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

177
7 Complete Bilateral Cleft Lip and Palate
a
b
c
e
d
Fig. 7.37 ( a – e ) Various palatal expansion appliances. ( a )
“W” appliance with fi nger springs designed to move the
central incisors forward while correcting the posterior
crossbite. ( b ) “W” appliance. ( c ) Arnold expander: a .040
wire is inserted into a .040 tube; the compressed open coil
spring exerts a gentle lateral force moving the two seg-
ments apart. A larger diameter (.045) tube wire allows the
cuspids to be moved laterally more than the molars. ( d ) A
Hyrax expander, which needs a lever and parent involve-
ment to activate the very strong expansion force. This
appliance is rarely necessary with meager transpalatal
scarring. ( e ) A three-part removable expansion plate used
to simultaneously advance and expand the anterior and
buccal segments in a BCLP. Appliances that attach to the
teeth are more reliable and ef fi cient than removable ones

178
S. Berkowitz
Fig. 7.38 ( a – s ) Case ML (KK-56) demonstrates severe
premaxillary protrusion at birth in IBCLP. “Whisker”
forked fl ap was performed at 2 months, de fi nitive lip sur-
gery at 6 months, and palatal cleft closure at 18 months.
Secondary alveolar cranial bone grafting was placed at
8 years, 3 months. Maxillary surgery with chin augmenta-
tion was performed at 15 years, 7 months. ( a – g ) Facial
and intraoral photographs show progressive facial and
occlusal changes
a
d
e
f
g
b
c

179
7 Complete Bilateral Cleft Lip and Palate
h
i
k
l
m
n
j
Fig. 7.38 (continued) ( h – j ) Facial photographs at 8 years
of age. ( k ) After Lefort I advancement, the lateral incisor
pontics were attached to the arch wire for aesthetics. ( l ,
m ) Occlusal photographs showing missing incisor spaces.
( n – p ) Intraoral photographs showing retainer with lateral
incisor pontics in place. ( q – s ) Facial photographs at
17 years of age. Case ML (KK-56) demonstrates severe
premaxillary protrusion at birth in IBCLP. ( n ) A partial
upper retainer in place with pontics for missing lateral
incisors. Case ML (KK-56) demonstrates severe premax-
illary protrusion at birth in IBCLP

180
S. Berkowitz
o
q
r
s
p
Fig. 7.38 (continued) ( o , p ) Intraoral photographs show-
ing a fi xed bridge to replace both upper lateral incisors.
( q – s ) Facial photographs at 17 years of age. A prominent
symphysis is noted. Comment: This case shows the need
to keep the lateral incisors spaces open in order to obtain
good anterior overbite and overjet in the presence of
strong mandibular growth

181
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.39 Case ML (KK-56). Serial casts from 0–0–2 to
4–3: With the establishment of an intact lip musculature,
the premaxilla and lateral palatal segments are molded
into a good arch form. The premaxilla, although latero-
and ventro fl exed, still caused the upper lip to be pushed
forward. The left buccal crossbite was corrected by 8 years
of age, and a fi xed palatal retainer was placed

182
S. Berkowitz
Fig. 7.39 (continued) 15–7 Orthodontic treatment was
designed not to correct the slight Class II occlusion of the
left segment. 15–9 After Lefort I osteotomy and fi nal teeth
alignment. Because the premaxilla was positioned slightly
to the right and could not be centered orthodontically, it
was decided to leave the left occlusion in Class II and the
right occlusion in Class I, thereby equalizing the space for
the lateral incisors. 17–0 A cuspid-to-cuspid fi xed bridge
replaced the missing lateral incisors and stabilized the
relationship of all segments

183
7 Complete Bilateral Cleft Lip and Palate
SNA
88.7
SNPO
90.3
87.5
ANB
175.3
4.2
SNPO
NAPO
ANB
176.7
2.8
NAPO
3–9
11–4
15–3
90.9
76.9
151.0
14.3
SNA
SNA
SNB
SNB
93.2
80.1
153.7
13.1
17–3
SNPo
SNPo
NAPo
SNA
ANB
91.1
82.6
161.9
9.1
SNPO
NAPO
NAPo
7–10
SNA
90.0
Fig. 7.40 Case ML (KK-56).
Serial cephalometric tracings
showing well-proportioned facial
growth with a fl attening of the
facial pro fi le. The protrusive
premaxilla was present at 7–10.
Orthodontia at 11 years of age
improved the axial inclination of
the maxillary incisors. The pro fi le
at 15–3 is more attractive than
that at 17–3 as a result of the chin
augmentation at 15–7. The chin
point is too protrusive, resulting
in a prominent sublabial fold
Gn
17–3
15–3
7–10
11–4
α, Α
Go
3–9
N
S
Fig. 7.41 Case ML (KK-56). Superimposed polygons
show an excellent facial growth pattern and fl attened the
pro fi le by 15–3. Midfacial osteotomy corrected the
maxillary asymmetry. A chin augmentation was
performed at 15–7 years which created a too prominent
chin. The mandible continued to grow until 17–3 years
of age, creating a slightly concave skeletal pro fi le. The
patient is considering having the chin prominence
reduced. Comment: Rarely should a chin augmentation
be performed with a LeFort I advancement to avoid
creating a “dished in” face if the midfacial advancement
relapses. Note the small forward growth increments at
the anterior cranial base and midface. The midfacial
changes did show good vertical growth to maintain
normal facial proportions

184
S. Berkowitz
Fig. 7.42 Case CW (BG-71). Serial casts demonstrate
forward advancement of the buccal segments to reduce a
very large anterior palatal cleft space. There are instances
when a marked osteogenic de fi ciency exists in both lateral
incisor areas where the premaxilla is in a slight overjet-
overbite relationship and the buccal segments in a good
Class I relationship. In these cases, there may be
insuf fi cient contiguous soft tissue to close the anterior
palatal cleft space when performing a secondary alveolar
bone graft and create a normal site for tooth replacement.
The treatment of choice is to advance both buccal seg-
ments, simultaneously placing secondary alveolar bone
grafts, yet leaving space for the lateral incisors. After sur-
gery, the cuspids were to return to their original Class I
position. It was believed that with early premaxillary set-
back, there would be inadequate soft tissue to obtain ade-
quate cleft closure, but worst of all, it would have created
a severely retruded midface which would have required
midfacial advancement

