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

334
G. Semb and W.C. Shaw
by a few teams, and in the 1990s, the technique
was modi fi ed and popularised by Brusati and
Mannucci ( 1992 ) and Cutting and Grayson
( 1993 ) as gingivoalveoloplasty. Normally accom-
panied by active presurgical orthopaedics or
nasoalveolar moulding, the evidence required to
validate it as a desirable routine intervention will
have to con fi rm that it matches mixed dentition
bone grafting in quality and reliability, that the
additional burden imposed by the presurgical
preparation offsets the burden of mixed dentition
bone grafting and that the risk of requiring later
orthognathic surgery is not increased.
Concerns about adequacy of the bone in the
former cleft alveolus and subsequent maxil-
lary growth have been reported. With respect to
Skoog’s original procedure (Skoog 1965 ) and a
free tibial periosteal graft variation, Hellquist and
Svardström ( 1990 ) found good bone formation in
only 47 % of patients, Rintala and Ranta ( 1989 )
found 72 % required secondary bone grafting and
Renkielska et al. ( 2005 ) found 50 % of patients
operated according to the Skoog protocol-
required orthognathic surgery.
Millard adopted the active pin-retained or
“Latham appliance” as a means of reducing the
size of the cleft by aligning the alveolar segments
prior to surgery (Millard and Latham 1990 ) .
However, this led to an increased level of anterior
crossbite in unilateral and bilateral cases (Millard
et al. 1999 ) , and Berkowitz et al. ( 2004 ) reported a
likely need for orthognathic surgery in the major-
ity of patients. Similar conclusions were reached
by Henkel and Gundlach ( 1997 ) , who followed 60
Latham appliance/GPP patients with UCLP or
BCLP and found substantial horizontal and verti-
cal maxillary growth disturbance compared with a
similar group treated without Latham appliance
GPP. The success of grafting was not reported.
Two Canadian studies compared, respectively,
54 UCLP Latham appliance/GPP patients with
16 UCLP mixed dentition alveolar bone graft
patients and 53 BCLP Latham appliance GPP
patients with 10 BCLP secondary bone graft
patients in their mid-teens (Matic and Power
2008 ; Power and Matic 2009 ) . Both revealed
considerably fewer successful grafts, more
fi stulae and disturbed growth in the Latham/GPP
groups. Interestingly, no rebuttal of these critical
reports was published by the originators of the
protocol, and a subsequent report of BCLP
patients treated by the Latham appliance and GPP
con fi rmed the negative experience of others
(Latham 2007 ) . The author proposed an alterna-
tive method of palate closure and the postpone-
ment of de fi nitive lip repair till 18 months to
overcome this (Latham 2007 ) .
It is of course dif fi cult to distinguish between
the Latham appliance and gingivoperiosteoplasty
as the source of growth inhibition, and the advent
of NAM was regarded by some authors as a supe-
rior preparation for GPP since it is “a passive pro-
cess that directs the growth of the alveolar
segments” (Hopper and Birg fi eld 2009 ) . Hsieh
et al. ( 2010 ) found maxillary growth at age 5 to be
worse with GPP and NAM than with NAM alone.
Long-term follow-up of a GPP variant postponed
till the time of palate repair at 18–36 months indi-
cated a higher need for orthognathic surgery in
comparison with a sample from the same centre
and a sample from another centre who received
conventional mixed dentition bone grafting
(Meazzini et al. 2010 ) .
15.6.11 High-Volume Surgeons
It is self-evident that regardless of the protocol
selected, the end result will bene fi t from skilful
performance of the surgery, and there is ample
evidence from the fi ndings reported above that
surgeons who have selected the same protocols
may achieve remarkably different results.
Differing interpretations of the detail of what
should be done to execute a procedure that has
been described or even demonstrated by a differ-
ent surgeon may be a factor in explaining differ-
ent outcome; differing stages of progress along a
learning curve of a new procedure may be another
factor. However, the individual intrinsic skill
brought to the operating room, be that dexterity,
delicacy, lightness of touch or whatever, seems
crucial if impossible to quantify.
An investigation of factors in fl uencing the suc-
cess of alveolar bone grafts on 825 cleft sites
treated at the same centre examined 22 possible

335
15 Facial Growth Related to Surgical Methods
explanatory variables regarding patient age, cleft
type and related features. In a multiple regression
analysis, the most in fl uential single factor was the
surgeon performing the graft (Semb et al. 2003 ). In
general, it is possible that surgical skill is more
in fl uential than the choice of protocol.
