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

127
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.21 Serial casts of Case AB. 3–4–0 After island
fl ap hard and soft palate closure at 16 months of age
resulting in bilateral buccal and anterior crossbites. 11–8–
12 Occlusion just prior to orthodontic treatment. 13–11–1
After protraction mechanics using a Delaire-style facial
mask. 15–4–2 Occlusion after orthodontics. Comments:
Because maxillary de fi ciency is almost always present,
“A” point (subnasal) in the premaxillary area needs to be
brought forward by using labile root torque on a rectangu-
lar arch
14–11
16–2
S
Ar
N
Ba
A(a)
FH
14–4
16–2
Go
Po
a
b
Fig. 6.22 ( a , b ) Case AB. ( a ) Cephalometric tracings at
14–11 and 16–2. ( b ) Superimposed polygons using basion
horizontal method. A slight change in midfacial protru-
sion is noted after protraction forces were used to correct
the midfacial retrusion and anterior crossbite. In this case,
the changes in the maxillary incisor axial inclination aided
anterior crossbite correction more than maxillary
protraction

128
S. Berkowitz
Fig. 6.23 Conservative treatment of a patient with
CUCLP. Lip adhesion at 3 months. Rotation advancement
at 6 months. Palatal closure at 22 months using a von
Langenbeck and vomer fl ap. Excellent occlusion and a fl at
face pro fi le resulted

129
6 Complete Unilateral Cleft of the Lip and Palate
Fig. 6.24 Case AL 64. Complete unilateral cleft lip and
palate. Serial casts, 0–0–23 to 2–0–0: Lip adhesion brings
the overexpanded palatal segments together. The premax-
illary portion of the larger noncleft segments palatally
positioned placing the teeth into an anterior crossbite. The
palatal cleft was closed at 1–11 with von Langenbeck plus
vomer fl ap

130
S. Berkowitz
8–9–13 to 15–4–7 The maxillary
anterior teeth were advanced into a proper overjet and
overbite. Due to arch crowding, the fi rst bicuspids were
extracted and spaces closed. The alveolar bone graft at
approximately 8 years permitted the impacted lateral inci-
sors to erupt into place. Note: The right lateral incisor
crown is malformal, but the root size and shape is normal.
The crown will eventually be capped
Fig. 6.24 (continued)

131
6 Complete Unilateral Cleft of the Lip and Palate
5–10
SNA
ANB
SNPo
NAPo
81.06
5.66
75.40
166.48
SNA
ANB
SNPo
NAPo
77.83
0.84
77.51
179.46
SNA
ANB
SNPo
NAPo
a
N
S
Ba
Go
b
Gn
BaH
A(a)
5–10
8–10
15–4
76.15
2.69
74.50
176.63
8–10
15–4
Fig. 6.25 ( a , b ) Case DM-AL 64. Very good facial
growth pattern. The fl attening of facial pro fi le was depen-
dent on good growth of all parts of the facial skeleton. The
extraction of all the maxillary and mandibular fi rst bicus-
pids was necessary to retract the incisors and uncrowd the
dentition

132
S. Berkowitz
References
Aduss H (1971) Craniofacial growth in complete unilat-
eral cleft lip and palate. Angle Orthod 41(3):202–213
Aduss H, Pruzansky S (1967) The nasal cavity in com-
plete unilateral cleft lip and palate. Arch Otolaryngol
85:53–61
Bergland O (1973) Treatment of cleft palate malocclusion
in the mixed and permanent dentition. Fortschr Kiefer
Gesichtschir 16/17:571–574
Bergland O, Sidhu SS (1974) Occlusal changes from the
deciduous to the early mixed dentition in unilateral
complete clefts. Cleft Palate J 11:317–326
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, Duncan R, Evans C, Friede F, Kuijpers-
Jagtman AM, Prahl-Anderson B, 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 seg-
ments and not on the age alone. Plast Reconstr Surg
115(6):1483–1499
Hayashi I, Sakuda M, Takimoto K, Miyazaki T (1976)
Craniofacial growth in complete unilateral cleft lip
and palate: a roentgeno-cephalometric study. Cleft
Palate J 13:215–237
Hoswell BB, Levant BA (1988) Craniofacial growth in
unilateral cleft lip and palate: skeletal growth from 8 to
18 years. Cleft Palate J 25(2):114–121
Kwon S (1998) A mixed longitudinal study of skeleto-
facial growth in UCLP samples. Senior Research
Eastman Dental Center, Rochester
Latham RA (1980) Orthopaedic advancement of the cleft
maxillary segment: a preliminary report. Cleft Palate J
17:227
McNeil CK (1950) Orthodontic procedures in the treat-
ment of congenital cleft palate. Dent Rec 70:126–132
Pruzansky S (1955) Factors determining arch form in
clefts of the lip and palate. Am J Orthod 41:827
Ross RB (1987a) Treatment variables affecting facial
growth in complete unilateral cleft lip and palate. Cleft
Palate J 24:5–77
Ross RB (1987b) Treatment variables affecting facial
growth in complete unilateral cleft lip and palate.
Part 1: treatment affecting growth. Cleft Palate J 28:
5–23
Ross RB (1987c) Treatment variables affecting facial
growth in complete unilateral cleft lip and palate. Part
7: an overview of treatment and facial growth. Cleft
Palate J 24:71–77
Semb G (1991) A study of facial growth in patients with
unilateral cleft lip and palate treated by the Oslo CLP
team. Cleft Palate Craniofac J 28(1):1–21
Smahel Z, Mullerova Z (1986) Craniofacial morphology
in unilateral cleft lip and palate prior to palatoplasty.
Cleft Palate J 23(3):225–232
Smahel Z, Mullerova Z (1996) Postpubertal growth and
development of the face in unilateral cleft lip and pal-
ate as compared to the pubertal period: a longitudinal
study. J Craniofac Genet Dev Biol 16(3):182–192
Smahel Z, Machovav P, Mullerova Z, Skvarilova B (1992)
Growth and development of the face in unilateral cleft
lip and palate during prepubertal and pubertal periods.
Acta Chir Plast 34(3):163–177
Subtelny JD (1955) Width of the nasopharynx and related
anatomic structures in normal and unoperated cleft
palate children. Am J Orthod 41:889–909

133
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_7, © Springer-Verlag Berlin Heidelberg 2013
7
The surgeon is confronted with the following
options when faced with a protruding premaxilla
at birth:
1. Uniting the lip over the protruding premaxilla
and considering later surgical setback and
other surgical options
2. External elastics attached to a head bonnet or
elastic tape to the cheeks to ventro fl ex the
premaxilla
3. Early surgical premaxillary setback
4. Complete removal (excision of the premaxilla)
5. Early mechanical retrusion prior to lip surgery
or presurgical orthopedic treatment (PSOT)
Complete Bilateral Cleft 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
a) Excision
b) Early
setback
c) Ventroflexion
d) Lip only
surgery
e) Late surgical
set back
a.‘Telescoping
(Popla
Millard-latham)
b.’Surgical
a. ‘Passve
pso plate
b.’Head bonnet
& elastic

134
S. Berkowitz
without retraction and with or without primary
bone grafting or periosteoplasty
6. Lip adhesion followed by de fi nitive lip sur-
gery at a later age
7.1
Premaxillary Protrusion: Real
or Apparent? Is the Palate
De fi cient in Bone?
A bilateral cleft of the lip and palate can be
complete or incomplete on one or both sides (see
Chap. 4 ). Any number of variations can exist. In
both incomplete and complete bilateral clefts of
the lip and alveolus, the size and shape of the pre-
maxilla are dependent on the number of tooth
buds and their distribution, making it symmetri-
cal or asymmetrical (Fig. 7.1 ). Because clefts of
the lip/alveolus and the hard and soft palate come
from different embryological sources, the cleft
may involve the lip and alveolus with or without
involving the hard and soft palate.
Based on the observations of Veau and Borel
( 1931 ) , Veau ( 1934 ) and Browne ( 1969 ) and the
later work of Friede and Pruzansky ( 1972 ) ,
Bergland and Borchgrevink ( 1974 ) , Harvold
a
b
c
d
Fig. 7.1 ( a ) Small premaxilla: three deciduous incisors
with one unerupted permanent central incisor. ( b ) Large
premaxilla: four deciduous incisors with two permanent
unerupted incisors. ( c ) Occlusal radiographs of premaxil-
lae showing variations in the number of anterior deciduous
teeth and permanent tooth buds. ( d ) Occlusal radiographs
of premaxillae showing variations in the number of ante-
rior deciduous teeth and permanent tooth buds

135
7 Complete Bilateral Cleft Lip and Palate
( 1954 ) , Berkowitz ( 1959 ) , Friede ( 1977, 1978 ) ,
Atherton ( 1967, 1974 ) , and Handelman and
Pruzansky ( 1968 ) , the cause of premaxillary pro-
trusion is the result of tension and the resulting
bony overgrowth produced at the premaxillary-
vomerine suture (PVS) by displacement of that
bone by the aberrant muscular forces of the
detached outer musculature combined with
the pushing force of the tongue fi tting within the
cleft (Fig. 7.2 ). These investigators, using
Fig. 7.2 ( a ) Line drawing of a complete bilateral cleft lip
and palate with an arrow pointing to the premaxillary-
vomerine suture ( PVS ) ( b ) A small protruding premaxilla
IBCLP extends forward of the facial pro fi le and lateral
palatal segments. ( c ) Variations in bilateral cleft lip and
palate. The size of the premaxilla varies with the number
of teeth it contains. Classi fi cation is dependent on the
completeness of clefting of the lip and alveolus and
whether there is a cleft of the hard and soft palate. Yet one
or both sides of the hard palate may or may not be attached
to the vomer. If it is attached to the vomer, it is classi fi ed
as being incomplete. Even in complete clefts of the lip and
alveolus, the extent of premaxillary protrusion will vary.
( a ) Incomplete bilateral cleft lip and palate. Complete
cleft lip and palate – left side . Incomplete cleft lip and pal-
ate – right side . ( b ) Complete bilateral cleft lip and palate.
Complete cleft palate – both sides . ( c ) Incomplete bilat-
eral cleft lip and palate. Incomplete palatal clefts – both
sides . ( d ) Complete bilateral cleft lip and palate.
Incomplete right and complete left palate. ( e ) Incomplete
bilateral cleft lip and palate. Incomplete left palate and
complete right palate. ( f ) Complete bilateral cleft of the
lip and palate. Incomplete right and left palatal segments
PVS
Vo.
P
a
b
c
d
e
f