185
7 Complete Bilateral Cleft Lip and Palate
15–5 Good premaxillary relation-
ship with a large anterior palatal cleft space. Class I pos-
terior occlusion. Sectioned plaster casts with the posterior
segments placed in a Class II relationship. 16–3 and 17–2
Both buccal segments relapsed into Class I. The main
objective of closing the anterior palatal cleft spaces was
achieved. Final casts show a good Class I occlusion with
a satisfactory overjet-overbite relationship. The anterior
palatal cleft space was closed. However, the alveolar bone
graft did not take. In most cases, the advanced lateral pala-
tal segments will remain forward with the cuspids in the
lateral space
Fig. 7.42 (continued)

186
S. Berkowitz
Fig. 7.43 ( a – z ) Case CS (AF-48) demonstrates severe
premaxillary protrusion in a child with CBCLP at birth,
resulting in maxillary retrusion in adolescence with the
eventual loss of the premaxillary incisors. Lip adhesion
was performed at 3 months with forked fl ap and posterior
palate cleft closure at 3 years. No secondary alveolar bone
grafts were utilized. Premaxillary surgical advancement at
15 years to correct its retrusion. The premaxillary incisors
were extracted due to severe periodontal bone loss, and
the anterior palatal oronasal opening was closed at
16 years of age. ( a , b ) Newborn. ( c – i ) Even with premax-
illary ventro fl exion, the upper lip was still pushed
forward
a
e
f
g
h
i
b
c
d

187
7 Complete Bilateral Cleft Lip and Palate
k
l
j
n
o
m
p
q
r
( i – l ) A plastic obturator was uti-
lized at 6 years of age to close the very large anterior pala-
tal cleft space to aid speech development and feeding.
( m – o ) At 14 years, a retrusive-looking midface with an
extremely tight upper lip and depressed nasal tip masked
a good premaxillary overjet
Fig. 7.43 (continued)

188
S. Berkowitz
s
t
u
v
x
w
y
z
Fig. 7.43 (continued) ( u ) At 15 years following an
unsuccessful attempt to surgically center the premaxilla
and close the anterior cleft space. The maxillary incisor
roots began to show severe external root absorption. A
very large anterior cleft space remains. ( v – y ) After lip and
nose revision, the anterior teeth were extracted and the
oronasal opening closed with adjoining soft tissue. ( z ) A
removable maxillary prosthesis replaced missing teeth
and bumpered the upper lip forward. Comments: It would
have been better treatment to have surgically advanced
both palatal segments to close the very large anterior pala-
tal cleft space. The root absorption was secondary to trau-
matic orthodontics utilized to maintain the incisor overjet
with a protective facial mask and cross elastics

189
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.44 Case CS (AF-48). Serial casts show that the extreme premaxillary protrusion with large anterior cleft space
at birth is still present at 6–1 years of age

190
S. Berkowitz
11–6 With increased facial growth,
the increasing tonicity of the buccal muscle forces col-
lapsed the maxillary arch placing the posterior teeth in
crossbite. The premaxilla is now upright and in an accept-
able overbite-overjet relationship. 12–3 Maxillary expan-
sion has been initiated. The maxillary central incisors are
in tip-to-tip relationship. 14 Continued orthodontic treat-
ment to advance the premaxilla and position the incisor
teeth in proper overjet-overbite relationship
Fig. 7.44 (continued)

191
7 Complete Bilateral Cleft Lip and Palate
14–6
15–2
16–9
17–8
4–6
6–4
7–2
11–6
12–3
13–11
0–9
1–1
1–8
1–9
2–1
4–2
Fig. 7.45 Case CS (AF-48). Computerized tracings of
serial casts drawn to scale. This shows the lack of palatal
growth and reduction in cleft space over 2 years prior to
surgical closure of the palatal cleft. The anterior cleft
space remains large up to 15–2 years. 16–9 and 17–8 The
premaxillary incisors were extracted. Comment: This case
clearly demonstrates the severe degree of osteogenic
de fi ciency that can exist in bilateral clefts of the lip and
palate. The once protruding premaxilla can become retru-
sive with growth (time) and may eventually need to be
brought forward. Although palatal growth does occur, it
may not be suf fi cient to appreciably reduce the posterior
cleft space
Fig. 7.44 (continued) 15–2, 16, and 16–6 Premaxillary
repositioning with soft tissue closure of the anterior cleft
space was unsuccessful. As a result of the premaxillary
central incisors showing external root absorption and loss
of periodontal support, they were extracted and the orona-
sal opening closed with adjacent soft tissue. A removable
maxillary prosthesis replaces the missing teeth and bum-
pers the upper lip. Comment: As already suggested, the
treatment of choice is to reposition the lateral palatal seg-
ments anteriorly while leaving the premaxilla as is

192
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
00
12
24
38
48
60
72
84
96
108 120 132 144 156 168 180 192 204 216 226
Right lateral segment
Surface area
Left lateral segment
Total cleft space
Total surface area +cleft space
Premaxilla
Anterior space
Posterior space
Total surface area
Square millimeter
Months
Fig. 7.46 Case CS (AF-48). The palatal segments show a very gradual growth acceleration curve, while the posterior
cleft space gradually reduces in size

