Khe Hở Môi Và Vòm Miệng: Chẩn Đoán Và Quản Lý Điều Trị (Cleft Lip and Palate)

75
4 The Effect of Clefting of the Lip and Palate and the Palatal Arch Form
7−4
7−11
8−6
9−0
4−6
4−9
6−0
6−6
2−2
2−4
2−10
3−0
0−2
0−5
0−11
2−0
Fig. 4.15 Superimposed
computerized 3D tracings of
isolated cleft palate. Isolated
cleft palate. Superimposition
horizontally on the rugae and
registered vertically on the
vomer line. This shows that
most of the growth occurs
posteriorly to accommodate the
developing deciduous molars.
Growth changes of the cleft
space are highly variable. In
some instances, the cleft space
can narrow or stay the same
size. However, in all instances,
the palate increases in size so
the ratio of cleft space to
surrounding palatal size reduces.
In most cases, time for surgery,
determined by the ratio of 10 %,
is reached at 18–24 months. It
can be earlier or even later in
some cases
C.R.
0−2
4−6
9−0
BI-39
Fig. 4.16 Case CR-BI 39

76
S. Berkowitz
1,600.00
1,400.00
1,200.00
1,000.00
800.00
600.00
400.00
200.00
0.00
0−2
0−5 0−11 2−0
2−2
2−4
2−10 3−0
4−6
4−9
6−0
6−6
7−4 7−11 8−6
9−0
R.S.A..................Right surface area
L.S.A..................Left surface area
Cleft space
Right + Left S.A.
Right + Left S.A. + Cleft spaces
Suface area palatal and cleft space
changes
Fig. 4.17 Serial size changes of the palate and cleft space
Fig. 4.18 Case AN-92. Palatal closure at 1–5 using von Langenbeck procedure resulting in good occlusion

77
4 The Effect of Clefting of the Lip and Palate and the Palatal Arch Form
Fig. 4.19 ( a – h ) Variations in isolated cleft palate. The
length and width of the cleft space is highly variable. The
cleft extends anteriorly to various distances but not beyond
the incisal canal. Note the relative size of the cleft palate
space which re fl ects differences in the degree of osteo-
genic de fi ciency. In some instances, the cleft space dimin-
ishes with time; however, there are occasions when the
cleft’s relative size remains the same

78
S. Berkowitz
4.3.4 Submucous Cleft Palate (Fig. 4.20 )
The classic triad of diagnostic signs is the bi fi d
uvula, partial muscle separation in the midline
with an intact mucosal surface, and the midline
notch in the posterior edge of the bony palate.
Hypernasality may or may not exist. Caution
needs to be exerted prior to performing tonsillec-
tomies and adenoidectomies because the velum
may be functionally too short without the pres-
ence of the adenoid mass.
Berkowitz’s cephalometric and nasopharyn-
goscopic studies have shown wide and unpre-
dictable variability in the pharyngeal skeletal
architecture and velar size and shape in submu-
cous cleft palate as well as in all other cleft types
(see Chap. 12 ). In some cases, due to a shallow
pharyngeal space with relatively good velar
length and mass with good lateral pharyngeal
wall movement, no hypernasality existed.
However, in most cases, the velum is usually too
short, as well as too thin, and it fails to obturate
the pharyngeal space properly. The problem
appears to be due to an inadequate velum rather
than a de fi ciency in lateral wall movements.
The treatment of choice is a well-positioned
and adequately wide superior-based pharyn-
geal fl ap. There is no apparent need to com-
bine a palatoplasty with the pharyngeal fl ap. In
patients with recurring infections of the ade-
noids, it is recommended that the adenoids
be removed before the fl ap is placed. Speech
therapy is an integral part of postoperative
management.
a
b
c
d
Fig. 4.20 ( a – d ) Submucous cleft palate. This cleft is
characterized by a bi fi d uvula, lack of muscle continuity
across the soft palate, and a pink zone of mucosa (zona
pellucida) across the cleft in the hard palate. A palpable
notch in the posterior border of the hard palate is always
indicative of the presence of a cleft

79
4 The Effect of Clefting of the Lip and Palate and the Palatal Arch Form
4.4
Congenital Palatal
Insuf fi ciency (CPI)
It has been said that cleft palate is a type of
defect that can be “seen, felt, and heard.” By
contrast, the defect known as congenital palatal
insuf fi ciency (CPI), until recently, has been more
readily heard than seen or felt. This anomaly is
seldom apparent at birth, and the fi rst awareness
of the defect occurs when the child develops the
hypernasality characteristic of uncorrected cleft
palate speech. The variety of factors produc-
ing this kind of speech defect can be examined
by roentgenographic and nasopharyngoscopic
methods.
Normally, during deglutition and during
phonation, except for the sounds of “m,” “n,”
and “ng,” the soft palate elevates, making con-
tact with the posterior and lateral walls of the
pharynx. The complicated synergies that con-
tribute to this multidimensional contraction
serve to separate the nasopharynx from the
oropharynx. If for any reason this velopharyn-
geal closure cannot be achieved, deglutition is
compromised, and in phonation, the air stream
necessary to create speech is misdirected
through the nose. Palatal insuf fi ciency may be
caused by the velum being too short and/or by a
de fi ciency in the anteroposterior dimension of
the hard palate.
4.5
Clefts of the Lip and Alveolus
(Figs. 4.21 , 4.22 , 4.23 , 4.24 , and
4.25 )
The alveolar portion is usually distorted outward
in complete lip clefts. When the lip is united, the
newly created lip force molds the alveolar section
into proper alignment. A secondary alveolar bone
graft is performed at the same age as in other cleft
types (Fig. 4.22 ).
Fig. 4.21 Clefts of the Lip and Alveolus: (Figs. 4.21–
4.27) The alveolar portion is usually distorted outward in
complete lip clefts. When the lip is united, the newly cre-
ated lip force molds the alveolar section into proper align-
ment. A secondary alveolar bone graft is performed at the
same age as in other cleft types

80
S. Berkowitz
a
b
c
d
e
f
Fig. 4.22 ( a – f ) Cleft of the lip and alveolus. Facial pho-
tographs: ( a ) before and ( b ) after surgery, ( c ) 4 years later
showing good lip/nose aesthetics and palatal casts, ( d )
before and ( e ) after surgery showing the molding of the
cleft alveolar segment into alignment, and ( f ) ideal ante-
rior and buccal occlusion

81
4 The Effect of Clefting of the Lip and Palate and the Palatal Arch Form
a
b
c
d
e
f
Fig. 4.23 Case AS-30. Cleft of the lip and alveolus. Various lip revisions were performed

82
S. Berkowitz
a
b
c
e
d
Fig. 4.24 Case AS-30. Cleft of the lip and alveolus after orthodontics

83
4 The Effect of Clefting of the Lip and Palate and the Palatal Arch Form
a
b
c
Fig. 4.25 Case AS-30. Lip
adhesion treatment and
alveolar bone graft. Palatal
growth and development was
normal as seen by the
occlusion

84
S. Berkowitz
4.6
Clefts of the Uvulae and Soft
Palate (Fig. 4.26 ) and Cleft of the
Uvulae Alone (Fig. 4.27 )
When the health of the child permits, soft tis-
sue clefts can be sutured within the fi rst
3-month forces as Latham and his mentor
McNeil have suggested. There are, however,
some cases when, because of an unfavorable
facial growth pattern coupled with a retruded
maxilla relative to the anterior cranial bases,
orthopedic protraction forces will be bene fi cial
in the mixed (transitional) and permanent
dentition.
Fig. 4.27 Uvulae. Always indicative of the presence of a
cleft
Fig. 4.26 Soft palate