136
S. Berkowitz
cephalometric data, concluded that the premax-
illa is postured forward in the facial pro fi le at
birth (Fig. 7.3 ).
Bergland and Borchgrevink ( 1974 ) reported
that, in complete bilateral clefts of the lip and alve-
olus with intact palates, the premaxilla was protru-
sive but palatal size was well within normal limits.
In these cases, the septum was detached from the
normally developed palates and the protrusion of
the premaxilla was interpreted as representing a
108°
121°
142°
0–1–1
0–1–1
0–10–3
Fig. 7.3 Two-stage lip closure in a CBCLP. Ten months
after lip closure, the angle of facial convexity changed from
108° to 142° as a result of the ventro fl exion of the premax-
illa at the premaxillary-vomerine suture (PVS) coupled
with some additional mandibular growth. A two-stage lip
closure is rarely necessary (Courtesy of S Pruzansky)
g
h
i
Fig. 7.2 (continued) ( g ) Complete bilateral cleft of lip
and palate. Incomplete left palate and complete right pala-
tal segment. ( h ) Complete bilateral cleft lip and palate.
Incomplete left palate and complete right palate.
( i ) Incomplete bilateral cleft lip and alveolus. Normal
palate

137
7 Complete Bilateral Cleft Lip and Palate
premature release of the normal growth potential
of the septum. The premaxilla apparently reached
its geometric position within the skull at an earlier
time prior to birth, yet the palatal segments fol-
lowed a normal growth rate. Berkowitz’s clinical
records support the fi ndings of Coup and Subtelny
( 1960 ) , who reported marked palatal hypoplasia in
bilateral clefts of the lip and palate. Berkowitz
reports in this book that palatal growth rates are
highly variable according to the amount of scar-
ring created when closing the cleft space.
7.2
The Premaxillary-Vomerine
Suture
Pruzansky ( 1953, 1971 ) and Friede and Morgan
( 1976 ) used metal implants on either side of the
premaxillary-vomerine junction to demonstrate
cephalometrically that this suture was a major site
of bony overgrowth (Fig. 7.4 ). Earlier, Berkowitz
( 1959 ) and later Pruzansky ( 1971 ) , Friede and
Morgan ( 1976 ) , Pruzansky and Friede ( 1975 ) ,
Friede ( 1973 ) , Vargervik ( 1983 ) , and Berkowitz
( 1959 ) suggested that the overgrowth was proba-
bly a secondary reaction to the lack of restraint
from the cleft orbicularis oris muscle. They showed
that midfacial growth continued for 1–3 years even
after the lip was united but at a slower rate.
Berkowitz ( 1959 ) serial cephalometric tracings
and digital cast study demonstrated that the mid-
face continued to protrude for 2–3 years after the
lip was united, then its forward growth slowed
markedly (Fig. 7.5 ). Not surprisingly, in some
instances, the facial convexity did not change due
to the continued forward growth of the maxilla
and premaxilla but was due to more vertical rather
than forward growth of the mandible, maintaining
the facial convexity (Figs. 7.6 and 7.7 ).
Pruzansky ( 1953, 1971 ) , Friede ( 1973 ) , and
Atherton ( 1967, 1974 ) described the premaxil-
lary-vomerine suture as resembling other facial
sutures. Friede and Morgan ( 1976 ) con fi rmed the
presence of small islands of cartilage in the
suture; these were secondary occurrences result-
ing from mechanical stresses and not part of a
force system causing growth.
Burston ( 1960, 1967 ) and Latham ( 1969,
1973 ) following Scott (Scott 1956a, b ) “Nasal
Septum Growth” thesis, believe that the displace-
ment is not real but only apparent. Burston
thought that the lateral segments of the maxilla
were retroplaced and considered the premaxilla
to be in normal position. Latham suggested that a
contributing factor in producing the projecting
premaxilla was the shortening of the septomaxil-
lary ligament which drew it forward.
Pruzansky and Friede ( 1975 ) roentgencepha-
lometric data con fi rmed the existence of a true,
rather than a relative, premaxillary protrusion.
Metallic implants were inserted on either side of
the PVS at the time of initial surgery and were fol-
lowed up roentgencephalometrically. Although
continuous growth was recorded in the PVS,
there was a postsurgical decrease in the premax-
illary protrusion. On the basis of both histology
and cephalometrics, Friede ( 1973 ) concluded
that traumatic surgery involving the PVS would
be likely to contribute to the impaired midfacial
Fig. 7.4 To test growth at the premaxillar-vomerine
suture (PVS) in complete bilateral cleft of the lip and pal-
ate, two pairs of metal pellets were placed on either side of
the PVS at 6 months of age. At 3 years, 5 months of age,
the distance between the anterior and posterior sets of pel-
lets had increased with the growth at PVS. Note that there
was no change in distance within each set of metal pellets
(Courtesy of S Pruzansky)

138
S. Berkowitz
growth. This has been veri fi ed by Berkowitz’s
more recent follow-up studies of the effects of
mechanical premaxillary retraction on pro fi le
development. He has observed similar midfacial
problems of impaired growth (see Chap. 21 ).
Berkowitz speculated that severe pressure at
the PVS would cause a hemorrhage followed by
fi brosis and synostosis with cellular destruction,
both acting to inhibit sutural growth. In contrast,
a united lip across the protruding premaxilla
exerts a more tolerant retrusive force within the
PVS, acting well within its physiologic threshold
level for slowing down bone growth but not
totally inhibiting it.
Based on conclusions drawn from his clinical
fi ndings and those of Pruzansky and Friede ( 1975 )
research, Berkowitz rejects Latham ( 1969, 1973 )
“force of the cartilaginous septum via the septo-
premaxillary ligament” as the cause of premaxillary
protrusion. Enlow ( 1982 ) description of the naso-
maxillary complex’s growth is worth repeating:
The nasomaxillary complex is in contact with
the fl oor of the cranium. The whole maxillary
region in total is displaced downward and for-
ward away from the cranium by the expansive
growth of the soft tissues in the midfacial region.
This then triggers new bone growth at the
various sutural contact surfaces between the
nasomaxillary composite and the cranial fl oor.
Displacement thus proceeds downward and for-
ward as growth by bone deposition simultane-
ously takes place in an opposite upward and
backward direction.
McNeil ( 1950 ) mistakenly had stated that the
detached palatal segments from the nasal septum
are not only reduced in mass but also are not
brought forward with the developing nasal
septum.
This failure of the palatal segments to move
forward with growth would lead to a retrusive
midface with a Class III malocclusion (he did not
want to blame the suggestions).
Fig. 7.5 ( a – f ) A method used to show serial changes in
facial growth and development in CBCLP using sella for
registration while superimposing on the anterior cranial
base. Facial angles and landmarks ( upper left ): nasion
( N ), pogonion ( Po ), gonion ( Go ), sella ( S ), alpha ( a ) most
anterior point on the premaxilla, menton ( Me ), con-
structed Frankfort horizontal ( FHc ), anterior point of the
lateral palatal processes ( M ), pterygomaxillary fi ssure
( Ptm ). Facial polygon ( upper middle ) drawn connecting
landmarks S-N-a-Po-Me-Go-S. Landmark points ( upper
right ) projected to a constructed Frankfort horizontal line
which is drawn 6° from the anterior cranial base (SN) at
S. ( b ) An example of excellent facial growth. The cultural
standard for a good aesthetic Caucasian face is a “ fl at”
face, having an angle of facial convexity of approximately
180°. Most newborn noncleft faces have a relatively acute
facial pro fi le associated with relative retrognathia
which usually fl attens with growth
a
b
c

139
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.5 (continued)
A
B
8–6–28
3–8–4
2–0–3
0–3–14
0–0–21
a
a
Go
Po’
Po’
CP #72
A
S
N
N
e
0–0–21
3–8–4
145°
145°
148°
158°
155°
154°
4–2–2
4–11–22
6–1–11
7–1–8
8–6–28
113°
125°
139°
139°
143°
142°
143°
143°
0–3–14
0–8–3
1–4–30
2–0–3
2–2–20
2–9–18
3–3–11
NaP0
CP #72
d
( d ) Serial lateral cephalometric
tracings showing changes in the angle of facial convexity
(NaPo) from 113° to 154° in 8 11/42 years. ( e ) Facial
polygon of the case shown in Fig. 7.5d . Each polygon
showing pro fi le changes is superimposed on SN and
registered at Sella. The midfacial protrusion at a had not
increased after 2 years, whereas both the anterior cranial
base (SN) and mandible had increased in size. The man-
dible grew forward and downward, fl attening the facial
pro fi le. The timing of these growth changes is variable

140
S. Berkowitz
Fig. 7.5 (continued) ( f ) Projection of landmark points to the constructed
Frankfort horizontal line drawn 6° from SN at S. This growth projection
system also shows that the midfacial protrusion did not increase after
2 years, whereas the forward projection of the mandibular body increased
markedly until 8 11/42 years of age. These are the main factors leading to
the fl attening of the facial pro fi le. Good facial growth changes can occur
early or late (From Millard 1980 )
f
0–3–14
Salla
PTM
Pogonion
Maxilla
Nasion
premaxilla
0–8–3
1–4–30
2–0–3
2–2–20
2–9–18
3–3–11
3–8–4
4–2–2
4–11–22
6–1–11
7–1–8
8–6–28
O S
Ptm
Po M
Na
CPC #72