193
7 Complete Bilateral Cleft Lip and Palate
4–2
a
b
SNPo 80
93
SNA 80
SNA 96
SNPo 80
81
84
82
6–1
12–3
14–4
N
S
Ar
Ba
Go
Gn
6–4
11–6
12–3
14–6
A (a)
BaH
4–2
Fig. 7.47 ( a , b ) Case CS (AF-48). ( a ) Serial cephalomet-
ric tracings. This analysis shows a protrusive midface at
4–2 becoming recessive at 14–4. ( b ) Serial facial poly-
gons superimposed according to basion horizontal method
(Coben). The midface advanced only slightly after 6–4,
while the mandible showed progressive downward and
forward growth until 14–6, fl attening the facial pro fi le.
Comments: This case clearly shows that (1) even with a
severely protruding premaxilla at birth, the premaxillary
incisors can be in anterior crossbite after the pubertal
growth spurt; (2) traumatic orthodontic advancement of
the premaxillary incisors can lead to external root absorp-
tion and loss of alveolar support; (3) surgical advance-
ment of one or both lateral palatal segments, placing the
cuspids in the lateral incisor spaces, with secondary alveo-
lar bone grafting is the treatment of choice in cases when
the premaxilla is in good overjet-overbite relationship and
a large anterior cleft space exists. Only in very rare
instances should the premaxilla be surgically set back to
the lateral palatal segments; and (4) Premaxillary surgical
setback is contraindicated prior to the postpubertal facial
growth spurt

194
S. Berkowitz
Fig. 7.48 Case ML demonstrates poor facial growth pat-
tern in a BCLP leading to a retruded midface with a severe
anterior open bite. This patient came to the clinic at
5 years, 7 months of age with an anterior open bite. The
upper lip was long and tight with the lateral elements
brought together below the prolabium. The palatal cleft
was closed at 12 months of age. At 13–10, a removable
plate replaced the right central incisor. At 15–11, orth-
odontic preparation for Lefort I posterior impaction. At
16–4, after maxillary surgery. At 19–9, after anterior fi xed
bridge used to stabilize the palatal segments and replace
missing teeth. The changes in occlusion and total facial
height led to a more relaxed soft tissue pro fi le. With reduc-
tion in lower vertical facial height, the upper to lower lip
position became more aesthetic

195
7 Complete Bilateral Cleft Lip and Palate
M.L
a
b
M.L
years/months
15–11
16–00
16–01
16–07
22–03
Pre-surgical
Post-surgical
S
S
Age
year-months
05–07
06–07
13–10
15–11
Fig. 7.49 ( a , b ) Case ML.
Superimposed serial
cephalometric tracings on SN
and registered at S before
surgery. ( a ) Between 5–7 and
15–11, the face demonstrated
a very poor growth pattern
associated with diminished
midfacial growth. The
incisors were in tip-to-tip
relationship at 5–7; by 6–7,
the anterior open bite with a
retruded midface was present,
which became worse with
time. ( b ) Serial cephalometric
tracing superimposed on SN
and registered at S after
posterior impaction and
maxillary advancement. The
mandible autorotated closing
the anterior open bite. The
curvature to both lips became
more prominent and
aesthetic. Comment: Placing
the lateral lip elements below
the prolabium creates a long
and tight upper lip. Maxillary
growth disturbance is always
expressed in all three
dimensions, resulting in
diminished vertical and
horizontal growth increments.
Maxillary advancement with
slight posterior impaction
causes mandibular autorota-
tion, bringing the lower
incisors upward and
anteriorly closing the anterior
open bite. The middle and
lower vertical facial heights
became more harmonious

196
S. Berkowitz
Fig. 7.50 Case CT (AV-62) demonstrates a severe pre-
maxillary overjet leading to a retruded midface and the
successful use of protraction orthopedics. This patient
was adopted from Central American parents. 4–6 It is
important to note the wide cleft space with an excellent
Class I buccal occlusion prior to surgical cleft closure. 5–3
Two months after palatal cleft closure, the occlusion is
still acceptable

197
7 Complete Bilateral Cleft Lip and Palate
7–6 and 8–5 A secondary alveolar
bone graft was placed at 8–0. The anterior teeth are in a
tip-to-tip relationship with the buccal occlusion in cross-
bite. 13–0 Complete anterior and buccal crossbite.
Preparation is made to begin orthodontic treatment to
expand the maxillary arch as well as to advance the maxil-
lary complex with protraction mechanics. 17–4 After
orthodontic treatment. A lower central incisor was
extracted to allow for incisor retraction. Excellent occlu-
sion is retained with a Hawley appliance. Comment: This
case clearly demonstrates that, in complete clefts of the
lip and palate, the lateral palatal segments at birth can be
in good relationship with the lower arch and not collapsed,
as McNeil suggests. In most cases, the surface area of the
lateral palatal segments can be considered to be too small
when compared to the cleft size. Too early cleft closure
using a von Langenbeck procedure will leave large areas
of uncovered bone when the mucoperiosteum is moved
medially. Denuded bone undergoes epithelialization with
scarring, which in turn interferes with palatal growth in all
three dimensions, leading to the buccal and anterior cross-
bite. In this case, protraction mechanics were successful.
However, because the ideal overjet-overbite relationship
could not be achieved, it was necessary to remove a lower
central incisor to retract the anterior segment. This
bene fi ted the buccal occlusion as well
Fig. 7.50 (continued)

198
S. Berkowitz
Fig. 7.51 Case RB (AG-73). Serial dental casts. Closure
of a large anterior cleft space in a BCLP by bringing
impacted cuspids into position and aligning the lateral
incisors. 10–2 Class II malocclusion in the mixed denti-
tion with a severe overjet and overbite. Bilateral decidu-
ous cuspid crossbite with no anterior cleft space. 10–7
With loss of the deciduous cuspid and its supporting alve-
olar bone along with the horizontal impaction of the per-
manent cuspids, there was de fi cient alveolar bone between
the lateral palatal segments and the premaxilla, creating a
large anterior cleft space. 11–2–0 Waiting for the eruption
of permanent bicuspids before initiating orthodontics.
13–0–0 After the horizontally impacted cuspids and their
supporting alveolar bone and the lateral incisors were
brought within the arch, the premaxillary overjet was
reduced. Both of these factors were responsible for the
closure of the anterior cleft space. This was followed by a
secondary alveolar cranial bone graft to close fi stulae and
remaining cleft spaces