Other than ensuring the completion of recogn-
ised training pathways, there is not much that can
be done to assure high levels of performance. One
possible step might be to require that a cleft sur-
geon has suf fi cient regular practice of cleft surgery
to maintain competence. This was explored in the
national review of cleft care standards carried out
in the UK, and outcomes for surgeons who had 30
or more new referrals for primary surgery per year
were compared with those who had less and found
to have better outcomes in some measures, whereas
the low-volume operators never had better out-
comes (Bearn et al. 2001 ; Table 15.1 ). Following
restructuring of national services on regional cen-
tres, improvements in outcome for dental arch
relationship have been demonstrated (Russell
et al. 2011 ) . Volume per se provides no guarantee
of course, and the worst case scenario would be
when a high-volume surgeon is unskilful. At least
high-volume surgery makes it much easier for the
surgeon to audit outcomes.
15.7
Bilateral Cleft Lip and Palate
Closure
A number of single-centre studies have been
reported, but since complete BCLP is less fre-
quent, occurring in around 7 % of individuals with
clefts (Sivertsen et al. 2008 ) , these are fewer and
often include small samples. A previous review
identi fi ed 15 case series with samples ranging
from 90 to 7 cases (Semb and Shaw 1996 ) .
The sample with 90 complete BCLP patients
followed longitudinally provides a reference frame
for comparison (Semb 1991b ) , its protocol involv-
ing two-stage lip repair and a vomer fl ap to close
the hard palate at 3–4 months of age, and subse-
quent posterior palatal closure by a modi fi ed von
Langenbeck technique at 18 months. Comparable
values for maxillary prominence were attained by
several other protocols including a Czech group
of 26 males whose protocol included palatoplasty
with pushback and primary pharyngeal fl ap at a
mean age of 5.8 years and premaxillary setback
surgery in one third of cases (Smahel 1984 ) ; three
groups from the same Swedish centre, two of
whom underwent periosteoplasty (Hellquist and
Svardström 1990 ) ; an American group who under-
went primary bone grafting (Rosenstein et al.
1991 ) ; and a centre that used presurgical orthopae-
dics and delayed hard palate closure (Heidbüchel
et al. 1994 ; Gnoinski and Rutz 2009 .) More favour-
able values were achieved by a Canadian sample
whose protocol included vomerplasty (Trotman
and Ross 1993 ) . Melissaratou and Friede ( 2002 )
also reported better occlusion in a comparison
of 16 patients after delayed closure with 12 with
early closure, treated at the same centre, though
there were few statistically signi fi cant differences.
Formal intercentre studies are scarce, but a
large longitudinal study including 204 patients
from three centres in the Netherlands, Norway
and Sweden has recently been reported (Bartzela
et al. 2010 ) . Despite the use of quite different pro-
tocols, dental arch relationships for patients in the
three centres were similar at age 9 and 12 years.
Delaying hard palate closure and employing infant
orthopaedics did not appear advantageous in the
Variable
5-year-olds
12-year-olds
Intelligibility a
–
p < .001
Hypernasality a
p < .05
p < .001
GOSLON
–
–
Fistula with symptoms a
p < .05
–
Nasal appearance a
p < .05
–
Lip appearance
–
–
Pro fi le appearance
–
–
a Better outcome was achieved by high-volume operators
Table 15.1 Signi fi cant
differences between
high- and low-volume
operators

336
G. Semb and W.C. Shaw
long run, at least for the outcome studied in this
investigation. Premaxillary osteotomy at 8–9 years
appeared to be associated with less favourable
development of dental arch relationship between 9
and 12 years. These fi ndings were con fi rmed in a
later cephalometric study (Bartzela et al. 2012 ) .
15.7.1 Surgical Setback
of the Premaxilla
The premaxillary setback procedure is an espe-
cially controversial issue, but the fi ndings from two
centres in which it has been practised selectively
indicate a tendency for more growth impairment in
the setback groups (Friede and Pruzansky 1985 ;
Bardach et al. 1992 ) , con fi rming the experience of
Bartzela et al. ( 2010 ). Bardach et al. ( 1992 ) also
report and highlight a risk of devitalisation and loss
of the central incisors with setback around age 5.