141
7 Complete Bilateral Cleft Lip and Palate
a
CP #139
0–1–21
0–6–0
4–2–0
4–8–21
5–2–12
5–11–15
6–6–1
7–6–16
0–8–10
1–0–22
2–0–14
2–6–8
3–0–14
3–6–30
N∝B
117°
135°
A
B
N
N
Po’
Po’
7–6–16
4–2–0
5–2–12
3–0–14
0–8–10
0–1–21
∝
122°
131°
131°
134°
134°
140°
135°
b
Fig. 7.6 ( a , b ) An example of “poor” pro fi le growth
changes. This evaluation is made when the acute facial
pro fi le seen at birth remains the same or worsens with
time. ( a ) Serial cephalometric tracings showing poor
facial growth leading to premaxillary excision. The acute
angle of facial convexity remained the same after 2 years.
This treatment plan should be abandoned at any age even
with severe midfacial protrusion. In similar growing faces,
some clinicians believe premaxillary surgical setback is
preferable for psychosocial reasons prior to starting ele-
mentary school. ( b ) Superimposed polygons of case show
a mandible that is growing vertically with very few hori-
zontal growth increments. The premaxilla continued to
grow forward although there was no forward growth
between 3–0–14 and 4–2–0. Note the placement of the
lower lip lingual to the premaxilla. The premaxilla was
excised at 4–9. This case came from Pruzansky’s records
(From Berkowitz 1959 )

142
S. Berkowitz
7.3
Facial Growth Studies Show
That Midfacial Retrusion
Is Not Predictable
Semb ( 1991 ) and Ross ( 1987 ) established that,
in the cleft population, both the maxilla and
mandible – not solely the maxilla – are retropo-
sitioned within the face. If McNeil ( 1950 )
belief that the bilateral cleft palatal segments
are left behind in their growth was accurate, a
greater proportion of the cases must show a
Class III malocclusion of one or both sides. As
previously mentioned, Berkowitz ( 1982 ) mixed
cross-sectional study of the occlusion in
CBCLP determined that the maxillary complex
was not positioned posteriorly relative to the
mandible. Also, a buccal crossbite is not a pre-
dictable outcome, as McNeil had suggested.
Semb ( 1991 ) and Ross ( 1987 ) concluded that,
although the midface and mandible are posi-
tioned posteriorly within the face, the maxilla
is not retropositioned relative to the mandible
and that McNeil’s hypothesis that the maxilla
in complete clefts of the lip and palate is
retruded and needs to be brought forward was
in error.
CP 72
0–0–21
2–0–3
CP 139
0–0–21
2–0–14
Fig. 7.7 The fi rst 2 years of maxillary and mandibular
tracings of the cases with good (see Fig. 7.5 ) and bad (see
Fig. 7.6 ) facial growth are compared to show the reasons
for these evaluations. CP-72: Good facial growth. In this
case, the degree of premaxillary protrusion relative to the
lateral palatal segments (the anterior cleft space) was
markedly reduced with growth. Premaxillary protrusion
relative to the anterior cranial base was reduced as well.
CP-139: Poor facial growth. The degree of premaxillary
protrusion relative to the lateral palatal segments remained
the same, while the premaxillary protrusion relative to the
anterior cranial base increased (Courtesy of S. Pruzansky).
Comments: Although mandibular growth in the two cases
was similar in degree, the superimposed polygons show
that the vertical direction of growth of the “bad” grower’s
mandible and not its size was the determining factor for
the changes in the angle of facial convexity (NaPo).
Tension at PVS created by the lower lip positioned lingual
to the premaxilla increased premaxillary growth

143
7 Complete Bilateral Cleft Lip and Palate
7.4
Long-Term Facial Growth
Findings Show Class III
Outcomes Are Not Predictable
Semb ( 1991 ) conducted a serial lateral and fron-
tal cephalometric study of 90 cases from the
Oslo archives with bilateral cleft lip and palate.
Since 1962, the treatment procedure has involved
uniting the lip and closing the hard palate cleft
space in two stages. No presurgical orthodontics
were utilized because the surgeon and Bergland,
an orthodontist and director of the program,
believed that any bilateral cleft lip can be closed
without presurgical palatal manipulation. In the
period spanning 1950–1960, a von Langenbeck
procedure was performed to close the hard pal-
ate cleft between 3 and 4 years of age; after
1960, the timing of the closure was reduced to
18 months of age. Secondary alveolar bone
grafting using cancellous iliac crest bone was
performed prior to the eruption of the permanent
canine teeth.
Twenty- fi ve percent of the cases needed supe-
rior-based pharyngeal fl aps, which were per-
formed before the child started school. No
orthodontics were utilized in the deciduous den-
tition. Protraction headgear was used in the
mixed dentition in one third of the cases. Fixed
retention was necessary in all cases. Semb’s
study showed that: (1) the maxilla progressively
receded over time, (2) the mandible was retru-
sive with a steep mandibular plane with an
increased gonial angle, (3) anterior lower face
height was elongated and posterior facial height
reduced, and (4) the facial growth pattern was
notably different from the normal Bolton stan-
dards: (a) Male and female facial growth patterns
were similar except that the males’ linear dimen-
sions were larger, (b) the prominent premaxilla
would gradually realign in the preschool years,
and (c) surgical premaxillary setback was never
required. Berkowitz’s unpublished serial cast
cephalometric data support these statements
(unpublished data).
Vargervik ( 1983 ) cross-sectional study of 51
males with BCLP treated with a variety of pri-
mary procedures (excluding premaxillary set-
back) showed pro fi le values similar to those
reported by Hellquist et al. ( 1983 ) , Dahl ( 1970 ) ,
Smahel ( 1984 ) , Semb ( 1991 ) , and Friede and
Johanson ( 1977 ) . The Oslo team’s average for
maxillary prominence and lower face height were
slightly more favorable. Narula and Ross ( 1970 ) ,
reporting cross-sectional data on thirty 6-year-
old subjects and mixed longitudinal data on 34
subjects with BCLP treated conventionally with-
out surgical setback and vomer fl ap, concluded
the maxillary length reached normal values at
16 years of age.
In the Swedish sample followed longitudinally
by Hellquist et al. ( 1983 ) , similar facial convexity
was also noted, although both the maxilla and
mandible were reported to be slightly more
prominent. The patients analyzed by Hellquist
et al. ( 1983 ) had a two-stage lip closure, push-
back palatoplasty, and, at an average age of 6, a
delayed periosteoplasty.
Friede and Johanson ( 1977 ) reported facial
growth in 13 Swedish children with bilateral
clefts of the lip and palate (BCLP), fi ve at age 7
and eight at age 10 years. The patients, who had
had lip adhesion and vomer fl ap (without pre-
maxillary setback) and velar closure with push-
back, also exhibited facial convexity similar to
the Oslo sample.
Friede and Pruzansky ( 1972 ) , Bergland and
Borchgrevink ( 1974 ) cephalometric reports of 27
North American children in three treatment
groups who were followed to 17 years of age do,
however, show some differences in comparison
with the Oslo sample. Six subjects treated by
early premaxillary setback and seven treated by
late setback (3–8 years of age) had pro fi le values
similar to those reported by the Oslo group.
However, 14 subjects with no premaxillary set-
back had average values signi fi cantly more con-
vex than those reported for the Oslo and other
samples. None of the North American subjects
had had vomer fl aps, and it is implied that a more
convex facial pro fi le will be obtained if vomer-
plasty is excluded from primary surgery.
Also, the negative growth affect of the surgical
premaxillary setback may become evident at a
later age.