199
7 Complete Bilateral Cleft Lip and Palate
13–2
Final occlusion with a full
complement of teeth.
Comment: The clinician must
always consider the importance
of the alveolar bone supporting
the teeth whether they are in
alignment or malpositioned.
When all of the teeth in the
lateral palatal segments can be
accommodated within the arch,
the anterior cleft space can
usually be closed without an
osteotomy
Fig. 7.51 (continued)
Fig. 7.52 Case RB. Cephalometric view of the pharyn-
geal at rest and with space and velar elevation. 10–2 Left :
At rest and when vocalizing “Youu …” Although there is
good velar elevation, the velum does not make contact
with the adenoid. Right : Vocalizing “Sss …” This sound
produces velar stretch, permitting contact to be made with
the adenoid. 13–2 Good velar elevation when vocalizing
“Youu …” and “Sss …”. Comment: Cephalometric evalu-
ation is necessary to view the structure of the pharyngeal
space. This is not a functional test to evaluate velopharyn-
geal competency, but it may give some insight into why
velopharyngeal incompetency may exist

200
S. Berkowitz
a
d
g
e
f
b
c
Fig. 7.53 ( a – r ) Case ES (EE-34) demonstrates excellent
facial growth pattern in a IBCLP showing good midfacial
growth. An external elastic off a head bonnet was used to
ventro fl ex the premaxilla prior to lip surgery. The lip was
united at 5 months of age using a forked fl ap procedure.
The palatal cleft was closed at 43 months of age using a
modi fi ed von Langenbeck procedure. ( a , b ) Face and pal-
ate at birth. ( c , d ) 3 months after lip surgery. ( e – i ) 5 years
of age with excellent buccal occlusion and good overbite-
overjet relationship of the anterior teeth. Upper lip is
protrusive

201
7 Complete Bilateral Cleft Lip and Palate
h
i
j
k
l
m
( j , k ) 10 years of age after secondary alveolar bone grafting. ( l , m ) A left cuspid crossbite
resulted from secondary alveolar bone graft surgery
Fig. 7.53 (continued)

202
S. Berkowitz
n
o
p
q
r
Fig. 7.53 (continued) ( n – r ) 16 years. After orthodontics
was completed. The left lateral incisor erupted through
the bone graft; the right lateral incisor is missing. The arch
form is maintained with a removable Hawley retainer,
which carries a lateral incisor replacement

203
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.54 Case ES (EE-34). Serial dental casts. 0–0–12
At birth. 0–1–0 After uniting the lip, the premaxilla has
been positioned adjacent to the lateral palatal segments.
2–7 The palatal cleft is still open. Tongue force has moved
the premaxilla forward. 3–5 After palatal cleft closure,
there is excellent buccal occlusion. 4–3, 5–1, 7–3, and 8–1
Good buccal and anterior occlusion is present for the next
4 years

204
S. Berkowitz
12–4 and 13–3 This crossbite remains for the next 3 years and does not hinder dental function.
16–10 and 18–1 After orthodontics. Good Class I occlusion with good anterior overjet and overbite
Fig. 7.54 (continued)

205
7 Complete Bilateral Cleft Lip and Palate
EE–34
0.0.12
1.10
2.7
3.5
4.3
5.1
10.7
13.3
16.10
18.1
6.2
7.3
8.1
8.10
12.4
Fig. 7.55 Case ES (EE-34). Computer-generated images
of serial palatal casts. All of the casts are in proportion.
Palatal growth occurs on all surfaces but mainly trans-
versely and posteriorly to accommodate the unerupted
molars. Although the palatal surface is gradually increas-
ing in size, the posterior cleft space remains almost con-
stant in size over the same period of time. When the palatal
cleft was closed at 43 months, more mucoperiosteal tissue
was available to prevent growth-inhibiting scar tissue
from being created
0.0.12
4.3
Z
a
Z
P´
P´
P
P
Rugae: age:
0.0.12
2.7
4.3
13.3
18.3
2.7/4.3
Fig. 7.56 Case ES (EE-34). Computer-generated out-
lines of palatal casts superimposed on the palatal rugae.
This study demonstrates that palatal growth occurs mainly
in the posterior and transverse areas with very little pre-
maxillary growth. More signi fi cantly, it shows that the
premaxilla is relatively stable in its geometric position
within the maxillary complex, that is, the face grows up to
and around the original position at birth

206
S. Berkowitz
3,000
2,000
2,600
2,400
2,200
2,000
1,800
1,600
1,400
1,200
1,000
500
600
400
200
00
12
24
36
48
60
72
84
96
106 120 132 144 156 168 180 192 204 216 228
Surface area
EE–34
Square millimeter
Months
Right lateral segment
Left lateral segment
Total cleft space
Total surface area +cleft space
Premaxilla
Anterior space
Posterior space
Total surface area
Fig. 7.57 Case EE-34. Very gradual growth acceleration curve, while the posterior cleft space closed very rapidly
between 42 and 52 months of age. The premaxilla’s growth was negligible