85
4 The Effect of Clefting of the Lip and Palate and the Palatal Arch Form
References
Berkowitz S (1959) Growth of the face with bilateral cleft
lip from 1 month to 8 years of age. Thesis, University
of Illinois Graduate School, Chicago
Fogh-Andersen P (1942) Inheritance of harelip and cleft
palate.
Nyt
Nordisk
Forlag,
Arnold
Busck,
Copenhagen
Fogh-Andersen P (1961) Inheritance patterns for cleft lip
and palate. In: Pruzansky S (ed) Congenital anomalies
of the face and associated structures. CC Thomas,
Spring fi eld, pp 123–133
Friede H (1973) Histology of the premaxillary-vomerine
suture in bilateral cleft case. Cleft Palate J 10:14–22
Friede H (1977) Studies on facial morphology and growth
in bilateral cleft lip and palate. University of Göteborg,
Göteborg
Kraus BS, Kitamura H, Latham RA (1966) Atlas of devel-
opmental anatomy of the face. Hoeber Medical
Division of Harper and Row, New York
Pruzansky S (1953) Description, classi fi cation, and analy-
sis of unoperated clefts of the lip and palate. Am J
Orthod 39:590
Pruzansky S (1971) The growth of the premaxillary-vom-
erine complex in complete bilateral cleft lip and pal-
ate. Tandlaegebladet 75:1157–1169
Wolfe SA, Berkowitz S (eds) (1989) Plastic surgery of the
facial skeleton. Little, Brown and Co, Boston, p 292

87
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_5, © Springer-Verlag Berlin Heidelberg 2013
5
5.1
Effects of Reversing the Facial
Force Diagram
The in fl uence of soft-tissue forces on palatal form
and growth has been the topic of several studies.
Ritsila and coauthors ( 1972 ) reported that there was
“slight shortening” of the maxilla, “marked shorten-
ing” of the body of the mandible, and alterations of
several mandibular angles after closure of the lip.
As perhaps an interesting footnote (Ritsila et al.
1972 ; Bardach et al. 1982 ) , physical changes to the
palate in clefts of the lip and palate in animals are
very similar to the corresponding changes that are
seen in humans. Bardach et al. (Ritsila et al. 1972 ;
Bardach et al. 1982 ) studied lip pressure changes
following lip repair in infants with unilateral clefts
of the lip and palate. They con fi rmed the belief that
lip repair signi fi cantly increases lip pressure when
compared with a noncleft population.
Berkowitz’s ( 1959, 1969 ) data demon-
strated that the force of the united lip against
the protruding premaxilla in complete bilateral
clefts of the lip and palate (CBCLP) acts fi rst to
bring about premaxillary ventro fl exion. After
2–3 years, there is some appearance of midfacial
growth retardation to various degrees. There is
strong evidence that uniting the lip does not “tele-
scope” the premaxilla into the vomer, whereas
mechanical premaxillary retraction “telescopes”
the premaxilla in almost all instances (see Chap.
21 ). In very rare instances, it may even cause a
vomer fracture.
5.2
Variations in the Palate’s Arch
Form
The size and relationship of the palatal segments to
each other are highly variable (see Figs. 4.8 and 4.9 ).
As already described, in complete clefts of the lip
and palate, the lateral palatal segments are displaced
laterally and the slopes of both palatal segments are
steeper than normal, with the palatal segments at the
cleft space extending into the nasal chamber
(Berkowitz 1985 ) . This steepness decreases with
time, the slopes becoming more obtuse under the
in fl uence of tongue force. In clefts of the lip and pal-
ate, uniting the cleft orbicularis oris-buccinator supe-
rior constrictor muscle ring or using external facial
elastics reestablishes the outer compressive muscu-
lar forces. This change in the muscle force vectors
causes the laterally displaced palatal segments to
move together. Moreover, this reduction in the width
of the cleft is not limited to the alveolar process but
Alternative Method Used to Correct
Distorted Neonatal Cleft Arch Forms
Samuel Berkowitz
S. Berkowitz , DDS, M.S., FICD
Adjunct Professor, Department of Orthodontics ,
College of Dentistry, University of Illinois ,
Chicago , IL , USA
Clinical Professor of Surgery and Pediatrics (Ret),
Director of Research (Ret),
South Florida Cleft Palate Clinic,
University of Miami School of Medicine ,
Miami , FL , USA
Consultant (Ret), Craniofacial Anomalies Program ,
Miami Children’s Hospital , Miami , FL , USA
e-mail: sberk3140@aol.com

88
S. Berkowitz
extends as far back as the tuberosities of the maxilla
and perpendicular pterygoid processes. The surgeon
is challenged to establish muscle balance without
disturbing the growth potential of the bony tissue
being manipulated and to avoid scars that will tie or
bind down the normally expansive forces of growth.
5.3
Reversing Aberrant Cleft Facial
Forces in the Neonate
5.3.1 Lip Surgery, Elastic Traction,
or Presurgical Orthodontic
Treatment (Figs. 5.1 , 5.2 , 5.3 ,
and 5.4 )
1. Lip surgery creates suf fi cient forces to bring
the overexpanded palatal segments medially
narrowing the alveolar and palatal cleft spaces.
The surgeon often does this in two stages:
fi rst, a lip adhesion at 3–5 months followed by
a more de fi nitive lip/nose surgery, which is
more artistic. A cupid bow and normal nostrils
are the eventual goals (see Chap. 8 ).
2. Head bonnet with elastic strap to be placed over
the premaxilla in all lip clefts. The force system
needs to be worn for 1 or 2 weeks along with arm
restrains to prevent the infant overjet from remov-
ing the elastic strap. A premaxillary ventro fl exion
in CBCLP cases occurs very quickly creating an
overjet and overbite. In CBCLP with a protrud-
ing premaxilla at birth, the lateral palatal seg-
ments move medially behind the premaxilla.
This relationship does not cause palatal growth
retardation. Should a crossbite occur, the involved
palatal segment usually can be moved laterally
into proper occlusion at 4–6 years of age when
the child is manageable in a dental chair.
3. Presurgical orthopedics: There are active and
passive appliances, which are designed to cre-
ate an alveolar butt joint (Berkowitz et al.
2004 ) . In the distant past, primary bone graft-
ing was utilized with the hope of stabilizing
the palatal segment’s position. However, with
primary bone grafting, it was found to cause
midfacial deformity. Berkowitz, in a recent
longitudinal palatal growth study, determined
that the plates do not stimulate growth. Some
surgeons who have used gingivoperiosteo-
plasty have created an anterior crossbite in
most instances, which is hard to correct with
expansion. Berkowitz strongly rejects the use
of primary bone grafting and gingivoperios-
teoplasty ( 10 ).