144
S. Berkowitz
7.5
The Vomer Flap: Good or Bad?
Are All Vomer Flaps the Same?
Semb ( 1991 ) report on the longitudinal data of the
Oslo group is critical of those who condemn the
vomer fl ap. She states that the possible growth-
retarding effect of a vomer fl ap has been discussed
by several authors (Friede and Pruzansky 1972 ;
Friede and Morgan 1976 ; Friede and Johanson
1977 ; Pruzansky and Aduss 1967 ; Blocksma et al.
1975 ; Delaire and Precious 1985, 1986 ; Friede
et al. 1987 ; Molsted 1987 ; Enmark et al. 1990 ) .
Friede and Pruzansky ( 1972 ) observed more
favorable growth in patients treated without a
vomer fl ap; however, this is not a uniform fi nding
in the comparative studies. Some clinical centers
not using a vomer fl ap have shown results similar
to those where a vomer fl ap has been utilized. The
extent to which the observation of a growth-
retarding effect of a vomer fl ap can be generalized
remains in some doubt and may re fl ect other vari-
ations in sample composition or surgery.
The effects of a vomer fl ap on facial growth
have also been considered by the Oslo CLP team
(Molsted 1987 ) which reported the fl ap to be
clinically insigni fi cant. Only one patient in their
sample of 90 cases exhibited any degree of max-
illary retrusion where surgical maxillary advance-
ment was judged necessary.
In the opinion of the Oslo team, a vomer fl ap
provides the particular advantages of early sepa-
ration of the nasal and oral cavities without
arti fi cial obturators, a low prevalence of symp-
tomatic fi stulae, an acceptable arch form, and a
good foundation for mixed dentition alveolar
bone grafting (Bergland et al. 1986 ) .
Berkowitz’s fi nding of serial complete bilat-
eral cleft lip show results similar to those of the
Oslo group. A modi fi ed vomer fl ap was used in
conjunction with a von Langenbeck procedure.
He believes that the negative effect of a vomer
fl ap on midfacial growth and arch form, as
described by Prysdo et al. ( 1974 ) , has not been
conclusively proven. Patients who have needed
LeFort I advancement of only the lateral palatal
segments have had very large anterior cleft spaces
in the permanent dentition even after the poste-
rior hard palate had been surgically closed at
18–24 months of age with a vomer fl ap. The pre-
maxillae in these cases were in good overbite-
overjet relationships prior to moving the palatal
segments into a Class II relationship to close the
missing lateral incisor(s) space. Other times, the
lateral incisor spaces are left open.
7.5.1 External Elastics Attached to a
Head Bonnet or Elastic Tape
Strapped to the Cheeks (Fig. 7.9 )
These force delivery systems will reduce pre-
maxillary protrusion prior to lip surgery and only
need to be utilized for approximately 1 or
2 weeks. Elastic forces exert the same backward
pressure against the protruding premaxilla as a
lip adhesion. There are no valid reasons to object
to the use of external facial elastic traction with
arm restrains to prevent its removal forces for
1–2 weeks prior to lip surgery.
7.5.2 Uniting the Lip
(Figs. 7.8 , 7.9 , and 7.10 )
In all complete clefts of the lip and palate at
birth, the wide dislocation of the lateral palatal
segments coupled with the protruding premaxilla
can be gradually overcome by following a treat-
ment protocol that allows the palatal segments
to move into proper orientation by the applica-
tion of the physiological forces of a united lip
without the need for presurgical orthopedic
treatment. Lip adhesion is followed by de fi nitive
lip surgery and observation of facial and pala-
tal changes (Fig. 7.8 ). If necessary, later surgi-
cal premaxillary setback, or surgically moving
the lateral palatal segments forward to close a
very large persistent anterior cleft space, can be
considered.
Clinicians who favor this procedure believe
the degree of midfacial protrusion will decrease
with facial growth under the in fl uence of the mid-
facial growth-restraining forces of the united lip
(Friede and Pruzansky 1972 ; Berkowitz 1959 ;
Coup and Subtelny 1960 ; Pruzansky 1953 ;
Vargervik 1983 ; Wolfe and Berkowitz 1983 ;
Mazaheri et al. 1971 ; Bishara and Olin 1972 ;
Aduss et al. 1974 ) .

145
7 Complete Bilateral Cleft Lip and Palate
Findings by Bishara and Olin ( 1972 ) and
Aduss et al. ( 1974 ) support the conclusions drawn
from earlier facial growth studies by Berkowitz
( 1959 ) , Friede and Pruzansky ( 1972 ) , Handelman
and Pruzansky ( 1968 ) , and Vargervik ( 1983 ) that
the protruding premaxilla tends to be molded
back by lip pressure and can sometimes be
aligned within the lateral palatal segments with-
out resorting to neonatal maxillary orthopedics.
If not, then the premaxilla in most cases can be
aligned within the arch in the deciduous dentition
using a fi xed orthodontic quad helix appliance.
The use of lip adhesion within the fi rst
3 months followed by a de fi nitive lip revision,
usually within the fi rst 6 months of age, permits
the surgeon to perform surgery in stages as the
face changes. Logan’s bow can be used to reduce
the strain at the lip suture when the de fi nitive lip
surgery is performed. Surgeons who favor stage
treatment procedure are willing to postpone
obtaining a maximum early aesthetic result for
what they believe will offer superior long-term
bene fi ts. The most severe unaesthetic premaxil-
lary overbite in the deciduous and mixed (transi-
tional) dentition, even with a buccal crossbite,
a
b
c
Fig. 7.9 ( a – c ) A head bonnet with an elastic strap (exter-
nal facial traction) placed against premaxilla is an ef fi cient
and painless procedure to ventro fl ex the premaxilla prior
to lip surgery. ( a ) At birth. ( b ) With head bonnet in place.
( c ) After lip repair. The head bonnet aids the surgeon in
reducing tension at the lip suture site. The force generated
at PVS is less than that created by using mechanical pre-
maxillary retraction (see Chap. 20 )
Fig. 7.8 Various surgical techniques used to unite the lip
in BCLP. Experience has shown that the best results are
obtained when the prolabium is used to construct the
entire midportion of the lip (From Millard 1980 )

146
S. Berkowitz
a
c
b
Fig. 7.10 ( a – c ) Use of the prolabium for the center por-
tion of the lip. IBCLP. ( a – c ) Facial photographs at 20 days,
3 and 18 months. The banked forked fl ap (Millard): the
tissue in the nostril is used to lengthen the columella at a
later date. The procedure avoids going back to a good lip
for tissue to reconstruct the columella
will not interfere with dental function or
swallowing or have any long-term deleterious
effects on speech and midfacial growth.
Serial facial photographs indicate that surgi-
cal procedures that use the entire prolabium for
the central portion of the lip produce the best
aesthetic results. A long tight lip is the predict-
able result when the lateral lip elements are
brought together beneath the prolabium (see
Fig. 7.10a , b ).
7.6
Pro fi le Changes (Figs. 7.14 , 7.15 ,
7.16 , 7.17 , and 7.18 )
Hanada and Krogman ( 1975 ) , Berkowitz ( 1959 ) ,
Bishara and Olin ( 1972 ) , Boyne ( 1974 ) , Vargervik
( 1983 ) , Handelman and Pruzansky ( 1968 ) , Friede
( 1977 ) , Semb ( 1991 ) , and Narula and Ross ( 1970 )
all have performed longitudinal studies of the
changing soft tissue pro fi le of bilateral cleft lip
and/or palate (BCL/P) and reported that, with the

147
7 Complete Bilateral Cleft Lip and Palate
slow resolution of the protruding premaxilla with
growth, the pro fi le became more harmonious in
appearance. In the Oslo study of BCLP, Semb
( 1991 ) concluded that early dentofacial orthope-
dics were not a necessary precursor to lip and
palate closure in order to attain long-term posi-
tive pro fi le changes.
Serial pro fi le analyses of cast and cephalo-
graphs reported in Berkowitz’s earlier studies and
the serial studies presented in this text demon-
strate that, during the fi rst 2 years following sur-
gery, the united lip exerts a posteriorly directed
pressure force on the protruding premaxilla. He
speculates that this force is exerted through the
nasal septum to the premaxillary-vomerine
suture, gradually retarding the forward and verti-
cal growth of the nasal septum with the attached
premaxilla. The growth of the lateral palatal seg-
ments does not appear to be affected by this force.
Inhibition of midfacial growth coupled with for-
ward and vertical growth of the upper face and
mandible is responsible for the eventual fl attening
of the facial pro fi le (Figs. 7.5 and 7.6 ).
Protrusion of the midface is only slightly
reduced by the reduction-remodeling of the labile
surface of the premaxilla associated with the
eruption of the permanent incisors. Facial growth
data suggest that the tendency toward mandibular
prognathism can be considered advantageous,
insofar as it reduces the earlier protrusion of the
premaxilla. Comparison of the pro fi le changes in
children whose lips were united at 6 years with
infants whose lips were united soon after birth
showed less premaxillary protrusion for children
whose lips were repaired in infancy. This suggests
that the bene fi cial effect of lip repair is long-act-
ing in that it continues to exert a restraint on the
growth of the premaxillary-vomerine complex
long after the lip is repaired (Friede and Pruzansky
1972 ; Berkowitz 1959 ; Vargervik 1983 ) .
After the lip is united, there are no docu-
mented long-term bene fi ts to using intraoral
neonatal maxillary orthopedics to control the
premaxilla’s position relative to the lateral pala-
tal segments (i.e., to inhibit the palatal segments
from spontaneously moving together) nor is it
important that the premaxilla be accommodated
within the arch at this time. There is no evidence
that overlapping palatal segments suffer growth
inhibition. In most cases, proper premaxillary
alignment within the lateral palatal segments can
be easily achieved with orthodontics in decidu-
ous or mixed dentition without resorting to neo-
natal maxillary orthopedics. The following cases
show that orthodontics in the permanent denti-
tion, in the absence of growth-inhibiting palatal
surgery, and with a good or poor facial growth
pattern eventually will lead to excellent facial
aesthetics and dental function. Any resulting
buccal crossbite can be easily corrected at 4 or
5 years of age, when the child is manageable in a
dental chair, using fi xed tooth-borne or even
removable arch expansion appliances. The author
strongly favors the use of fi xed appliances for
arch expansion and retention.
There are many occasions when the pro fi le
shows midfacial retrusion due to severe
ventro fl exion of the premaxilla. As long as dur-
ing the mixed dentition gingivoperiosteoplasty
has not been performed (see Chap. 20 ), the pre-
maxilla can easily be brought forward orthodon-
tically and held in place until alveolar bone
grafting is performed. Retention of the corrected
maxillary arch is still necessary until orthodon-
tics are completed (Fig. 7.11 ).
7.6.1 Why Some Premaxillae Continue
to Project Following Lip Repair
and Others Do Not
The cases being presented will show that there
are a number of treatment planning facial factors.
For example, the patient’s facial growth pattern
and the amount of palatal osteogenic de fi ciency
are beyond the control of the surgeon. The
integrated growth of the entire face is important
to resolve the pro fi le deformity. When the end
result is unfavorable – that is, the facial pro fi le
remains highly convex – the premaxilla and the
body of the maxilla usually have grown forward
with limited forward mandibular projection or
tension has been created at the PVS, causing fur-
ther premaxillary protrusion.
Facial growth studies by Handelman and
Pruzansky ( 1968 ) and by Berkowitz (presented