207
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.58 ( a , b ) Case ES (EE-34).
( a ) Serial cephalometric tracings
show ideal facial measurements
evolving. A superior-based
pharyngeal fl ap is outlined in 18–1.
( b ) Serial polygons superimposed
according to the basin horizontal
method (Coben). This series
demonstrates an ideal facial growth
pattern and re fl ects the use of
physiological maxillary surgery:
(1) The anterior cranial base
shows good growth increments.
(2) Midfacial growth increments
are continuous and only slightly
less than those seen at N (Nasion).
(3) Mandibular growth shows more
forward than downward changes
which are conducive to the
fl attening of the facial pro fi le.
Comment: Taken together, all of
these growth changes are conducive
to the fl attening of the facial pro fi le.
Such extensive midfacial growth is
usually not seen in BCLP cases with
such a large cleft space relative to
the palate’s surface area that have
had the palatal cleft closed earlier
than 43 months of age. We speculate
that this fi nding strongly suggests
that: (1) delaying palatal surgery to
3 years of age may be more
conducive to good midfacial growth
in some cases than early (before
1 year) palatal closure. However, we
believe that it is not necessary to
postpone palatal closure to after
5 years of age in all cases. (2)
Hypotonic lip pressure has not
exerted suf fi cient pressure through
the premaxilla to the premaxillary-
vomerine suture to reduce its growth
before 16–6. However, between
16–6 and 18–1, midfacial growth
has ceased
5–2
SNA
SNA
SNA
SNA
SNB
SNB
SNB
SNPo
SNPo
SNPo
NAPo
NAPo
NAPo
84.66
70.65
69.95
146.17
SNB
SNPo
NAPo
SNA
SNB
SNPo
NAPo
SNA
SNB
SNPo
NAPo
SNA
SNB
SNPo
NAPo
7–3
8–11
12–4
83.45
81.04
78.94
71.23
72.45
165.86
70.53
70.99
156.88
71.85
71.25
152.87
18–1
16–6
13–3
79.71
72.95
74.11
167.68
74.46
78.88
75.17
172.56
N
S
a
b
Ar
Ba
Go
5–2
8–11
12–416–6
18–1
Po
FH’
Α(α)
78.18
74.58
75.35
174.27

208
S. Berkowitz
Fig. 7.59 ( a – n ) Anterior positioning of the lateral palatal
segments in an adolescent with CBCLP to close a large
anterior cleft space Semb ( 1991 ) . A 16-year-old with
repaired BCLP underwent combined orthognathic-orth-
odontic procedure to align the teeth, close the large cleft
space while maintaining the existing premaxillary overjet-
overbite relationship. ( a ) Initial cleft lip and palate defor-
mity at 8 weeks of age. ( b ) Palatal view at 10. ( c , d )
Preoperative palatal and frontal view at 15 years showing
large anterior cleft space and dental crowding of the lat-
eral palatal segments. The right second bicuspid is to be
extracted. ( e ) Preoperative occlusal view showing large
cleft space with posterior positioned lateral palatal seg-
ment. ( f ) Preoperative panorex at 17 years of age
a
c
d
f
e
b

209
7 Complete Bilateral Cleft Lip and Palate
g
h
i
k
l
j
Fig. 7.59 (continued) ( g ) Occlusal radiograph. ( h ) Line
drawing of the proposed palatal surgery showing the pos-
terior widening and anterior movement of the lateral pala-
tal segments. ( i – k ) Postoperative intraoral photographs.
( l ) Postoperative panorex

210
S. Berkowitz
m
n
( m )
Occlusal radiographs. ( n )
Postoperative frontal facial
view. Comment: There was
limited alveolar bone support to
the lateral incisor areas. The
premaxilla was mobile. Marked
velopharyngeal incompetence
with regurgitation of fl uid while
drinking and intake of air while
speaking required a palatal
obturator. The surgical plan was
to extract the questionable
lateral incisors and reposition
the maxillary lateral segments
to close the lateral incisor and
large anterior cleft spaces
Fig. 7.59 (continued)
0–1–10
a
b
0–3–18
CP 444 ♀
N
FH
OP
S
Fig. 7.60 ( a , b ) Case CP (444) demonstrates the effects
of early premaxillary surgical setback. The purpose of this
surgical procedure is to establish ideal arch form prior to
lip surgery. The procedure lost favor when surgeons found
that it led to severe midfacial growth retardation and an
anterior open bite. ( a ) Before and after premaxillary set-
back. The premaxilla is positioned within the arch. ( b )
4 years later, the premaxilla, having been detached from
the vomer, fails to descend with the palate with growth,
creating on anterior open bite. Orthodontics in the perma-
nent dentition will super erupt the maxillary incisors with
only slight change in maxillary position (Courtesy of S.
Pruzansky)

211
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.61 A Kirschner wire that penetrated dental sacs of
the central incisors, causing tooth malformation. Due to
the spatial relationship of the premaxilla to the vomer, the
Kirschner wire frequently fails to enter the vomer as seen
here
Fig. 7.62 Lateral cephalograph showing a malpositioned
Kirschner wire. After the premaxilla is surgically retroposi-
tioned, surgeons used to attempt to stabilize it by placing
wires of various sizes through the premaxilla into the vomer.
The procedure has not been successful and should be aban-
doned because it can devitalize the teeth in the premaxilla
and the wire can migrate to various areas within the skull
a
b
Fig. 7.63 ( a , b ) Two views
of a Kirschner wire 35 years
after insertion. ( a ) Panorex
and ( b ) Lateral cephalometric
fi lms show the displaced
Kirschner wire located high
in the vomer

212
S. Berkowitz
a
b
c
d
e
f
g
h
j
i
Fig. 7.64 ( a – j ) Case LN demonstrates the effects of pre-
maxillary incision. This case was referred to us 25 years
ago after the premaxilla had been excised. This is the only
case in our fi les where the premaxilla was removed at
birth. The remaining teeth were badly decayed. The treat-
ment plan required overlay dentures to both arches. As a
precaution, all the teeth were crowned prior to the con-
struction of the dentures. The upper lip was revised. ( a – c )
Facial photographs, at the start of the treatment. ( d )
Maxillary arch with decayed teeth. ( e ) Denture over
decayed teeth. ( f ) Upper and lower teeth were crowned.
( g ) Lateral head plate after dental reconstruction. ( h )
Upper and lower over dentures. ( i , j ) Facial photographs
after lip revision

213
7 Complete Bilateral Cleft Lip and Palate
0–0–18
1–10–6
0–0–18
1–10–6
a
b
Fig. 7.65 ( a ) Premaxillary excision. Removal of the pre-
maxilla leads to a large oronasal opening with a retruded
midface. Even at 1 year, 10 months of age, the upper lip is
severely retruded (Courtesy of S Pruzansky). ( b )
Premaxillary excision results in direct communication
between the oral and nasal chambers