89
5 Alternative Method Used to Correct Distorted Neonatal Cleft Arch Forms
Fig. 5.1 ( a – f ) The use of an external elastic force to
reduce premaxillary protrusion. ( a , b ) The protruding pre-
maxilla extends forward in the facial pro fi le. ( c ) Head
bonnet with attached elastic placed against the protruding
premaxilla causes it to ventro fl ex with the fulcrum at the
premaxillary vomerine suture. ( d , e ) Facial photographs at
3 years of age. The lateral lip elements are united with the
medial positioned prolabium over the protruding premax-
illa in one stage. Because the premaxilla is already
ventro fl exed at the time of surgery, there is reduced muscle
tension at the suture sites. ( f ) Intraoral photograph shows
excellent anterior and buccal occlusion even with bilateral
deciduous cuspids in crossbite. Comment: A severe over-
bite or overjet with a buccal crossbite at this age does not
create a functional dental problem or inhibit palatal
growth. Midfacial protrusion is expected and even desir-
able at this age. A straight pro fi le in the mixed dentition
usually indicates a concave pro fi le will develop in adoles-
cence after the pubertal growth spurt
a
c
f
d
e
b

90
S. Berkowitz
a
c
f
d
e
b
Fig. 5.2 ( a – f ) Case MD (AM-17). Conservative surgery
with no presurgical orthopedics in CUCLP. Lip adhesion
to start molding action to bring the separated palatal seg-
ment together. ( a ) At birth. ( b ) After lip adhesion at
5 months. ( c ) After de fi nitive lip surgery at 9 months. ( d , e )
Facial appearance at 8 years of age. ( f ) Occlusion at
8 years. The right deciduous lateral incisor erupted
through a secondary alveolar bone graft performed at
7 years of age using cranial cancellous bone

91
5 Alternative Method Used to Correct Distorted Neonatal Cleft Arch Forms
a
c
f
d
e
i
g
h
b
Fig. 5.3 ( a – i ) Presurgical orthopedic treatment ( PSOT )
appliance for a CUCLP utilized from birth to 1 year and
11 months at the University of Nijmegen (Courtesy of
AM Kuijpers-Jagtman). ( a ) Lip and nose distortion at
birth; ( b ) tongue posture within the cleft; ( c ) orthopedic
appliance; ( d ) orthopedic plate prevents the tongue from
entering the cleft; ( e ) 15 weeks after PSOT and before lip
closure; ( f ) 6 weeks after palate closure; ( g ) 17 months
before soft palate closure; ( h ) at 14 months of age, before
soft palate closure; ( i ) 8 weeks after lip closure

92
S. Berkowitz
a
c
d
e
j
k
h
l
i
b
f
g
Fig. 5.4 ( a – l ) Presurgical orthopedic treatment from
birth to 1 year for a CBCLP at the University of Nijmegen
(Courtesy of AM Kuijpers-Jagtman). Lip closure at 1 year
of age. Hard palatal cleft is closed between 6 and 9 years
of age together with bone grafting of the alveolar cleft.
( a – c ) Facial photographs and palatal cast at birth; ( d )
6 months after wearing PSOT appliance; ( e ) presurgical
orthopedic appliance and when placed on the palate; ( f )
wearing appliance; ( g ) 8 weeks after lip closure; ( h ) at
birth, ( i ) after 6 months of PSOT and before lip closure;
( j ) 8 weeks after lip closure; ( k ) 1 year and 6 months,
before soft palate closure; ( l ) 6 weeks after soft palate
closure

93
5 Alternative Method Used to Correct Distorted Neonatal Cleft Arch Forms
References
Bardach J, Mooney M, Giedrojc-Juraha ZL (1982) A
comparative study of facial growth following cleft lip
repair with or without soft tissue undermining: an
experimental study in rabbits. Plast Reconstr Surg
69:745–753
Berkowitz S (1959) Growth of the face with bilateral cleft
lip from 1 month to 8 years of age. Thesis, University
of Illinois, School of Dentistry, Chicago
Berkowitz S (1985) Timing cleft palate closure-age should
not be the sole determinant. J Craniofac Genet Dev
Biol 1(Suppl):69–83
Berkowitz S, Pruzansky S (1969) Stereophotogrammetry
of serial cast of cleft palate. Angle Orthod
38:136–149
Berkowitz S, Mejia M, Bystrik A (2004) A comparison of
the effects of the Latham-Millard procedure with those
of a conservative treatment approach for dental occlu-
sion and facial aesthetics in unilateral and bilateral
complete cleft lip and palate: part 1. Dental occlusion.
Plast Reconstr Surg 113:1–18
Berkowitz S, Duncan R, Prahl-Andersen B, Friede H,
Kuijpers-Jagtman AM, Mobers MLM, Evans C,
Rosenstein S (2005) Timing of cleft palate closure
should be based on the ratio of the area of the cleft to
that of the palatal segments and not on the age alone.
Plast Reconstr Surg 115(6):1483–1499
Ritsila V, Alhopuro S, Gylling U, Rintala A (1972) The
use of free periosteum for bone restoration in congeni-
tal clefts of the maxilla. Scand J Plast Reconstr Surg
6:57–60

95
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_6, © Springer-Verlag Berlin Heidelberg 2013
6
As previously described (Pruzansky 1955 ) , in
complete unilateral and bilateral clefts of the lip
and palate, after the lip is united, the overexpanded
palatal segments move together, reducing the cleft
width along its entire posterior length. Subtelny
( 1955 ) , using laminographs, has shown that new-
borns with complete clefts of the lip and palate
have wider than normal pharyngeal widths and the
perpendicular plates of the sphenoids are distorted
in their relationship. Aduss and Pruzansky ( 1967 )
have demonstrated that, in complete unilateral
cleft lip and palate, any one of three arch forms can
result after the lip is repaired (Fig. 6.1 ):
1. The alveolar segments can move into end-to-
end contact, producing a symmetrical arch
form.
2. The alveolar segments can overlap, producing
what is erroneously known as a “collapsed”
arch form.
3. The alveolar segments can move closer
together but not make contact. This occurs
because of an inhibiting factor of the inferior
turbinate on the cleft side, making contact
with the distorted bulge of the nasal septum.
In a series of 58 patients who had no presur-
gical orthopedics or primary bone grafting,
Aduss and Pruzansky ( 1967 ) found that approxi-
mately 43 % had overlap of the alveolar pro-
cesses (mistakenly called collapsed arch).
Among these patients, crossbites of the canine
and fi rst deciduous molar were the most com-
mon fi nding at 5 years of age. There were no
anterior crossbites. Other investigators have
reported
similar
results
(Bergland
1973 ;
Complete Unilateral Cleft of the Lip
and Palate
Samuel Berkowitz
S. Berkowitz , DDS, M.S., FICD
Adjunct Professor, Department of Orthodontics ,
College of Dentistry, University of Illinois ,
Chicago , IL , USA
Clinical Professor of Surgery and Pediatrics (Ret),
Director of Research (Ret),
South Florida Cleft Palate Clinic,
University of Miami School of Medicine ,
Miami , FL , USA
Consultant (Ret), Craniofacial Anomalies Program ,
Miami Children’s Hospital , Miami , FL , USA
e-mail: sberk3140@aol.com
Presurgical
orthopedics
Lip-adhesion

96
S. Berkowitz
a
b
Fig. 6.1 ( a ) CUCLP. Facial and palatal casts. ( b )
Complete unilateral cleft lip and palate (CUCLP) before
( A ) and after ( B ) lip surgery. With the establishment of
muscle continuity, the lesser segment moves medially,
while the premaxillary portion of the larger segment
moves medio-inferiorly, both acting to reduce the cleft
width. Any of the following segmental relationships can
result. ( B ) No contact between segments. The inferior tur-
binate on the cleft side makes premature contact with the
bowed nasal septum. ( C ) The premaxillary portion of the
larger segment overlaps the smaller segment. ( D ) The seg-
ments form a butt joint showing good approximation.
Pruzansky and Aduss have shown that there is no correla-
tion between the original cleft width and the resultant arch
form. Wider clefts seemed to demonstrate less of a ten-
dency toward collapse than did the narrower clefts (Aduss
and Pruzansky 1967 )

