Secondary surgery for the refinement can be done at any time to improve the appearance of the child.

3-4 years : A few patients may need minor surgery to improve the the alignment of the lip lines. The shape of the nose can also be improved.

4-6 years : Any child having speech problem in spite of palate repair and speech therapy may need second surgery to improve the speech and reduce the nasality.

6-9 years : All cases involving clefts through the alveolar ridge of the maxilla require surgical placement of cancellous (spongy) bone. This bone is usually harvested from the hip.

14-16 years : Many children born with cleft lip and/or cleft palate or other craniofacial anomalies are either born with significant imbalance of their jaws alignment or this is developed during their growth due to poor growth of upper jaw. Normal jaw relation ship is essential for good appearance, normal chewing process and speech. Any misalignment of jaws will need orthodontic treatment following by surgeries on both the jaws (orthognathic surgery). This often need long preoperative orthodontic treatment, removal of certain teeth. The orthodontic treatment may continue following surgery and prosthodontist help to replace the missing teeth.

16-20 years : Depending on the demand of the patients, final rhinoplasty (nose surgery) to improve the shape of nose can be done.
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Additional Procedures:
Osseointegrated Anchorage Implants

When teeth are lost, their replacement has been improved by the use of osseointegrated anchorage implants. These implants require precision planning, placement, and restorative procedures. When teeth are replaced by removable appliances, adverse stresses are usually applied to teeth used for anchorage, leading to early loss. Cleft cases usually have one or more missing teeth and in addition, the teeth adjacent to the cleft usually have a deficiency of supporting bone, making precarious their use as anchorage for the missing teeth. Thus the use of osseoiontegrated implants for anchorage of the missing teeth eliminates the use of the remaining teeth for anchorage and thus preserves the remaining teeth. Osseointegrated anchorage implants serve as support for prosthetic dental units that are fabricated by a prosthodontist. The surgery and subsequent placement of the prosthetic dental units requires the coordinated efforts of the orthodontist, the oral and maxillofacial surgeon, and the prosthodontist.

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