214
S. Berkowitz
a
d
e
f
g
b
c
Fig. 7.66 ( a – q ) Case CH (II-64). This case demonstrates
the need to advance the premaxilla after premaxillary sur-
gical setback. A chin augmentation was necessary to neu-
tralize the effect of excessive upper facial growth. ( a – i )
An external elastic off a head bonnet was used to ventro fl ex
the premaxilla prior to lip surgery. As a result of the con-
tinuous premaxillary overjet, at 4–9, it was surgically set
back. The palatal cleft was closed at 5–6 using a modi fi ed
von Langenbeck procedure. A secondary alveolar bone
graft was placed at 10–5. The patient’s family moved to a
different state where the orthodontist unsuccessfully
attempted to close the lateral incisor space by retracting
the central incisors

215
7 Complete Bilateral Cleft Lip and Palate
h
i
j
k
l
m
( j ) An anterior open bite was cre-
ated. The patient returned to Miami. Treatment plan was
changed to: (1) advance the premaxilla and open the lat-
eral incisor space and (2) along with chin augmentation
using autogenous bone from the inferior border of the
symphysis. ( k – m ) After mandibular sagittal split surgery
and orthodontic premaxillary advancement to recover lat-
eral incisor spaces and advance the midface. A Hawley
retainer with two false teeth were used to maintain the
arch form
Fig. 7.66 (continued)

216
S. Berkowitz
n
q
o
p
( n , o ) Facial photographs showing a pleasing facial pro fi le. ( p ) A fi xed bridge replaced the
removable retainer. ( q ) Shows a pharyngeal fl ap at A
Fig. 7.66 (continued)

217
7 Complete Bilateral Cleft Lip and Palate
Fig. 7.67 Case CH (II-64). Serial dental casts. 0–0–9
9 days of age. 0–8 Premaxillary ventro fl exion after unit-
ing the lip. The palatal segments have moved medially
making contact with the vomer. The premaxilla has
uprighted, but the anterior cleft space is slow in reducing.
2–9 Severe overbite and overjet. Mesioangular rotation of
both palatal segments placed the deciduous cuspids in
crossbite. 4–1 and 4–9 The anterior overbite and overjet
have reduced spontaneously

218
S. Berkowitz
Fig. 7.67 (continued) 4–11 The premaxilla was surgi-
cally set back. 5–5 The anterior open bite was eliminated.
6–5 The palate was expanded to correct the deciduous
cuspid crossbite and to allow the premaxilla to fi t within
the arch. 8–3, 10–7, and 11–5 Palatal retainer is used to
hold the corrected arch form

219
7 Complete Bilateral Cleft Lip and Palate
15–8 An attempt to close the lat-
eral incisor space orthodontically was unsuccessful. 16–5
Premaxilla advanced and lateral incisor spaces opened. 20
Fixed bridge replaces missing teeth and maintains the
arch width and form
Fig. 7.67 (continued)

220
S. Berkowitz
0–0–9
4–1
8–3
6–5
20–0
8–9
10–0
11–5
15–8
4–9
4–11
5–5
6–6
–8
1–10
2–6
2–9
Fig. 7.68 Case CH (II-64). Computer-generated palatal
images drawn to scale. This series shows the gradual
decrease in cleft space size from birth to 5–5 years. A pos-
terior cleft space remained until 5–6. Alveolar cleft closed
at 10–5. Comment: Hopefully, the research project cur-
rently under way will determine the best age, based on
parameters such as the ratio of the palatal surface area to
cleft space size, at which to close the posterior palatal cleft.
The various facial-palatal growth studies presented in this
chapter show great variation in palatal as well as facial
growth patterns. Differential diagnosis to select the “best”
time and surgical procedure to close the cleft space should
not be based on age alone, but should consider the nature
of the cleft defect – its size and the availability of tissue
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
00
12
24
36
48
60
72
84
96 108 120 132 144 156 168 180 192 204 216 228 240 252 264
Surface area
II–64
Months
Right lateral segment
Left lateral segment
Total cleft space
Total surface area +cleft space
Premaxilla
Anterior space
Posterior space
Total surface area
Fig. 7.69 Case CH (II-64)A rapid increase in palatal
growth as the posterior cleft space reduces at almost the
same rate. The reduction in anterior cleft space proceeds
at a lesser rate. Palatal growth rate after surgery is the
same as it was before surgery

221
7 Complete Bilateral Cleft Lip and Palate
Gn
16–6
15–8
17–2
4–11
11–0
Br
A(α)
Go
Gn
Ar
67.88
175.59
3.15
S
74.47
72.65
176.22
4.97
SNA
ANB
SNPo
NAPo
SNA
ANB
SNPo
NAPo
SNA
ANB
SNPo
NAPo
72.71
67.23
168.46
5.83
17–2
69.98
N
BaH
SNA
ANB
16–6
69.98
67.88
175.59
3.15
69.98
67.88
175.59
3.15
SNPo
NAPo
SNA
ANB
a
b
SNPo
NAPo
SNA
ANB
SNPo
NAPo
4–11
87.48
69.95
144.37
16–6–14
11–0
15–8
17.27
Fig. 7.70 ( a , b ) Case CH (IT-64). ( a ) Serial cephalomet-
ric tracings showing facial changes with a severely pro-
truding maxilla at 4–11 and ( b ) superimposed polygons
using the basion horizontal method (Coben). An excessive
amount of growth occurred at the anterior cranial base (at
N) and in the mandible mainly in the vertical dimension.
With some minor midfacial growth, the skeletal and soft
tissue pro fi le became more retrognathic and unaesthetic.
Because of the prominent upper face, it was decided to
improve facial aesthetics by advancing the premaxilla and
to open the lateral incisor space. Notice the resulting
larger incremental midfacial change resulting from the
movement of A point between 16–6 and 17–2. Chin aug-
mentation increased the mandibular prominence from an
SNPo angle of 67.88° to 72.65°. With the lack of contin-
ued growth of the anterior cranial base between 16–6 and
17–2, the angle at facial convexity changed slightly from
175.59° to 176.22°. Comments: The clinician should not
evaluate the alignment of teeth only within the arch and
occlusion without considering the effects of anterior tooth
position on the developing facial pro fi le. Retracting the
maxillary central incisors along with A point to close the
lateral incisor space made the midface appear very
de fi cient and aesthetically unpleasant. Because of the
large increment of anterior cranial base growth, it was
necessary to advance both the midface and augment the
chin. Therefore, when treatment planning, the protruding
premaxilla at birth needs to be considered as part of the
developing face, and treatment options need to be left
open until the facial growth pattern is identi fi ed and can
be adjusted to its best advantage. It is important to empha-
size that a mechanically or surgically retropositioned pre-
maxilla does not advance in the midface with growth as a
nonretracted conservatively treated premaxilla will do