97
6 Complete Unilateral Cleft of the Lip and Palate
Bergland and Sidhu 1974 ) . Berkowitz ( 1985 ) , in
a serial study of 36 cases with complete unilat-
eral clefts of the lip and palate in which the lip
had been united between the ages of 3 and
5 months and the palatal cleft closed between 18
and 24 months using a von Langenbeck with
modi fi ed vomer fl ap without neonatal maxillary
orthopedics, showed that 5 of the 36 cases had a
complete buccal crossbite which was corrected
within 6–10 months with fi xed palatal expand-
ers. Cuspid crossbite was the most frequent
occurrence and was due to angular palatal rota-
tion as well as to ectopic eruption of the decidu-
ous cuspids. The cleft and noncleft segments
were in either a class I or class II occlusal rela-
tionship. In no instance were any of the seg-
ments in a class III relationship.
This con fi rms Berkowitz’s belief that the cleft
palatal segment is not retropositioned within the
skull relative to the mandible and that the maxil-
lary-mandibular relationship is similar to that
seen in the noncleft population. Whether the
maxilla and mandible are both posteriorly posi-
tioned within skull has not been determined, and
others (Semb 1991 ; Ross 1987a, b, c ) have found
this to be the case. Therefore, the palatal seg-
ments do not need to be brought forward by the
use of neonatal protraction forces as Latham
( 1980 ) and his mentor McNeil ( 1950 ) have sug-
gested. There are, however, some cases when,
because of an unfavorable facial growth pattern
coupled with a retruded maxilla relative to the
anterior cranial bases, orthopedic protraction
forces will be bene fi cial in the mixed (transi-
tional) and permanent dentition.
According to Aduss and Pruzansky ( 1967 ) ,
four factors govern arch form:
1. The size and shape of the alveolar process
adjacent to the cleft. A bulbous and fully
toothed alveolar process acts as an impedi-
ment to the collapse of the arch, whereas a
thinly formed and dentally impoverished alve-
olar process leads to the overlapping of
segments.
2. The size and shape of the inferior turbinate on
the side of the cleft. A thick, rounded, well-
modeled inferior turbinate can block excessive
medial movement of the palatal segments.
3. The size and geometrical inclination of the
nasal septum. A highly inclined septum with
a contiguous bulbous turbinate will affect
the movement of the palate and its fi nal
position.
4. The size and shape of the palatal shelves.
Shelves of disproportionate size are more
prone to overlap. One can certainly visualize
that a long noncleft segment coupled with a
short cleft segment will end up with the pre-
maxillary portion overlapping the short cleft
palate segment.
6.1
Facial Characteristics
Aduss ( 1971 ) in 1971 examined 50 males and 21
females with UCLP; their age range was between 4
and 14 years. He described craniofacial growth in
the male cleft group as essentially equivalent to the
female cleft group. He found that the gonial angle
for the cleft patients was consistently larger than
the noncleft group and the mandible appeared to be
more retrognathic. He concluded that the craniofa-
cial complex in the cleft sample tended to grow in
a similar manner to that reported for the noncleft
populations. The results of his study, based on a
conservative method of surgery, negate the conclu-
sions reached at the time regarding the deleterious
effects of surgery on the growth of midface.
Hayashi et al. ( 1976 ) studied craniofacial growth
in unilateral complete clefts using lateral cephalo-
grams of 135 males and 120 females with an age
range of 4–18 years. Control subjects included 120
noncleft males and 120 noncleft females of similar
age to the cleft subjects. They concluded that the
cleft group differed from the control group in sev-
eral major respects: (1) Their overall growth trend
showed a more downward or vertical direction;
(2) the cranial base angle was more fl attened; (3)
the maxilla was smaller and was located in a more
posterior and upward position; (4) ramal height
was shorter, the gonial angle was more obtuse, and
mandible was generally retrognathic; (5) upper
face height was smaller and lower face height was
greater; (6) underdevelopment in both the maxilla
and the mandible was more pronounced in cleft
females than in cleft males.

98
S. Berkowitz
Smahel and Mullerova ( 1986 ) , in 1986, stud-
ied 30 boys with UCLP prior to palatoplasty
using cephalometry. A comparison with 27 nor-
mal individuals matched in age showed that most
basic deviations of the craniofacial con fi guration
recorded in adults developed at an early age,
often prior to palatoplasty, i.e., reduced height of
the upper anterior face, maxillary dentoalveolar
retroclination, displacement of the upper jaw
backwards, widening of some components of the
maxillary complex, and a shortening of the man-
dibular body and ramus. Only the length of the
upper jaw was not reduced. The shortening of
maxillary dimension occurred postoperatively at
a more mature age.
Later on 1992, Smahel et al. ( 1992 ) presented
another study of craniofacial morphology in
UCLP in 58 adult males. The results showed a
shortening of maxillary depth, reduction of the
upper face height, increased lower anterior facial
height, and mandibular changes resulting from
growth de fi ciency that consisted of shortening of
the body and ramus, obtuse gonial angle, steep
mandibular plane, and retrognathia.
Again in 1992, Smahel et al. ( 1992 ) studied
growth and development of the face in UCLP
during prepubertal and pubertal periods. He con-
cluded that there were no de fi nitive differences in
the growth rate between the pre- and postpubertal
periods. Therefore, the worsening of overjet dur-
ing puberty could be due to the depletion of the
compensation and adaptation after the previous
orthodontic treatment rather than to the enhanced
growth rate. In addition, he found that during the
prepubertal period, the lower jaw showed a very
slight posterior rotation, while during puberty, an
anterior growth rotation was present. A marked
retrusion of the maxilla developed already in the
prepubertal period. During both periods, there
occurred an identical impairment of sagittal jaw
relations and of the upper lip prominence, accom-
panied by a fl attening of the facial pro fi le and
reduction of the nasolabial angle.
In 1996, Smahel and Mullerova ( 1996 )
reported a longitudinal study regarding postpu-
bertal growth and development of the face in
UCLP as compared to the pubertal period. The
data showed that in boys, facial growth persists
after the age of 15 years and maxillary growth
attains almost half the values recorded in the
period of puberty, while mandibular growth
attains almost the same values as during puberty.
In girls, the growth is almost terminated except
for the lower jaw, where it is still signi fi cant
though several times slighter than during puberty.
Due to the gender differences in the amount of
postpubertal growth, developmental changes in
facial con fi guration do not occur in girls during
this period, while in boys, there is a further dete-
rioration of maxillary protrusion, sagittal jaw
relations, and fl attening of the face.
In 1988, Hoswell and Levant ( 1988 ) reported
another long-term follow-up of skeletal growth
of UCLP subjects ranging in age from 8 to
18 years. Serial cephalographs taken every
2 years were utilized for determination of six
cephalometric dimensions: anterior cranial base,
upper and lower facial heights, posterior naso-
maxillary height, maxillary horizontal length,
and mandibular length. These were compared to
published cephalometric standards of a noncleft
group. All dimensions except mandibular length
were smaller in the UCLP group. The horizontal
maxillary length appeared to be most affected in
UCLP. Mandibular length was not affected in the
cleft group.
6.1.1 The Oslo Study
Because of the stable and long history of meticu-
lous record keeping and protocols that character-
izes the data acquisition of the Oslo team, the
following studies on unilateral cleft lip and palate
are presented to provide a unique perspective on
treatment strategies and facial growth standards
based on longitudinal data. The author does not
follow the same surgical strategies as those of the
Oslo team but recognizes that the differences are
not signi fi cant enough to interfere with obtaining
a successful long-term outcome.
Semb’s ( 1991 ) 20-year serial cephalometric
study taken from the Oslo Archives gathered
during Bergland’s leadership involved 76 males
and 81 females (157 individuals) who did not
have neonatal maxillary orthopedics. All of the