148
S. Berkowitz
in this chapter) have shown that, in highly con-
vex facial pro fi les with a moderately protrusive
premaxilla and a recessive mandible, the lip
musculature usually is hypertonic and positioned
over the upper incisor teeth, resulting in severe
premaxillary ventro fl exion. In mesognathic
faces with isotonic or hypotonic lip musculature
and a severely projecting premaxilla, the lower
lip may be positioned lingual to the premaxilla
and between the upper and lower incisors, creat-
ing an anterior component of force at the pre-
maxillary-vomerine suture (PVS). This may
cause additional bony growth at the suture, lead-
ing to greater premaxillary protrusion with a
normal maxillary incisal axial inclination. The
lower incisors may be tipped lingually (Figs. 7.11
and 7.12 ).
The serial record present in the case reports to
follow will show that it can be anticipated that in
most cases (53 out of 59 CBCLP; S Berkowitz,
unpublished data), good faces will have devel-
oped at adolescence. Figure 7.14 shows serial
computer-generated CBCLP palatal cast outlines
which were superimposed on the palatal rugae
and registered on the vomer. All of these cases
had the palate closed between 18 and 24 months
using a von Langenbeck with modi fi ed vomer
fl ap (it was readily observed at every age period).
This illustration clearly demonstrates that the
premaxilla is in the same place in the palate at
adolescence as it was at birth. It is retained in
place by the surrounding facial musculature in
most cases. There are exceptions, usually depen-
dent on the balance of the facial musculature.
Age
5–9
Age
7–6
17 mm
cc
27 mm
inter – inc 183°
inter – inc 145°
mm
25 mm
cc
37 mm
mm
Fig. 7.11 Before and after line drawings demonstrating
the use of orthopedics for the correction of a malocclusion
in a BCLP. 5–9 Frontal and lateral tracings of a child with
a bilateral cleft lip and palate before orthopedic treatment.
Intracuspid width was 17 mm, intramolar width was
27 mm, and the interincisal angle was 183°. 7–6 After pre-
maxillary advancement and buccal expansion, the intrac-
uspid width changed to 25 mm, intramolar width to
37 mm, and the interincisal angle to 145°. All changes in
measurements were dependent on the bodily (orthopedic)
movement of the bony segments and not on the movement
of teeth (orthodontics). After the palatal segments are
properly aligned, the movement of teeth will follow.
While waiting for the permanent teeth to erupt, the new
arch form needs to be retained with a fi xed appliance

149
7 Complete Bilateral Cleft Lip and Palate
7.6.2 Dental Occlusion
Analyses of the dental occlusion of many patients
with complete bilateral clefts of the lip and palate
at 6 years of age rarely show retruded maxillary
shelves (i.e., a Class III relationship) (Berkowitz
1959 ) . The buccal teeth are most often in a Class
I or II relationship. A Class III relationship exists
only if the maxilla is retrusive due to severely
retarded growth caused by traumatic surgery and/
or the patient’s phenotype. The mandible is rarely
prognathic at this age. In many cases, due to pala-
tal osteogenic de fi ciency and severe dental crowd-
ing in the maxillary arch, some teeth may need to
be extracted. This may or may not have to be done
in the mandibular arch. There is conclusive evi-
dence to suggest that the cleft palatal shelves may
be de fi cient in mass, but there is no evidence that
they have lost their growth impetus from having
been detached from the growing nasal septum.
Until proven otherwise, the surgeon should
have con fi dence that the severe facial convexity
seen at birth can diminish with time as the united
lip restrains the forward development of the mid-
Fig. 7.12 ( a – f ) Millard’s surgical lip procedure uses the
prolabium to construct the entire midportion of the lip
over the protruding premaxilla. This case was selected to
show an example of upper lip protrusion that can result
due to a severely protruding premaxilla. This case and
others presented in this chapter will show how the face
improves with time, that is, facial growth
a
b
c
d
e
f

150
S. Berkowitz
face, while the mandible increases in size and is
positioned more downward and forward relative
to the growing anterior cranial base and
midface.
7.6.2.1 After Birth
In general, no presurgical orthopedics were pro-
vided other than the use of a head bonnet. In
complete bilateral cases only, an external facial
elastic may be utilized to ventro fl ex the protrud-
ing premaxilla to reduce tension at the surgical
site when utilizing lip adhesion. External traction
is usually not necessary in incomplete clefts of
the lip and palate.
The Forked Flap (Fig. 7.13 )
All of the bilateral cases were treated with
Millard’s forked fl ap (Millard 1978a ) . It was
designed to lengthen the columella as a primary
or secondary procedure. Advantages include:
Release of depressed nasal tip
•
Lengthen the short columella
•
Reduce an unattractive wide prolabium
•
Revision of bilateral lip scars
•
Reduction of fl aring alar bases
•
Millard ( 1978a, b ) suggests that the primary
fork fl ap procedure is not appropriate for all bilat-
eral cleft cases. Whether to use the procedure
depends on: (1) The position of the premaxilla. It
should not be used when the premaxilla is severely
protruded. (2) The size of the prolabium. The
width of the prolabium determines whether the
fl ap is possible, and the vertical length indicates
the amount of columella lengthening available.
(3) Columella length. This discrepancy must be
measured not only in actual length in millimeters
First stage
Third stage
Whiskers
Second stage
B
A
B
B
A
B
B A
B
c
c
c
c
c
c
Primary forked flap
Fig. 7.13 In 1956–1957, Millard designed a secondary
forked fl ap for columella lengthening. He believed at times
it is best to take a little tissue from the prolabium and the
lip and store it in the area for later use in reconstructing the
columella. The forked fl ap was originally designed as a
secondary procedure; however, it can be used as a primary
procedure when the columella is extremely short and the
prolabium is of reasonable size. Top : In the primary forked
fl ap, the fork fl ap is elevated and advanced into the colu-
mella with release of the nasal tip. Bottom : The whisker
fork fl ap involves joining the lip muscle and banking the
fork. The alar bases are joined together in the midline, and
the forks partially tubed on themselves and led into the
transverse incisions between the lip and alar bases, whis-
ker fashion. This surgery is delayed several years. Millard
likes this procedure best of all

151
7 Complete Bilateral Cleft Lip and Palate
S.A.
AY–46
AH–62
AI–53
B.G.
V.L.
D.K.
AI–31
6–5
0–1
16–3
13–0
0–0–23
9–0
17–0
19–0
8–8
0–1
7–0
0–1
Fig. 7.14 Computerized digital tracings
of the perimeter of the outline of CBCLP
palatal casts superimposed on the palatal
rugae and registered on the vomer. Palatal
cleft closure between 18 and 24 months
using a von Langenbeck and vomer fl ap.
Note that the premaxilla is held in
place, while the palate grows in all
directions; posterior palatal growth
occurs to accommodate the developing
molars. None of these cases were treated
with presurgical orthopedics
Axial inclination of maxillary central incisor
(1mx to SN )
746 ♀
742 ♂
174 ♂
4–8–13
5–2–16
3–11–13
Fig. 7.15 In spite of the lip surgery performed, the posi-
tion of the premaxilla in the anterior dentition is determined
by the facial pattern and tonicity of the surrounding facial
musculature. Case #746: Protruding premaxilla surrounded
by hypotonic lip musculature. Case #742: Retrognathic
mandible with protrusive premaxilla. The lower lip is posi-
tioned between the upper and lower incisors creating a for-
ward force at the PVS. The resulting increase in tension at
the PVS stimulates additional growth and causes increase
in inclination of the upper incisors. Case #174: Retrognathic
mandible with less premaxillary protrusion hypertonic lip
musculature creating severe lip pressure which ventro fl exes
the premaxilla. Variations in premaxillary position are
unpredictable (Handelman 1968 )

152
S. Berkowitz
Fig. 7.16 Early premaxillary
surgical setback and palatal cleft
closure at 7 months of age. The
lateral lip elements were brought
together below the prolabium. Results
at 7 years of age: (1) long tight upper
lip, (2) anterior open bite due to
failure of the premaxilla to descend
with the palate, and (3) the surgery
(pushback) used to close the palatal
cleft at 7 months obliterated the vault
space interfering with tongue posture.
The tongue is, therefore, being
carried forward with the tongue tip
protruding, preventing the incisors
from reaching the occlusal plane
a
b
c
Fig. 7.17 ( a – c ) The lateral lip elements were brought below the prolabium creating a long tight lip
Fig. 7.18 ( a , b ) Good facial growth pattern with hyper-
tonic lip musculature. a Lateral cephalometric tracing shows
a gradual increase in the angle of facial convexity (NaPo)
from 116° to 169° with the greatest change (159–169°)
occurring between 5 and 6 years, 5 months of age. At 5 years,
the axial inclination of the anterior teeth is vertical with an
appreciable incisor overjet. However, at 6 years, 5 months,
the premaxilla is palatally inclined, placing the upper and
lower incisors in a tip-to-tip relationship. This usually occurs
with a relatively retrognathic mandible when the lower lip
also overlaps the upper incisors, increasing the muscle pres-
sure against the premaxilla. If the lower lip is positioned
between the upper and lower incisors, the premaxilla with its
incisors will fl are. ( b ) Superimposed polygons show a very
small mandible with a protruding premaxilla at 0–1–18.
There is a marked anterior growth of the anterior cranial base
( N ) and, together with the mandible’s vertical and horizontal
growth changes, a reduction in the angle of facial convexity.
Note that there is very little change in premaxillary protru-
sion within the face between ages 1–2–22 and 7–8–12

153
7 Complete Bilateral Cleft Lip and Palate
a
CP #127 ♀
0–1–18
3–5–23
0–1–18
1–2–22
1–7–26
7–8–12
4–5–23
5–0–12
6–5–3
7–8–12
N∝
116°
125°
140°
144°
145°
145°
149°
0–5–12
0–9–0
1–2–22
1–7–26
2–1–15
2–11–4
b
175°
169°
159°
156°
156°
CP #127
Co
Po’
Po’
a
a
♀