222
S. Berkowitz
a
e
h
i
j
k
f
g
b
c
d
Fig. 7.71 ( a – k ) Case AO (BM-82) shows surgical repo-
sitioning of the premaxilla in an adult. This patient had
been under orthodontic-surgical care elsewhere. The
orthodontist was reluctant to orthodontically correct the
severe premaxillary overbite and left it to the surgeon.
Because of the patient’s age, it was decided that surgical
premaxillary alignment was the treatment of choice. ( a – k )
Before and after surgery. The maxillary central incisors
are stabilized with a Hawley retainer with two false teeth
in the lateral incisor position
Before 10/13/89
After 12/21/90
Fig. 7.72 Case AO
(BM-82). Lateral cephalo-
metric tracings showing
correction of the premaxil-
lary overjet and overbite in
an adult. Comment: When a
severe premaxillary overbite
exists in the mixed and early
permanent dentition, in most
cases, it can be successfully
treated with orthodontics.
The surgical cut is made
between the premaxilla and
the vomer. The need to
protect the integrity of the
PVS is not crucial at this age.
Rigid arch wire stabilizes the
corrected premaxillary
position during healing

223
7 Complete Bilateral Cleft Lip and Palate
a
d
g
e
h
i
f
b
c
Fig. 7.73 ( a – i ) Case TK. Lip-Switch (Abbe Flap). The
combination of a short columella and a short or long and
tight upper lip requires secondary cleft lip surgery. (Millard
1978b ) strongly believes that, had the primary surgery been
planned and executed properly, a lip switch fl ap would most
likely never be required. Unfortunately, there are occasions
when the destruction of the lip landmarks and midfacial
growth retardation require that tissue be brought in from
outside and used to remove scars, bring in muscle continu-
ity, create a philtrum and even a bow, correct free border
defects, and relieve tension. Millard suggests that the fl ap
form the total central vertical length of the upper lip. It will
then resemble the natural philtrum and can appear normal
in spite of its scars. ( a – c ) Repaired bilateral cleft lip and
palate has resulted in a malformed, recessive midface with
a scarred upper lip. ( d – f ) The fl ap was taken from the mid-
dle of the lower lip and inserted in the total central portion
of the upper lip. ( g – i ) After lips were separated. The upper
lip is symmetrical and shows a more normal looking ver-
million. A dental prosthesis bumpers the upper lip

224
S. Berkowitz
Table 7.2 Surface area of CBCLP. Case DK (AI-31)
Skeletal area
Cleft space
Total
Age
Premax
RLS
LLS
Tot
Ant
Post
Tot
SA + CS
0–1
55.6
314.1
254.2
623.9
102.9
138.8
341.7
965.6
0–3
79.2
366.6
317.5
763.3
150.5
191.8
342.4
1,105.7
0–4–15
86.1
362.4
300.8
749.3
56.1
259.3
315.4
1,064.7
0–5–10
99.5
356.2
322.5
778.2
70.3
175.8
245.5
1,023.7
0–7
111.7
361.9
321.3
794.9
45.2
168.0
213.2
1,008.1
0–8
106.8
376.0
351.0
833.8
85.6
149.1
234.7
1,068.5
1–0
100.3
428.1
327.2
855.6
55.6
198.8
249.4
1,105.0
1–2
132.8
432.6
389.3
954.7
55.7
189.8
245.5
1,200.2
1–5
127.6
507.3
418.1
1,053.0
51.2
180.8
232.0
1,285.0
1–10
132.6
493.4
421.1
1,047.1
39.4
194.9
234.3
1,281.4
2–1
117.8
492.6
473.0
1,083.4
32.3
168.8
201.1
1,284.5
2–5
116.7
503.0
456.0
1,075.7
16.1
177.3
193.4
1,269.1
2–10
133.6
556.3
449.3
1,139.2
17.8
191.2
209.0
1,348.2
3–5
102.2
451.8
434.3
988.3
11.2
97.7
108.9
1,097.2
3–11
110.7
506.1
427.6
1,044.4
94.4
94.4
1,138.8
4–4
112.1
501.9
438.5
1,052.5
95.4
95.4
1,147.9
5–2
115.3
547.0
481.3
1,143.6
97.2
97.2
1,240.8
5–11
112.2
541.5
514.0
1,167.7
82.5
82.5
1,250.2
6–5
106.9
646.8
547.5
1,301.2
85.7
85.7
1,386.9
6–8
102.2
635.8
552.1
1,290.1
97.8
97.8
1,387.9
7–1
102.1
638.8
591.7
1,332.6
67.8
67.8
1,400.4
7–11
107. 1
667.2
592.4
1,366.7
53.3
53.3
1,420.0
8–2
104.8
650.9
624.4
1,380.1
40.6
40.6
1,420.7
8–5
72.5
647.0
597.4
1,316.9
40.5
40.5
1,357.3
8–11
68.9
704.2
638.8
1,411.9
41.6
41.6
1,453.5
9–10
81.7
770.5
708.4
1,560.6
42.8
42.8
1,603.4
10–5#
64.5
726.4
702.4
1,493.3
44.9
44.9
1,538.2
10–9
86.5
745.0
704.0
1,535.5
55.6
55.6
1,591.1
11–4
109.9
782.8
804.1
1,696.8
32.2
32.2
1,729.0
12–6
103.7
799.8
895.7
1,799.2
1,799.2
13–8
81.1
895.4
914.3
1,890.8
1,890.8
15–11
83.8
1,060.6
1,037.2
2,181.6
2,181.6
16–3
75.4
1,086.4
1,069.3
2,231.1
2,231.1
Note : Premax premaxilla, RLS right lateral segment, LLS left lateral segment, Tot total surface area, Ant anterior cleft
space, Post posterior cleft space, Tot Ant + Post, SA + SC bony surface area + cleft space area, # changing teeth