99
6 Complete Unilateral Cleft of the Lip and Palate
children in the study had lip closure in infancy
using a modi fi ed Le Mesurier or, after 1969, a
Millard procedure. During the same operation,
the nasal fl oor was closed using a one-layer
vomer fl ap. The remaining posterior palatal cleft
was closed between 4 and 5 years of age using a
von Langenbeck palatoplasty. Secondary alveo-
lar bone grafts from the iliac crest were placed
at between 8 and 11 years of age. By 1974, all
palate repairs were completed by 18 months of
age. Superior-based pharyngeal fl ap surgery for
velopharyngeal insuf fi ciency was performed in
about 20 % of the cases.
Compared with normal males and females, the
pooled sample with unilateral cleft lip and palate
showed (1) skeletal and soft tissue maxillary
retrusion, (2) elongation of the anterior face (even
though the upper face height was shorter), (3) a
retrusive mandible, (4) reduction in posterior face
height, and (5) a slight increase in the angle of the
cranial base.
The pattern of growth also was different from
that of noncleft individuals. Between 5 and
18 years of age, there was almost no increase in
the length of the maxilla. There was a marked
reduction in maxillary and mandibular promi-
nence. Vertically, the excessive lower face angu-
lations changed slightly.
6.1.2 Multicenter CUCLP
Cephaloradiographic Study
(Ross 1987a, b, c )
Ross’s multicenter study involved data from 15
cleft palate centers around the world collected for
the purpose of determining the effects of manipu-
lative and surgical treatment on facial growth.
A sample of 1,600 cephalometric radiographs of
males with complete unilateral cleft lip and pal-
ate were traced, digitized, and analyzed in the
Craniofacial Center of the Hospital for Sick
Children. The seven series of studies considered
virtually every aspect of treatment that might
in fl uence facial growth.
Ross concluded that the type of surgical
repair used does not make an appreciable differ-
ence to facial growth. It appears, however, that
there are differences that can only be explained
on the assumption that some surgeons induce
less growth inhibition than others. Variation of
the timing of hard and soft palate repair within
the fi rst decade does not in fl uence facial growth
in the anteroposterior or vertical dimension.
Ross admits that very early soft palate repair
was not well represented in this study, and there
is some suspicion that there might be untoward
results.
Berkowitz et al. ( 2005 ) clinical fi ndings sug-
gest a different conclusion that, in most cases,
early surgery (before 12 months) will have a neg-
ative effect on palatal growth in all three dimen-
sions. It all depends on the size of the cleft defect
relative to the area of the surrounding mucope-
riosteum (see Chap. 7 ).
Ross’s study did not include palatal surgery
from 6 to 12 months. This study also reported
that the resulting face is fl at in pro fi le and
decreased in depth, with a vertical de fi ciency in
the midface and vertical excess in the lower face.
The mandibles in these faces characteristically
are slightly shorter in total length so that the chin
is retruded. The occlusion is more of a molar and
incisor mesiocclusion in clefts with less overbite
and overjet. The soft palate in this sample is
appreciably more posterior. The mandibular
plane angle is greater, possible due to the need
for more interincisal space.
Ross further stated that the bony pharynx
was unaffected by treatment and that the varia-
tion in midface development can be attributed
to maxillary length rather than to maxillary
position. He also noted that the mandible is not
directly affected by treatment. Facial growth is
intrinsically compromised by an underlying
de fi cit, and surgery acts to further interfere with
growth of the midface by inhibiting forward
translation.
The best results appear to follow lip repair
at 4–5 months with no repair of the alveolus.
Early alveolar repair restricts its vertical growth
and should be avoided in individuals with poor
growth potential. This leads to de fi cient midfa-
cial height and poor vertical height proportions,
with more acute nasolabial angles. There is no
evidence that periosteoplasty will cause simi-

100
S. Berkowitz
lar results. Berkowitz et al. ( 2005 ) study con-
clusively shows that periosteoplasty inhibits
midfacial development, especially that of the
premaxilla (see Chap. 10 ).
Ross further states that the maxilla in the
UCLP is not more posteriorly positioned to any
appreciable extent, but it is much shorter in
length. The repaired lip affects the basal maxilla
more than the alveolar process. Vertical develop-
ment of the posterior maxilla is more de fi cient
than the anterior part. The mandible is shorter
with a steeper mandibular plane angle.
Hard and soft palate surgical repair procedures
provide the greatest potential for inhibiting the
maxilla in length, forward translation, and poste-
rior height.
Kwon’s ( 1998 ) retrospective longitudinal
study of the skeleto-facial growth in unilateral
cleft lip and palate documented and evaluated the
proportional craniofacial growth horizontally and
vertically in 14 UCLP patients of the ages
5–18 years by using modi fi ed Coben’s basion
horizontal analysis. There were three populations
included in this study: The Eastman cleft group
(sample size, 24) and the Miami cleft group
(sample size 23) served as patient group, and the
Bolton templates (ages 5–18) served as controls.
Samples were divided into four age periods
according to the chronological ages, and then the
growth pattern of each period were evaluated and
compared. A total of 301 images of lateral cepha-
lograms were examined and digitized. These
characteristics of the skeletal facial growth of the
UCLP are summarized as: (1) There is no differ-
ence of posterior cranial base over time; (2) max-
illa is positioned posteriorly relative to basion
(BA) during the early ages and is getting retru-
sive due to the de fi cient growth with time; (3)
upper anterior facial height (UAFH) is almost the
same as the control; (4) lower posterior facial
height (LPFH) is increased but is not as much as
lower anterior facial height (LAFH); (5) lower
anterior facial height (LAFH) is signi fi cantly
increased; (6) total facial height (TFH) is
signi fi cantly increased; (7) mandible is posi-
tioned backward and downward due to the poste-
rior position of the maxilla and the elongation of
LPFH and LAFH; and (8) skeletal pro fi le is more
convex and is getting straight and fi nally is fl atter
over time in the clefts than in the controls.
Generally, the manifestation of the cleft charac-
teristics of the Miami group is increased when
compared to that of the Eastman cleft group. The
skeletal growth leads to not only the maxillary
retrusion but also to position the mandible down
and back. Early orthopedic intervention followed
by the fi xed edgewise appliance and prolonged
retention is recommended to try to correct the
skeletal problems, camou fl age by dental correc-
tion, and maintain to the treatment outcome with
reasonable retainer.
6.1.3 Re fl ection on Ross’ Excellent
Multicenter Study
(Ross 1987a, b, c )
In the foreword of the multicenter study,
Treatment Variables Affecting Facial Growth in
Complete Unilateral Cleft Lip and Palate, Bruce
Ross discussed the dif fi culty of performing this
type of study due to the variability in sample size,
age, sex, precise cleft type, and ethnic origin. He
then mentioned the problems associated with
doing cephalometric measurements and sug-
gested using one center to control measurement
errors; this was an excellent solution. According
to Ross ( 1987a, b, c ) , the study considered virtu-
ally every aspect of treatment that might in fl uence
facial growth. An attempt was made to control
many variables that in fl uence growth research, so
that a clear picture of the effects of each proce-
dure would be available. Two major assumptions
about the study are necessary if any conclusion
can be drawn from these studies. The fi rst is that
all groups of infants with complete unilateral
cleft lip and palate have exactly the same facial
morphology at birth in spite of enormous indi-
vidual variation within the group. The second
assumption is that one group of infants will
respond on the average in exactly the same way
as any other group to a particular treatment. The
intent was to assemble relatively pure samples of
individuals who had received the given manage-
ment techniques used consistently on all subjects
from a particular center.

