have a significant overjet, where the upper teeth are too far forward of the lower teeth, it's hard to make bilabial sounds such as /p/, /b/ and /m/, for example, because it's hard to get the lips closed over that dentition. One may get dentalization of those bilabial sounds, such that the upper teeth occlude with the lower lip rather than both lips, resulting in an inverted bilabial," said Dr. Trost-Cardamone, speech consultant for the Ventura County Medical Center Cleft Lip and Palate Team in Ventura, CA.

While dental and occlusal contributors are relatively minor issues in the big picture of cleft lip and palate speech, they should not be ignored during assessment. Clinicians may want to categorize them as problems to wait on and reassess since many will require physical management to be corrected.

"The therapist should not try to work on correcting dentalization of bilabials when it's occurring because of the structural relationship between upper and lower jaw," she emphasized.

Clinicians should make sure the tongue is free to do the kind of movement it wants and needs to do. "We always want to look for and be able to rule out a significant tongue tie, or ankyloglossia, especially if we are seeing reduced tongue tip and tongue elevation in the absence of any neuromotor component," she said.

Check the relative size of the tongue, and make sure it is adequately housed in the lower jaw. In some syndromes where clefts occur, the tongue may be a normal size, but the lower jaw may be small. The jaw will grow to accommodate the tongue in most instances, such as Pierre Robin sequence.

"There are also syndromes that are characterized by an excessively large tongue that may require some physical management to carefully reduce its size to help it fit better into the jaw," said Dr. Trost-Cardamone.

Clinicians should look for fistulas in cleft palate, with or without cleft lip, because they are pathways for air to escape. Airflow that enters the oral cavity can leave through these openings, causing nasal air emission and distorting the target sound or sounds.

There is a direct relationship between the location of a fistula and the sounds that will be affected by it, she said. "In more anteriorally located fistulas we often hear and see nasal airflow on the sounds that are made in the anterior oral cavity, such as /t/, /d/, /s/ and /z/. A posterior fistula, which is close to the junction of the hard and soft palate, is more likely to affect /k/ and /g/ and maybe even 'chuh' and 'juh,' depending on where those placements occur."

Objective instrumental assessments can determine if velopharyngeal closure is occurring, she stated. "The speech we hear tells us that there is audible nasal air emission and hypernasal resonance, but we won't find the answer by looking in the mouth. Having an individual phonate 'ah' and making the judgment on velopharyngeal closure is not a valid assessment." Accurate assessment of velopharyngeal closure requires instrumental assessment.

Speech-language pathologists may want to consider the presence of a submucous cleft when a child presents with hypernasal speech but no obvious indication of a cleft. Clinicians should look for signs of bifid uvula: a pale, bluish-white area (diastasis) in the midline palate; feel for a notch in the posterior border of the hard palate.

"In many instances speech is hypernasal and we can't see anything," said Dr. Trost-Cardamone. "Submucous cleft may be the basis for that speech as well since visible signs are not always evident when the cleft is "hidden" under the mucosal tissue. When individuals present with non-cleft velopharyngeal function disorders, we need to get an instrumental assessment to confirm or disprove our diagnostic hunch regarding what may be going on."



  • Peterson-Falzone, S.J., Trost-Cardamone, J.E., Karnell, M.P., Hardin-Jones, M.A. (2006). The Clinician's Guide to Treating Cleft Palate Speech. St. Louis: Mosby-Elsevier.


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Jason Mosheim is a Senior Associate Editor at ADVANCE. He can be contacted at

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