225
7 Complete Bilateral Cleft Lip and Palate
References
Aduss H, Friede H, Pruzansky S (1974) Management of
the protruding premaxilla. In: Georgiade NG, Hagerty
RF (eds) Symposium on management of cleft lip and
palate and associated deformities. April 12–14, Duke
University, Durham, NC, 1973. CV Mosby, St Louis,
pp 111–117
Atherton JD (1967) Morphology of facial bones in skulls
with unoperated unilateral cleft palate. Cleft Palate J
4:18–30
Atherton JD (1974) The natural history of bilateral cleft.
Angle Orthod 44:269–274
Bergland O, Borchgrevink H (1974) The role of the nasal
septum in mid-facial growth in man elucidated by
maxillary development in certain types of facial clefts.
Scand J Plast Reconstr Surg 8:42–48
Bergland O, Semb G, Abyholm F, Borchgrevink H, Eskeland
G (1986) Secondary bone grafting and orthodontic treat-
ment on patients with bilateral complete clefts of the lip
and palate. Am J Plast Surg 17:460–471
Berkowitz S (1959) Growth of the face with bilateral cleft
lip from 1 month to 8 years of age. University of
Illinois School of Dentistry, Chicago
Berkowitz S (1982) Some questions, a few answers in
maxilla-mandibular
surgery.
Clin
Plast
Surg
9:603–633
Bishara SE, Olin WH (1972) Surgical repositioning of the
premaxilla in complete bilateral cleft lip and palate.
Angle Orthod 42:139–147
Blocksma R, Leuz CA, Mellerstig KE (1975) A conserva-
tive program for managing cleft palates without the
use of mucoperiosteal fl aps. Plast Reconstr Surg
55:160–169
Boyne PJ (1974) The use of marrow cancellous bone
grafts in maxillary alveolar and palatal clefts. J Dent
Res 14:821–824
Browne D (1969) Hare-lip. Am R Coll Surg 5:1949
Burston WR (1960) The pre-surgical orthopaedic correc-
tion of the maxillary deformity in clefts of both pri-
mary and secondary palate. In: Wallace AB (ed)
Trans-actions of the international society of plastic
surgeons, second congress, London, 1959. E&S
Livingston Ltd, Edinburgh, London, pp 28–36
Burston WR (1967) Treatment of the cleft palate. Ann R
Coll Surg Engl 25:225
Coup TB, Subtelny JD (1960) Cleft palate de fi ciency or
displacement of tissue. Plast Reconstr Surg 26:600
Dahl E (1970) Craniofacial morphology in congenital clefts
of the lip and palate – an x-ray cephalometric study of
young adult males. Acta Odontol Scand 28(Suppl):57
Delaire J, Precious D (1985) Avoidance of the use of vom-
erine mucosa in primary surgical management of velo-
palatine clefts. Oral Surg Oral Med Oral Pathol
60:589–597
Delaire J, Precious D (1986) In fl uence of the nasal septum
on maxillonasal growth in patients with congenital
labiomaxillary cleft. Cleft Palate J 23:270–277
Enlow DH (1982) Handbook of facial growth. WB
Saunders, Philadelphia
Table 7.3 Surface area of CBCLP. Case PM (KK-22).The palatal surface area increased by 4,096 after 1 year, 4 months
and by 7,696 at 2 years, 1 month. By 8 years, 2 months, the palatal surface area had increased two and a half times when
the cleft space was closed
Skeletal area
Cleft space
Total
Age
Premax
RLS
LLS
Tot
Ant
Post
Tot
SA + CS
0–0–12
145.5
335.5
282.7
763.7
127.4
417.0
544.4
1,308.1
0–3
150.2
397.4
377.6
925.2
65.4
331.5
396.9
1,322.1
1–4
154.0
469.5
464.3
1,087.8
36.8
265.5
302.3
1,390.1
1–10
211.8
502.6
506.2
1,220.6
70.4
216.3
286.7
1,507.3
2–1
217.6
589.0
549.5
1,356.1
79.8
195.3
275.1
1,631.2
2–10
220.7
603.9
551.3
1,375.9
95.8
193.2
289.0
1,664.9
3–10
271.6
660.4
616.5
1,548.5
122.6
206.3
328.9
1,877.4
5–8
273.3
673.0
675.9
1,622.2
123.6
201.2
324.8
1,947.0
6–7
273.6
811.0
820.5
1,905.1
115.0
206.5
321.5
2,226.6
7–4
277.3
813.0
839.5
1,929.8
106.7
185.2
291.9
2,221.7
8–2
306.5
844.6
890.8
2,041.9
101.1
155.4
256.5
2,298.4
12–3
346.8
1,087.1
1,116.1
2,550.0
2,550.0
14–0
348.7
1,161.8
1,226.4
2,736.9
2,736.9
14–5
351.1
1,198.8
1,237.0
2,786.9
2,786.9
17–4
353.5
1,241.0
1,246.3
2,840.8
2,840.8
Note : Premax premaxilla, RLS right lateral segment, LLS left lateral segment, Tot total surface area, Ant anterior cleft
space, Post posterior cleft space, Tot Ant + Post, SA + SC bony surface area + cleft space area, # changing teeth