101
6 Complete Unilateral Cleft of the Lip and Palate
Berkowitz believes the study was a noble
attempt by excellent clinicians/researchers to
pool their sample cases to investigate treatment
results. By necessity, it was limited to cephalo-
metric records. By lumping all CUCLP cases
together, regardless of the degree of palatal
deformity at birth, much potential prognostic
information for the treatment of individual cases
is unavailable. Ross had no choice for discount-
ing Slavkin’s and Ross and Johnston’s statements
that palatal defects may be caused by either the
failure of the separated palatal segments to fuse
or, possibly, palatal osteogenic de fi ciency, a vari-
able that needs to be considered in treatment
planning. This statement on the embryo-patho-
genesis of cleft palate explains why all clefts
within a cleft type are not alike. It is not hard to
reason that as the extent of the cleft palatal defect
varies, so will the resulting quantity of palatal
surface area and the resulting quantity of post-
surgical scar tissue. Because excessive scarring
inhibits palatal growth and development, the
palatal surface area at the time of closure needs
to be considered in treatment planning. Berkowitz
believes that the variability of palatal surface
area within a particular cleft type weakens the
value of Ross’s ( 1987a, b, c ) conclusions, which
are based on the second assumption that “one
group of infants will respond on the average in
exactly the same way as any other group to a par-
ticular treatment.” Berkowitz concludes that the
next level of treatment evaluation studies
designed to improve differential diagnosis
requires the establishment of speci fi c criteria
based on quantitative and qualitative characteris-
tics of the palatal defect when related to treat-
ment outcome (see Chap. 7 ).
6.2
How the Palate Grows
As ready discussed in Chap. 1 on facial growth,
bone growth involves the increase in size as well
as remodeling. Serial palatal three-dimensional
growth studies by Berkowitz et al. ( 2005 ) have
shown that growth and remodeling occurs over
the entire palatal surface even at the medial bor-
der the palate at the cleft (Figs. 6.2 and 6.3 ).
6.3
Treatment Sequence
6.3.1 Usual Treatment Sequence
1. Lip adhesion: 3 months
2. De fi nitive lip surgery (rotation advancement):
10 months
3. Hard and soft palate closure (von Langenbeck
with vomer fl ap): 18–24 months (rarely
36 months)
4. Orthodontic
expansion
(quad
helix):
5–7 years
5. Superior-based pharyngeal fl ap: 6–8 years if
necessary
6. Bone graft (iliac crest): 7–9 years
7. Protraction facial mask (if necessary): 8 years
or later
8. Maxillary surgical advancement (Le Fort I or
distraction osteogenesis): varies
9. Lip/nose revisions techniques
6.4
Reports
In this section, treatment outcomes of selected
cases are presented with photographs and den-
tal casts. The casts started at birth and contin-
ued through adolescence; these records show
the natural history of palatal and facial growth
and development when conservative surgery
was performed without the use of presurgical
orthopedics.
In some cases, the lip was united after the use
of a Logan’s bow (Fig. 6.4 ), and in others, after
lip adhesion at approximately 3 months of age.
In some cases, the cleft of the soft palate was
united at the same time the hard palate was
closed. De fi nitive lip surgery was performed at
6 months, and hard palate closure using a
modi fi ed von Langenbeck procedure with a
vomer fl ap was performed between 12 and
24 months of age.
Selected cases are presented in Figs. 6.5 , 6.6 ,
6.7 , 6.8 , 6.9 , 6.10 , 6.11 , 6.12 , 6.13 , 6.14 , 6.15 ,
6.16 , 6.17 , 6.18 , 6.19 , 6.20 , 6.21 , 6.22 , 6.23 , 6.24 ,
and 6.25 to show various treatment solutions to
complex problems.

102
S. Berkowitz
1,500
1,350
1,200
1,050
900
750
600
450
300
150
00
8
16
24
32
40
Months
48
56
64
72
80
Square millimeter
Surface areas
Case kk_55(U)
Cleft
Right
Left
Total
Fig. 6.3 Case KK-55. Serial growth of
the palatal segments in CUCLP. Using
computer-generated 3D images, the
surface areas mesial to the alveolar
ridges were analyzed using an
electromechanical digitizer. The same
surgery stated in Fig. 6.2 was used.
Results: This case is an example of 60
cases analyzed in the study; it shows
(1) both palatal segments grow at the
same rate and (2) the most rapid period
(velocity) of growth occurs during the
fi rst 18 months. Comments: Because
the most rapid period of growth occurs
between 8 and 24 months when cells
are most active, it is best to postpone
palatal surgery until a later age in order
to not inhibit growth
J.K.
AF-64
R.F.
AJ-7
8-6
0-1
16-4
6-2
15-3
J.D.
7-1
17-4
7-1
17-4
AE-23
J.D.
AE-23
Fig. 6.2 ( a , b ) Superimposed computer-generated images
of serial CUCLP casts superimposed on the rugae and reg-
istered on the vomer AP line. The alveolar ridge is the
outer limits of the palate. Surgery: Lip adhesion at approx-
imately 3 months, de fi nitive lip surgery at approximately
6 months, and hard and soft palate closure between 18 and
24 months using a von Langenbeck procedure with a
vomer fl ap. No presurgical orthopedics. Results: These
four illustrations show the result of molding and growth.
The least growth occurs anteriorly. Most of the growth
occurs posteriorly to accommodate the developing decid-
uous and permanent molars. The palatal mucoperiosteum
covers increase palatal size and the palatal cleft, which
greatly reduced in size
Fig. 6.4 ( a , b ) Logan’s bow. Pressure is placed on the
cheeks to bring the lips together prior to surgery. The bow
helps to reduce tension at the suture line

103
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.5 ( a – v ) Case: KC (ZZ-1) demonstrates good palatal
and facial growth in CUCLP. A very small cleft space at
5 months of age allowed for easy closure without much scar
formation. Surgical treatment: No presurgical orthopedics.
Lip adhesion followed by Millard’s rotation advancement.
Soft palatal closure at 2 months. Palatal cleft closure at
15 months using modi fi ed von Langenbeck procedure.
Secondary alveolar cranial bone graft at 6 years and
8 months. Photographs showing various treatment stages
from birth to 17 years of age. ( a , b ) Newborn. ( c ) Lip adhe-
sion at 4 months. ( d ) Lip at 2 years of age. Orthodontics
during the deciduous dentition. ( e ) 2 years, showing ante-
rior crossbite. ( f ) 2 years, 7 months: palatal view showing
fi xed buccal expander
a
c
d
e
f
b

104
S. Berkowitz
g
i
j
k
l
m
h
( g ) Anterior teeth were advanced and the cleft buccal segment expanded. ( h ) 5 years. Fixed palatal
retainer. ( i – k ) Fixed palatal retainer with lateral incisor pontic (tooth). ( l , m ) Facial photographs at 6 years
Fig. 6.5 (continued)

105
6 Complete Unilateral Cleft of the Lip and Palate
n
o
p
r
s
t
u
v
q
Fig. 6.5 (continued) ( n , o ) 7 years, 3 months: Lateral
incisor is erupting through cranial bone graft. Orthodontics
in the adult dentition: ( o ) Lateral incisor is extracted due to
poor root development. ( p , q ) Conventional orthodontics.
Surgery to close the palatal fi stula was unsuccessful.
( r – t ) Facial photographs at 17 years. ( u , v ) Intraoral photo-
graphs. Hawley orthodontic retainer with lateral incisor
pontic