154
S. Berkowitz
of the columella, but an estimation of the patient’s
desired fi nal length must also be made.
There are occasions where the forked fl aps
from the prolabium are banked with a subalar
incision, whisker fashion. The alar base is not
advanced medially in an attempt to leave a subalar
gap in which to store the forks. Millard delays
shifting of the banked forked fl ap into the columella
for several years (from 6 months to 6 years).
7.6.2.2 In the Deciduous Dentition
(3–6 Years of Age)
The purpose of treatment at this age is to align the
palatal segments in order to obtain a more normal
contour to the alveolar ridge, reshape the palatal
vault, and provide a more symmetrical founda-
tion for the support of the lips and nose. These
changes are possible because orthodontic treat-
ment in cleft palate allows for the movement of
palatal segments when using a von Langenbeck
procedure in addition to altering the position of
the teeth within the alveolus. Because the roof of
the mouth is also the fl oor of the nose, realign-
ment of the palatal processes not only produces
desirable alteration in the contour of the palate
but also induces similar changes within the fl oor
of the nose.
Most clinicians agree that nontraumatic con-
servative surgery will not solve all problems for
all complete bilateral cleft lip and palate cases.
Although buccal crossbites can be corrected in
the deciduous dentition, some advocate orthodon-
tic/orthopedic repositioning of the premaxilla at a
later age (in the mixed dentition prior to or after
secondary alveolar bone grafting) when the facial
growth pattern leaves no alternative and dictates
that it is the procedure of choice. Some orthodon-
tists prefer to do this in the permanent dentition.
7.6.2.3 Mixed Dentition
(6–11 Years of Age)
When a child with a cleft starts elementary
school, even if the protruding premaxilla still
extends far forward of the lateral palatal segment
creating a severe convex facial pro fi le, a surgical
premaxillary setback should be considered solely
for aesthetic reasons because there can be long-
term deleterious effects. This decision is a
dif fi cult one. One is damned if one does or
doesn’t! One has to balance the child’s social and
psychological needs with long-term facial devel-
opmental factors.
In the last 20 years, many reports published
with improved documentation were critical of
surgical premaxillary setback performed in the
newborn period, or even in early adolescence
prior to the prepubertal growth spurt. Fortunately,
these criticisms led to abandonment of this pro-
cedure (Vargervik 1983 ) .
Orthodontics applied during the mixed denti-
tion, in preparation for or after secondary alveolar
bone grafting (the placement of bone in the alveo-
lar cleft after the fi rst year of age), can aid in reduc-
ing the premaxillary overbite and maintaining the
premaxilla within the lateral palatal segments.
Eliminating the alveolar cleft permits the unerupted
teeth (lateral incisors and cuspids) adjacent to the
cleft to erupt or be moved into proper position.
In Berkowitz’s experience, a protruding pre-
maxilla – with or without a large anterior cleft
space – at 6–7 years of age does not signify that
the same unpleasant aesthetic conditions will
persist into adolescence. After the pubertal facial
growth spurt, when the facial convexity is mark-
edly reduced because of increased mandibular
and upper facial growth, facial aesthetics will be
greatly improved in most patients.
There is strong psychosocial pressure on clini-
cians to improve facial aesthetics as soon as pos-
sible, even when the premaxilla cannot be
retropositioned in the absence of an anterior cleft
space. For this reason, many unsuccessful
attempts have been made to surgically or mechan-
ically set the premaxilla back at an early age in
the hope of preventing an unaesthetic midface at
a later age, believing the midfacial growth would
still be normal. At this dif fi cult period, every
effort should be made to convince both the par-
ents and the child, using before and after photo-
graphs, that facial aesthetics will greatly improve
as the face grows and that the long-term bene fi ts
far outweigh any early improvements at the
expense of future good facial growth.
7.6.2.4 At Adolescence
If a poor facial growth pattern at adolescence with
a large anterior cleft space leads to a protruding
premaxilla set well forward in the facial pro fi le
and the mandibular incisors, the premaxilla can
be surgically set back. A secondary alveolar bone

155
7 Complete Bilateral Cleft Lip and Palate
graft is simultaneously performed to close the
remaining anterior cleft space. A fi xed palatal
retainer or a heavy labile arch wire must be uti-
lized for at least 2 months as a supporting splint
for the three segments during the healing period.
There are cases in which both buccal segments
are in a Class I relationship, a large anterior cleft
space is present, and the premaxilla is missing one
or both lateral incisors, yet it is in an ideal overjet
and overbite relationship. If the surgeon believes
that the anterior cleft space is too large to be suc-
cessfully closed by a secondary alveolar bone
graft, the only remaining option is to surgically
advance one or both palatal segments, placing the
buccal teeth in a Class II relationship with at least
one, but sometimes both, of the cuspids in the lat-
eral incisor space. This usually necessitates the
surgical increase in posterior transpalatal width. A
secondary alveolar bone graft is performed at the
same time (Posnick and Tompson 1993 ) .
There are too many variations of orthodontic
problems to review each of the treatment plans
separately. However, in most cases, a common
treatment sequence is usually followed. First, the
posterior palatal crossbite needs to be orthopedi-
cally corrected in the deciduous or mixed dentition
using quadhelix mechanics. Reducing maxillary
arch crowding by tooth extractions may be neces-
sary due to the lack of palatal osteogenic tissue.
Achieving ideal anterior teeth aesthetics often
requires that the lost lateral incisor spaces be
recovered for the eruption of impacted lateral inci-
sors or cuspids. In most cases, establishing room
for four maxillary incisors by expansion and slight
incisor advancement is the ideal treatment. A
slightly retrusive maxilla with mild crowding may
require the advancement of the upper jaw using
protraction forces for at least 6–12 months to
obtain an ideal anterior overbite-overjet relation-
ship. In some instances, the extraction of one lower
incisor to correct the mandibular anterior arch will
be necessary to reduce an anterior crossbite.
In all cleft types, involving the lip and palate,
orthodontic surgical treatment decisions are often
dictated by the relationship of the premaxilla to the
lateral palatal segments and the facial growth pat-
tern (i.e., whether the face is prognathic, mesog-
nathic, or retrognathic). For example, if a slightly
retruded maxilla and a retrognathic mandible
coexist, it may be necessary to surgically advance
the lower jaw with or without doing the same to
the maxilla. In most cases, orthopedic protraction
to move the maxilla should be considered fi rst.
If one or both maxillary buccal teeth are in a
Class II relationship and one or both lateral inci-
sors are absent, it is advantageous to move one or
both cuspids into the lateral incisor space after
secondary alveolar bone grafting. Eruption of the
maxillary cuspids with its supporting alveolar
bone usually closes off any remaining anterior
cleft space. In very rare instances, when a large
anterior cleft space exists and there is insuf fi cient
mucoperiosteum to close this space and a good
anterior overbite-overjet relationship exists, the
treatment of choice is to advance one or both
palatal segments to make contact with the well-
positioned premaxilla. A secondary alveolar bone
graft can be performed at the same time (Posnick
and Tompson 1993 ) (Fig. 7.59).
After the pubertal facial growth spurt, the once
protruding premaxilla usually is no longer an
aesthetic problem. Not surprisingly, at this age,
the midface may be retruded even if the premax-
illa was not surgically or mechanically set back
and especially if there is good upper and lower
facial growth. Treatment now needs to be focused
on advancing the midface and/or the premaxilla
using either orthopedic forces from a protraction
facial mask or a maxillary osteotomy (LeFort I
advancement).
In 30 years of clinical experience, surgical
premaxillary retropositioning was performed
only twice and only for aesthetic demands. It was
never necessary to reduce its protrusion at the
adult stage. Facial growth (time) ultimately is the
surgeon’s and orthodontist’s best friend – and a
most trenchant critic.
7.6.2.5 Retention
Permanent retention of the maxillary arch form
in all clefts of the lip, alveolus, and palate is
sometimes necessary even after secondary alve-
olar bone grafting, depending on the extent of
transpalatal scarring and lip-cheek pressure. It
requires either a removable palatal prosthesis or
preferably a fi xed bridge spanning the cleft. Arch
collapse with a return of buccal and/or anterior
crossbite can occur rapidly in the presence of
extensive lip and transpalatal scar tissue because
scar tissue has limited stretch capability.

156
S. Berkowitz
7.7
The Following Case Studies
Represent Conservative
Surgical and Orthodontic
Treatment Sequence
Cleft lip and cleft palate defects offer a degree of
habilitation that is not available for many equally
serious congenital or acquired handicaps.
Achieving this potential requires careful planning
and skillful execution of treatment that respects
individual growth patterns (Table 7.1 ). The
following cases were selected to show various
treatment procedures, some of which were unsuc-
cessful but nevertheless have teaching value
because they re fl ect on physiological principles
(Figs. 7.19 , 7.20 , 7.21 , 7.22 , 7.23 , 7.24 , 7.25 ,
7.26 , 7.27 , 7.28 , 7.29 , 7.30 , 7.31 , 7.32 , 7.33 , 7.34 ,
7.35 , 7.36 , 7.37 , 7.38 , 7.39 , 7.40 , 7.41 , 7.42 , 7.43 ,
7.44 , 7.45 , 7.46 , 7.47 , 7.48 , 7.49 , 7.50 , 7.52 , 7.52 ,
7.53 , 7.54 , 7.55 , 7.56 , 7.57 , 7.58 , 7.59 , 7.60 , 7.61 ,
7.62 , 7.63 , 7.64 , 7.65 , 7.66 , 7.67 , 7.68 , 7.69 , 7.70 ,
7.71 , 7.72 , and 7.73 , Tables 7.2 , 7.3 ).
Table 7.1 Timing and sequencing of surgical-orthodontic treatment (conservative)
Age
Orthodontics
Surgery
After birth
CBCLP external elastics (off head bonnet) over protruding
premaxilla – no obturator
3–4 weeks
Lip adhesion
6 months
Millard forked fl ap
18–30 months
von Langenbeck a (simultaneous
closure of the hard and soft palate)
4–5 years
Correction of buccal crossbite only using a fi xed quad helix
palatal expander
5–7 years
Fixed palatal retention
7–8 years
Align anterior teeth prior to secondary alveolar bone graft
(SABG)
Secondary bone graft using cranial
or iliac crest bone
9–13 years
Full-banded treatment with or without maxillary protraction
(Delaire face mask)
Nasal tip revision
13–17 years
Full orthodontics. Evaluate need for surgical orthodontics
Maxillomandibular surgery b
(Distraction osteogenesis or Lefort I)
Nasal-lip revision
17–18 years
Postsurgical orthodontics followed by prosthetics
Nasal-lip revisions
a Timing of palate closure depends on the width of the cleft space relative to the adjoining palatal surface area. Anterior
cleft is left open.
b Maxillomandibular surgery is usually performed earlier for females (around 15–16 years of age) than males whose
surgery is performed during the summer prior to the senior high school year. This allows for maximum facial growth
changes and leaves enough time to perform postsurgical orthodontics and prosthetic treatment.
a
b
c
Fig. 7.19 ( a – i ) Case TM (WW-9) demonstrates excel-
lent facial and palatal growth changes in an incomplete
bilateral cleft lip and palate treated conservatively (no
PSOT). ( a ) Newborn. ( b ) At 7 months after lip closure.
( c ) 4 years, 2 months. Note buccal crossbite on the left
side. The crossbite was corrected by 4 years, 7 months
using a fi xed palatal expander

157
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.19 (continued)
d
g
i
h
e
f
( d ) At 8 years after the central
incisors were aligned and a secondary alveolar bone graft
was performed at 7 11/42 years. Note that lateral incisors
are erupting through the graft. ( e ) Palatal view at 7
11/42 years. ( f ) Full face at 17 years. ( g ) Close-up of lip.
( h ) Occlusion at 17 years after orthodontics. ( i ) Palatal
view showing good vault space with minimal scarring

158
S. Berkowitz
Fig. 7.20 Case TM (WW-9). Serial palatal cast changes
when no presurgical orthopedics were utilized. 0–1
Newborn, prior to lip surgery. 0–4 After lip adhesion, the
lateral palatal segment moved medially behind the
premaxilla. 0–8 The cleft space is much smaller and
continues to decrease in size with palatal growth. The
premaxillary position at this age poses no treatment or
growth problem. 1–2 The palatal cleft was closed with a
modi fi ed von Langenbeck procedure. 1–9 Ideal incisal
overbite and overjet. 2–6 and 4–2 Left buccal crossbite
which was corrected at 4–6 using a fi xed palatal expander.
4–7 Good occlusion

159
7 Complete Bilateral Cleft Lip and Palate
4–11 Outline of fi xed palatal
retainer is seen on the case. Note that the premaxilla is
now positioned within the palatal segments. 6–2 The cen-
tral incisors in the area of the cleft are frequently found to
be rotated. 8–0 Six months after a secondary alveolar
cranial bone graft. The right and left lateral incisors have
erupted through the graft. 10–5 The lateral incisors are
aligned with the central incisors. 15–5 Excellent occlu-
sion after orthodontia. A removable maxillary retainer is
being used to maintain the arch form
Fig. 7.20 (continued)

160
S. Berkowitz
SNA
4–9
Case. #MT . ww–9
a
b
6–4
83.41
72.11
156.11
11.23
82.58
74.68
162.40
8.06
SNPo
NAPo
ANB
7–9
19–8
14–11
SNA
SNPo
NAPo
ANB
SNA
79.83
78.08
167.27
3.05
77.51
77.30
179.56
2.12
82.58
74.68
162.40
8.06
SNPo
NAPo
ANB
SNA
SNPo
NAPo
ANB
SNA
SNPo
NAPo
ANB
Fig. 7.21 ( a , b ) Case TM (WW-9). This series depicts an
excellent facial growth pattern. ( a ) Computerized tracings
of facial skeletal and soft tissue pro fi le changes. At 14–11,
the pro fi le measurements are well within the normal
range. ( b ) Facial polygons superimposed on the SN line
and registered at S demonstrate that the excellent facial
growth pattern re fl ects some anterior cranial base growth,
very little forward growth of the midface, and excellent
mandibular growth in a downward and forward direction.
Note that the midface was still protrusive at 7–9, but after
the mandibular pubertal growth spurt (13–8), the facial
pro fi le fl attened markedly
s
N
a, A
Go
Gn
4–9
6–4
7–9
13–8
14–11
Fig. 7.22 Case TM (WW-9) Computerized tracings of
facial skeletal and soft tissue pro fi le changes. At 14–11,
the pro fi le measurements are well within the normal
range. Facial polygons superimposed on the SN line and
registered at S demonstrate that the excellent facial growth
pattern re fl ects some anterior cranial base growth, very
little forward growth of the midface, and excellent man-
dibular growth in a downward and forward direction. Note
that the midface was still protrusive at 7–9, but after the
mandibular pubertal growth spurt (13–8), the facial pro fi le
fl attened markedly

161
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.23 ( a – q ) Case DK (AI-31) demonstrates unsuc-
cessful use of Latham’s presurgical premaxillary mechan-
ical retraction procedure in a CBCLP, which then required
the use of external facial elastics prior to lip surgery. ( a )
At birth, note the very small protruding premaxilla. ( b )
Facial photograph with Millard-Latham (M-L) mechani-
cal premaxillary retraction appliance in place. ( c ) Intraoral
view of M-L appliance in place. The appliance was not
able to retract the premaxilla due to its small size and was
discarded. ( d ) After wearing a head bonnet with an elastic
strap for 2 weeks, the lip was united over the premaxilla.
At 2 months, the nasal tip is severely depressed. ( e ) At
3 years of age, the banked tissue of the “forked fl ap”
waiting to be placed in the columella. ( f ) 5 years of age.
Note excellent occlusion. Radiographs showed that there
were no permanent incisors in the premaxilla. ( g , h ) At
8 years of age, the nasal tip has been elevated, but there is
poor upper lip support due to the now retruded premaxilla.
Lower right and left fi rst bicuspids were extracted at
13 years to reduce the anterior crossbite. ( i – k ) At 15 years
of age, the mandible is growing forward at a more rapid
rate and degree than the maxilla. The earlier buccal and
anterior crossbites were corrected, and two lateral incisors
from the lateral palatal segments were brought into posi-
tion, improving facial aesthetics
a
d
g
h
i
j
e
f
b
c

162
S. Berkowitz
k
l
m
n
o
q
p
Fig. 7.23 (continued) ( l – q ) The maxillary anterior deciduous teeth were extracted and an anterior bridge fabricated to
improve dental function and aesthetics

163
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.24 Case DK (AI-31). a Serial dental casts. 1–1–0
and 0–2–0 Note the severely protruding and small pre-
maxilla. 0–2–0 and 0–6–0 The premaxilla ventro fl exed
under the in fl uence of extraoral elastics attached to a head
bonnet. 0–7–0 Marked increase in palatal size coupled
with a big reduction in the anterior cleft space. 2–0–0
Class II right and Class I left occlusions with a severe
anterior overjet. Premaxillary surgical setback should not
be performed

164
S. Berkowitz
3–6 Note only a small overjet and
overbite with a mesioangular rotation of the lateral seg-
ments placing the cuspids into crossbite. 4–4 The premax-
illa is forward of the lateral palatal segments, with a
normal dental overbite/overjet. This occlusal relationship
remained for the next 5 years. The anterior cleft space is
left open waiting for additional palatal growth. The ante-
rior palatal cleft did not pose a speech or feeding problem
and would allow for palatal expansion
Fig. 7.24 (continued)

165
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.24 (continued) 9–8 The remaining deciduous cen-
tral incisor is now in an anterior crossbite associated with
the lack of midfacial development. 12–4 The lower ante-
rior teeth were unsuccessfully advanced to reduce the arch
crowding. The excessive fl aring necessitated extraction of
the lower fi rst bicuspids. This was followed by retraction
of the incisor teeth and space closure with reduction of the
severe anterior crossbite. 15–8 Right and left deciduous
lateral incisors are brought into position; however, an
anterior arch discrepancy still remains. Because of the
poor root development of the deciduous lateral incisors,
they later were extracted and replaced with an anterior
fi xed bridge. Comment: This case clearly demonstrates
that the anterior occlusion cannot be predicted at birth;
therefore, early premaxillary surgical setback should not
be performed

166
S. Berkowitz
0–1
1–2
3–11
4–4
5–2
5–11
6–5
6–8
7–1
7–11
11–4
12–6
13–8
15–11
16–3
8–2
8–5
8–11
9–10
10–5
10–9
1–5
1–10
2–1
2–5
2–10
3–5
0–3
0–4–15
0–5–10
0–7
0–8
1–0
Fig. 7.25 Case DK (AI-31). Computerized drawings of
palatal casts using an electromechanical digitizer. Each
cast form is drawn to scale but not its size. The premaxilla
is gradually aligned within the lateral palatal segments
after the initial ventro fl exion. The ratio of palatal size to
cleft size increases with growth. The anterior cleft space is
left open until a secondary alveolar bone graft is placed.
The palatal cleft was closed at 4–0 leaving an anterior
palatal fi stula which was closed with a secondary alveolar
bone graft at 12–1