106
S. Berkowitz
Fig. 6.6 Case KC (ZZ-1). Serial casts from 0–1 to 0–5
show medial movement and growth changes to the palatal
segments. 0–5 The cleft space is extremely small with the
palatal segments making contact anterior to the cleft space.
2–6–0 and 4–3 Mesioangular rotation of the lesser segment
placed the deciduous cuspid in crossbite. 5–1 A fi xed pala-
tal expander rotated the segment outward, placing the teeth
in ideal occlusion

107
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.6 (continued) 6–1 Fixed retainer maintained the correction. Secondary alveolar bone graft was performed at
7 years, 3 months of age. 9–0 The maxillary anterior teeth were rotated for aesthetic reasons

108
S. Berkowitz
11–6 The left lateral incisor is now
in place within the arch. As a result of poor root develop-
ment, it had to be extracted. Conventional orthodontics was
instituted and completed by 15–3. Maxillary fi stula was
surgically closed at 16–3, and the arch form maintained
with a removable Hawley retainer with a lateral incisor
pontic. 17–0 Final occlusion. Comment: Because most cleft
palatal arches have some degree of osteogenic de fi ciency,
when all bicuspids are retained, it is usual for the second
molars to be blocked out and be impossible to position
within the arch. This then necessitates their removal with
possible replacement by the still unerupted third molars. In
some instances, a small palatal fi stula may not pose a speech
problem or be a source of nasal drainage
Fig. 6.6 (continued)

109
6 Complete Unilateral Cleft of the Lip and Palate
0–0–21
0–2
0–4
0–11
1–4
2–0
2–6
3–0
3–6
5–0
5–4
6–0
7–0
7–3
8–0
9–3
15–3
16–9
16–11
18–0
10–0
11–7
Fig. 6.7 Case KC (ZZ-1). Computer-generated drawings of
serial casts which are in the same scale. The soft palate was
united at 2 months and the hard palate closed at 15 months.
This series demonstrates a rapid reduction in palatal cleft size
with molding action and palatal growth. A palatal “ fi stula”
was exposed when the cleft buccal segment was expanded to
correct the crossbite. It was closed but reappeared when fi nal
orthopedic treatment moved the palatal segments slightly
apart. The “ fi stula” did not penetrate into the nasal chamber.
Therefore, it did not pose a speech or feeding problem
2,600
2,400
2,200
2,000
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
0 12 24
36
48
60
72
84
96 108 120 132 144 156 168 180 192 204 216
Surface area
Case # KC. ZZ–1
Right lateral segment
Left lateral segment
Total surface area
Total cleft space
Total surface + Cleft space
Square millimeter
Months
Fig. 6.8 Case KC (ZZ-1). The palatal growth chart shows
(1) rapid growth acceleration in the fi rst year which contin-
ues only slightly decreased until 36 months; (2) the palatal
growth rate did not diminish after palatal surgery at
15 months; (3) palatal growth slowed between 60 and
84 months and then steadily increased; (4) between 60 and
120 months, the growth of the lesser cleft segment increased
more rapidly than the noncleft segment; and (5) the palatal
growth rate accelerated after 136 months. Comment: Based
on palatal growth acceleration rates and the developing
occlusion, one can safely conclude that palatal surgery did
not interfere with its growth and development

110
S. Berkowitz
a
b
c
Fig. 6.9 ( a – c ) Case KC (ZZ-1). Tooth eruption into a
secondary alveolar cranial bone graft performed at 7 years
and 3 months of age. ( a ) The permanent lateral incisor is
erupting into the graft. ( b ) Good root development, the
lateral incisor, is brought into the arch orthodontically. ( c )
Its root began to absorb and was extracted, good alveolar
bone in the cleft space
18–0
S
N
Ar
Ba
Go
FH’
Po
A(α)
2–6
18–0
2–6
a
b
Fig. 6.10 Case KC (ZZ-1). ( a ) Lateral cephalometric
tracings and ( b ) superimposed polygons using basion
horizontal method (Coben). Both show an excellent facial
growth pattern. At 18–0, the midface is slightly recessive
but still very acceptable aesthetically

111
6 Complete Unilateral Cleft of the Lip and Palate
a
b
c
d
e
f
Fig. 6.11 ( a – m ) Case SP. Surgical and prosthetic treat-
ment to replace a missing portion of a premaxillary seg-
ment and to close an oronasal opening (a transfer patient).
Loss of blood supply to the right premaxillary area led to
its exfoliation. Treatment plan: Because the remaining
blood supply to the left maxillary and central incisor was
questionable and the teeth showed marked root absorp-
tion, the dentist (Alan Stoler) recommended their removal.
The remaining teeth were to be crowned to support an
anterior cast gold section to which a removable prosthetic
appliance would replace the missing incisor teeth and
bumper the lip. ( a – c ) Frontal and palatal view of an orona-
sal opening due to the loss of a portion of the right pre-
maxillary segment. ( d ) Palatal view following soft tissue
closure of the oronasal opening. ( e , f ) Anterior prosthetic
appliance with splinted posterior teeth; anterior appliance
with two holes and “o” rings to receive the two extensions
on the anterior splint

112
S. Berkowitz
g
h
i
j
k
l
m
f
Fig. 6.11 (continued) ( g ) Posterior teeth splints with
the anterior removable prosthesis in place on a model.
( h , i ) The gold anterior section spans the inter-cuspid
space. ( j ) Palatal view with the anterior prosthetic appli-
ance in place. ( k – m ) Facial photographs showing good
upper lip support with excellent dental aesthetics

113
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.12 ( a – k ) Case JK (AF-64). Excellent facial and
palatal growth in CUCLP when the palatal segments did
not make contact after the lip was united. The lateral inci-
sor is in position in the alveolar cleft area. ( a – i ) Serial
facial and intraoral photographs show changes to the lip
and nose after lip adhesion and de fi nitive lip surgery using
Millard’s rotation advancement procedure. Left facial
asymmetry is apparent in the frontal photograph and is
more noticeable in the intraoral photograph at completion
of orthodontic treatment. The left side was kept in class II
occlusion
a
c
f
g
h
i
d
e
b

114
S. Berkowitz
Fig. 6.13 Serial casts of Case JK. Newborn: The nasal
septum bows toward the cleft segment, creating a very
small cleft space. The great distance between alveolar
segments is due to the upward tilt of the larger segment
coupled with a small cleft segment. 0–6–0 After the lip is
united, both palatal segments move toward the midline,
narrowing the cleft space, more on the right than the left
side. However, the alveolar segments still do not meet due
to the inferior turbinate on the lesser segment making pre-
mature contact with the septum, preventing the lesser
palatal segment from further medial movement. Note that
the premaxillary portion of the larger segment has not
moved medioposteriorly 1–0–0, 1–6, 2–3, 3–2
( j , k )
Periapical fi lms show bone
closure of the alveolar cleft
space with good lateral
incisor alignment
Fig. 6.12 (continued)
j
k

115
6 Complete Unilateral Cleft of the Lip and Palate
The palatal segments are still
apart. 5–3 After removal of the inferior turbinate and with
palatal closure, the tissue contracture created by the
modi fi ed von Langenbeck procedure pulls the palatal
segments together, placing the buccal teeth in the cleft
segment in crossbite. 6–7 The palatal segments have been
expanded. 7–9 Without palatal arch retention, the cross-
bite returned. The ectopically erupted left central incisor
is in crossbite
Fig. 6.13 (continued)