167
7 Complete Bilateral Cleft Lip and Palate
5–5
a
b
7–9
S
N
BaH
A (a)
Gn
5–5
7–9
10–3
12–5
Go
Ba
Ar
10–3
12–5
87.24
76.42
154.14
11.13
76.60
74.10
167.16
6.59
79.80
75.40
170.20
5.60
80.98
77.33
171.27
5.54
SNA
SNPo
NAPo
ANB
SNA
SNPo
NAPo
ANB
SNA
SNPo
NAPo
ANB
SNA
SNPo
NAPo
ANB
Fig. 7.26 ( a , b ) Case DK
(AI-31). ( a , b ) Serial lateral
cephaloradiographic tracings
show changes in the skeletal and
soft tissue pro fi le. The upper lip
gradually became recessive,
re fl ecting the lack of midfacial
growth and superimposed basion
horizontal facial polygons of
Coben. The midfacial protrusion
seen at 12 years, 5 months is no
different to that seen at 5 years,
5 months of age. At 10 years of
age, the midface was more
recessive, but with the application
of premaxilla advancement
orthodontics for 2 years, it was
positioned more anteriorly. The
lower jaw showed progressive
downward and forward growth.
As in all faces that grow well, this
growth pattern was mainly
responsible for the fl attening of
the facial pro fi le. Comments: I
must stress that the Coben
analysis demonstrates the
forward/downward growth of the
entire maxillary and mandibular
growth; therefore, the maxilla
actually recedes due to growth at
the upper and lower face

168
S. Berkowitz
Fig. 7.27 ( a – p ) Case PM (KK-22). Serial photographs
demonstrate excellent facial and palatal growth in CBCLP.
Time is an ally! No presurgical orthopedics other than the
use of external elastics off a head bonnet for 10 days prior
to lip surgery; arm restraints were used to prevent removal
of the head bonnet. The palatal cleft was closed at 8 years
of age using a modi fi ed von Langenbeck procedure.
Secondary alveolar cranial bone grafting was done at
8 years of age. ( a , b ) At birth, an extremely protrusive
premaxilla. ( c ) Head bonnet with elastic over the premax-
illa. ( d ) The lip cleft was closed using Millard’s forked
fl ap procedure. The tissue in the nostril is used to recon-
struct the columella at a later date so that the surgeon need
not go back to the lip for tissue. ( e ) Occlusal view at
5 years of age. Note that the premaxilla is still protrusive.
( f ) The lip is being pushed forward by the protruding pre-
maxilla. The palatal cleft was closed at 8–6. The face at
5 years showing upper lip protrusion
a
d
f
g
h
e
b
c

169
7 Complete Bilateral Cleft Lip and Palate
i
k
l
m
n
o
p
j
( i ) 11–01 The premaxilla is still
protrusive. ( j – l ) At 20 years of age, the occlusion is ideal.
Minor imperfections in the anterior teeth were corrected
by the use of composite material. ( m ) Ideal arch form with
a normal palatal vault space. Good alveolar bone support
to the lateral incisors. ( n – p ) Facial photographs at 20 years
of age showing a harmonious and pleasing soft tissue
pro fi le. Comments: No protraction midfacial mechanics
were used
Fig. 7.27 (continued)

170
S. Berkowitz
Fig. 7.28 Case PM (KK-22). Serial casts: 0–1 At birth,
the septum is deviated to the left and the right palatal seg-
ment is laterally displaced. 0–4 With an external elastic
and lip surgery, the premaxilla fl exes ventrally and
medially, making contact with both palatal segments. The
remaining casts show excellent buccal occlusion in Class
II relationship with overbite and severe anterior overbite
and overjet

171
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.28 (continued) By 8–3, the anterior overjet is
markedly reduced by growth. 13–11 Conventional ortho-
dontics were eventually used to reduce the Class II occlu-
sion and align the anterior teeth into an ideal
overbite-overjet relationship

172
S. Berkowitz
0–0–12
2–10
8–2
12–3
14–0
14–5
17–4
3–10
5–8
6–7
7–4
0–3
1–4
1–10
2–1
Fig. 7.29 Case PM (KK-22). Computer-generated out-
lines of the serial casts were performed using an electro-
mechanical digitizer. All casts are drawn to scale. The
casts range from 12 days to 17 years, 4 months of age. This
series demonstrates the spontaneous closure of the anterior
and posterior cleft spaces after “molding action” brought
on by uniting the lip and then by gradual palatal growth at
the border of the cleft space. The premaxilla was initially
aligned forward of the lateral palatal segments but was sat-
isfactorily incorporated within the arch at a later age
0.0.12
2.0
PC
PC´
P
P´
H
P
V
P´
0.0.12
3.10
y
17.4
17.4
2.0
3.10
Fig. 7.30 Case PM (KK-22). Palatal outlines were super-
imposed using the rugae for registration. This series shows
that the premaxilla’s position within the maxillary com-
plex at 17 years of age is similar to that seen at birth.
Excellent growth occurs in all dimensions and is similar to
the growth pattern seen in noncleft palates. Increased pos-
terior palatal growth is necessary to accommodate the
developing molars. Alveolar bone growth with tooth erup-
tion increases midfacial height. Comments: The position
of the anterior premaxilla relative to the anterior cranial
base (Nasion) to the anterior position of pogonion of the
mandibular symposium shows the same relative position
from birth to 17 years of age. These 2 studies con fi rm that
midfacial growth is retarded

173
7 Complete Bilateral Cleft Lip and Palate
1,600
Right lateral segment
Left lateral segment
Total cleft space
Total surface area +cleft space
Surface area
AI-31
Premaxilla
Anterior space
Posterior space
Total surface area
1,400
1,200
1,000
800
600
400
200
00
2
4
6
8
10
12
14
16
18
20
22
24
Fig. 7.31 Case DK (AI-31). Premaxillary ventro fl exion
with medial movement of the lateral palatal segments
caused a great reduction in the anterior and posterior cleft
spaces by 5 months of age. Thereafter, for the next
19 months, the anterior cleft space gradually reduced,
while the posterior cleft space showed some increase due
to the increase in palatal length. Both lateral palatal seg-
ments showed a similar, gradually increasing growth rate
Right lateral segment
Left lateral segment
Total cleft space
Total surface area +cleft space
Premaxilla
Anterior cleft space
Posterior cleft space
Total surface area
2,520
2,340
2,160
1,980
1,800
1,620
1,440
1,260
Square millimeter
1,080
900
720
540
360
180
00
8
16
24
32
40
48
56
64
72
80
88
96 104
Months
112 120 128 136 144 152 160 168 176 184 192 200
Surface area
case dk AI - 31
Fig. 7.32 Case DK (AI-31). After the initial change in
cleft size brought on by medial movement of the lateral
palatal segments and ventro fl exion of the premaxilla, the
greatest acceleration of cleft space closure occurred
between 2–10 and 3–5. The premaxilla reached its largest
size by 3 years, which is associated with eruption of the
teeth. Palatal growth acceleration occurred between
1–3 months and 12–14 months and then gradually tapered
off. The palatal segments had increased 37 % in size by
1 year and 74 % by 2 years. Palatal growth at its medial
borders still occurs; even though it narrows the cleft space,
the total cleft space is increasing in size due to the increase
in palatal length

174
S. Berkowitz
3,000
2,800
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
Months
120
132
144
156
168
180
192
204
216
Surface area
KK-22
Square millimeter
Right lateral segment
Left lateral segment
Total cleft space
Total surface area + cleft space
Premaxilla
Anterior space
Posterior space
Total surface area
Fig. 7.33 Case PM (KK-22). Time sequence analysis of
serial palatal growth shows that both palatal segments are
growing at the same rate and to the same degree. The pre-
maxilla is also increasing in size with tooth eruption but at
a lesser rate. The greatest palatal growth acceleration
occurs the fi rst 2 years and then tapers off. The anterior
cleft space is initially reduced as a result of premaxillary
ventro fl exion, but thereafter it remains the same dimen-
sions until the palatal cleft is closed. The posterior cleft
space initially is reduced with palatal medial movement.
The resulting posterior cleft space remains approximately
the same size for the next 8 years. It must be remembered
that the cleft length is increasing, while the cleft width is
decreasing. The net cleft area is gradually reducing with
growth. All fi stulae are closed by 12–3 years of age

175
7 Complete Bilateral Cleft Lip and Palate
KK-22
Crest heights
Voult widths
2–0
2–10
3–9
5–8
VH 13.1 nn
CrW 37.5 nn
VH 13.0 nn
CrW 37.2 nn
VH 13.5 nn
CrW 39.7 nn
VH 15.5 nn
CrW 39.6 nn
+
+
+
+
KK-22
KK-22
Crest heights
Voult widths
0–0–12
0–3
1–4
1–10
VH 9.9 nn
CrW 37.7 nn
VH 12.5 nn
CrW 37.3 nn
VH 12.2 nn
CrW 38.3 nn
VH 12.2 nn
CrW 37.8 nn
KK-22
Crest heights
Voult widths
6–6
7–2
12–3
13–11
14–5
VH 15.6 nn
CrW 43.3 nn
VH 15.7 nn
CrW 33.1 nn
VH 20.1 nn
CrW 45.3 nn
VH 21.0 nn
CrW 42.5 nn
VH 20.9 nn
CrW 37.2 nn
+
+
+
+
+
+
Fig. 7.34 Serial midpalatal cross sections showing vault
height and palatal width changes using stereophotogram-
metry. The left lateral palatal segment is attached to the
vomer – while the right lateral palatal segment is displaced
laterally. A lip muscle adhesion causes the displaced pala-
tal segment to move medially, narrowing the cleft space.
The appositional growth of the alveolar segments is con-
tinuous and becomes more obtuse. Closure of the palatal
cleft space with a modi fi ed vomer fl ap maintains a normal
vault height, and vault space fl attening of the vault occurs
in almost all cases in the absence of a vomer fl ap.
Comments: A vomer fl ap with a von Langenbeck proce-
dure seems to create a minimum scarring. Vomer fl ap
alone performed early (6 months to 1 year) created exces-
sive scarring