116
S. Berkowitz
Fig. 6.13 (continued) 8–6 Arch expansion mechanics
were reinstituted, and the left central incisor advanced
into proper overjet. 11–4 and 14–2 Final orthodontic treat-
ment was instituted and completed at 14 years of age. The
impacted left lateral incisor was brought into alignment
through the secondary alveolar cranial bone graft.
Comment: After secondary alveolar bone grafting, arch
expansion in most cases is stable. However, in cases where
new bone does not extend to the nasal aperture, we believe
the buccal crossbite has a good chance of returning. The
left side was in class II occlusion, because it was not cer-
tain that the left lateral incisor could be properly aligned.
If it was to be extracted, the cuspid would be positioned in
the lateral incisor space
Fig. 6.14 ( a , b ) Case JK (AF-64). ( a ) Panorex: The left
lateral incisor is palatally and horizontally impacted.
( b ) After treatment, the lateral incisor is well-aligned
within the arch. Note that the curvature to the root possi-
bly occurred before it was fully formed and during orth-
odontic movement

117
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.15 Case JK (AF-64). Frontal cephaloradiograph
shows that the nasal chamber on the cleft side is very nar-
row with a very fl attened inferior conchae. The nasal sep-
tum is extremely bowed toward the cleft side. A lower
cuspid to cuspid retainer is being worn
4–11
SNA
81 . 57
SNPo
72 . 82
NAPo 159 . 23
ANB
10 . 16
SNA
78 . 51
SNPo
75 . 03
NAPo 172 . 15
ANB
5 . 64
SNA
72 . 40
SNPo
72 . 35
NAPo 179 . 89
ANB
2 . 68
SNA
71 . 35
SNPo
71 . 74
NAPo 179 . 20
ANB
2 . 49
SNA
71 . 03
SNPo
71 . 89
NAPo 178 . 11
ANB
1 . 74
8–4
a
Ba
A (a)
BaH
Go
Gn
4−11
8−4 11−7
13−3
15−0
S
N
Ar
b
Fig. 6.16 ( a , b ) Case JK (AF-64). ( a ) Skeletal and soft
tissue pro fi le changes shown by lateral cephalometrics.
The anterior projection of the midface and mandible rela-
tive to the anterior cranial base decreases with time as the
pro fi le fl attens. The decreasing ANB angle re fl ects this
change. ( b ) Superimposed polygons using the basion hori-
zontal method. This series clearly shows that the fl attening
of the skeletal facial pro fi le occurred around 8 years of age
and was brought about by the growth at the anterior cranial
base and the mandible, whose plane angle increased with
time. There was almost no forward growth of the midface
between 4–11 and 13–3 years with only a small postpuber-
tal growth increment between 13–3 and 15–0 years of age

118
S. Berkowitz
Fig. 6.17 ( a – s ) Case JD (AE 23). Complete unilateral
cleft lip and palate. Excellent palatal and facial growth. A
relatively large cleft space necessitated postponement of
palatal closure until 20 months. Early secondary alveolar
bone graft. Surgical history: Lip adhesion at 3 months fol-
lowed by rotation advancement de fi nitive lip repair at
6 months. Modi fi ed von Langenbeck palatal cleft closure
at 20 months. Secondary alveolar cranial bone grafts at
6 years. ( a ) Before and ( b ) after lip repair. ( c ) 2 years,
5 months. Anterior and buccal crossbite. ( d–f ) 3 years,
4 months. Anterior and buccal crossbite correction with
fi xed palatal expander
a
b
c
d
e
f

119
6 Complete Unilateral Cleft of the Lip and Palate
g
h
i
j
k
l
Fig. 6.17 (continued) ( g , h ) 4 years, 6 months. After
expansion, a fi xed palatal retainer. ( i , j ) 9 years. Central
incisor aligned in the mixed dentition. ( k , l ) Orthodontic
appliance with a false lateral incisor tooth with band
attached to the orthodontic arch wire

120
S. Berkowitz
m
n
o
p
q
r
s
( m – r ) Facial and intraoral photographs at 15 years of age – on completion of orthodontic treat-
ment. Ideal dental occlusion. ( s ) Maxillary retainer with an attached lateral incisor pontic tooth
Fig. 6.17 (continued)

121
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.18 Serial casts of Case JD. 0–1 At birth. 0–13,
1–4, and 1–7 With the institution of compressive lip mus-
cle forces by uniting the lip, the lesser cleft segment
moved medially to make contact with the vomer. The geo-
metric changes to both segments brought the alveolar seg-
ments in good approximation 1–10, 2–5, 2–11, and 3–4

122
S. Berkowitz
Fig. 6.18 (continued) However, after palatal cleft clo-
sure at 20 months, the lesser segment moved further medi-
ally placing the left cleft segment in crossbite. Due to
ectopic eruption, the left central incisor was in crossbite.
After palatal expansion and advancement of the left cen-
tral incisor, excellent buccal occlusion was established.
7–1, 7–9, 9–2, and 9–11. Fixed palatal retainer is worn to
maintain the arch forum

123
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.18 (continued) 10–6, 11–0, and 11–9 Palatal
form retained with palatal appliance. The upper central
incisors were rotated for aesthetic purposes. The left mal-
formed lateral incisor was left in place until orthodontic
treatment was instituted at 12 years of age. 15–4
Orthodontic treatment completed. Note the slight fl aring
of the upper incisors and upper left cuspid, which was due
to slight anterior maxillary bone de fi ciency. This is not an
uncommon fi nding in complete unilateral clefts of the lip
and palate

124
S. Berkowitz
3–7
a
N
S
Ar
Ba
FH
Go
Po
3–3
7–1
12–3
17–4
A(a)
b
12–7
16–0
17–8
7–5
11–4
Fig. 6.19 ( a ) Skeletal and soft tissue changes in Case JD.
( b ) Superimposed polygons using basion horizontal
method (Coben). Both of these analyses show excellent
facial changes. The midfacial protrusion actually reduced
between 7–1 and 17–4. Comments: One of the main
controlling factors in the treatment of children with clefts
that involve the anterior bony segment is the amount of
osteogenic de fi ciency in the area. In many noncleft chil-
dren, some advancement of the anterior teeth is essential;
however, advancing the anterior teeth in the child with a
cleft results in fl ared incisor teeth because the bone
de fi ciency prevents the roots from being brought forward,
even with anterior root torque using rectangular arch
wires

125
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.20 ( a – n ) Case AB (EE-49). UCLP illustrating use
of protraction maxillary orthopedics to correct midfacial
retrusiveness secondary to growth-inhibiting scar tissue
and/or maxillary osteogenic de fi ciency. Surgical history:
Lip closure at 6 months. Hard and soft palate cleft closure
at 16 months using an island fl ap pushback. Secondary
alveolar cranial bone graft at 10 years of age. ( a ) Two
years 11 months of age. Anterior and bilateral buccal
crossbite could not be corrected in the deciduous or mixed
dentition. ( b – d ) Orthodontic-orthopedic forces to correct
an anterior crossbite were initiated at 12 years of age using
a Delaire-style protraction facial mask. ( e , f ) Ideal class I
(neutroclusion) with an ideal overjet and overbite. Palatal
view shows thick transpalatal scar tissue caused by the
island fl ap. ( g , h ) Periapical fi lms after secondary alveolar
cranial bone graft. No left lateral incisor is present, but
good cleft space closure is evident
a
b
c
d
f
e
g
h