15.8
Reliability of Evidence
15.8.1 Retrospective Comparison
Studies
On the basis of the information identi fi ed in this
chapter, it is clear that confusion, uncertainty and
controversy still beset the choice of methods of
surgical closure. The bulk of the evidence base
currently comes from retrospective individual
centre reports that are commonly limited in sam-
ple size. However, formal sample size calcula-
tions for prospective studies generally require
quite large samples. For example, two groups of
75 in each of the Scandcleft trials of different sur-
gical protocols and two groups of 325 in the
TOPS trial of timing of cleft repair (NIH 2010 )
were estimated as the required sample. Few of
the retrospective comparisons described in this
chapter approach these levels.
Statistical comparison of different reports is
often not possible, and the common biases that
apply to comparison studies in general (Table 15.2 )
are generally more problematic when reports from
different centres are put side by side. These reports
may well have different case mixes, different
measurement techniques, different follow-up and
exclusion protocols and of course different sur-
geons. And, in the fi rst place, fi ndings that have
proved disappointing may not have been reported
at all, distorting the overall picture.
15.8.2 Intercentre Comparisons
Prospectively, planned recall of patients at partici-
pating centres allows data on outcome to be col-
lected in a more standardised way, and rigorous
planning and execution across centres can ensure
consecutive patient inclusion and consistent eval-
Table 15.2 Potential sources of bias in cleft research
Source of bias
Example
Case mix bias
Comparisons of facial growth data may be dubious where there are inherent differences in
facial form between communities. Or where differences in referral patterns in respect of
case dif fi culty occur
Pro fi ciency bias
The skill of a more gifted surgeon or clinical team can in fl ate the apparent effectiveness
of the technique. If operator A is 10 % better than operator B and technique X is 5 %
better than technique Y, a false conclusion will be reached in a comparison of technique
Y performed by A versus technique X performed by B
Follow-up bias
Without knowing about all the cases on whom a particular technique was tried, reliable
conclusions cannot be drawn. Follow-up should be equally rigorous for cases that went badly
Exclusion bias
Irregular application of grounds for retrospective exclusion, for example, “uncooperative”
or “did not really fi t the criteria”, can remove any equivalence that comparison groups
may have had
Analysis bias
When raters are not blinded to the treatment allocation of patients, or simply interpret
cephalometric x-ray features or apply indices of dental arch relationship differently
Reporting bias
When negative or disappointing fi ndings remain unpublished

337
15 Facial Growth Related to Surgical Methods
uation (Chap. 18 ). Of course, these studies are
comparing the protocols and the level of skill with
which they were executed, as well as other aspects
of the treatment program. None the less, they pro-
vide a valuable opportunity for centres to appraise
their standards of care, to reconsider choice of
protocol, to build research partnerships and to
stimulate prospective collaborative research (see
Chap. 18 ). Additional centres can also “partici-
pate” in these comparisons at a later date provided
they follow the same methodology in partnership
with members of the original group; they can also
obtain similar bene fi ts.
15.8.3 Intracentre Comparisons
Non-randomised intracentre studies potentially
avoid several biases (the surgeon, case mix and other
background variables may be the same), though
comparisons between groups treated in different
time periods can still be distorted (WHO 2002 ) .
15.8.4 Prospective Cohort Studies
These occupy an intermediate position between
non-randomised studies and randomised control
trials. As records of all consecutive cases are fi led
with the study registry prior to the start of treatment
as well as after it, justi fi cation for non-follow-up
would be required. As in well-conducted clinical
trials, analysis bias can be overcome by employing
blinded independent raters, while reporting bias
should be overcome by the greater impartiality of
the partnership and its predetermined conventions.
Case mix bias and exclusion bias cannot be mini-
mised with the assurance derived from random
allocation, but some checks of equivalence might
be possible. Clinical pro fi ciency however would
inevitably remain as a major bias.
15.8.5 Randomised Control Trials
For the fairest comparison of therapies, there is
little doubt that the randomised controlled trial is
generally the method of choice, scienti fi cally and
ethically. Prognostic factors, including clinical
pro fi ciency, whether known or unknown to the
investigator, tend to be balanced between treat-
ment groups. Since patients are registered prior to
treatment and followed up prospectively accord-
ing to a clearly de fi ned protocol, missing data are
less likely as the potential loss to follow-up and
late exclusion is reduced. Formalising the proto-
col at the outset, as required by an ethical review
board or funding agency, increases the likelihood
of consistent record collection and impartial anal-
ysis. The likelihood of reporting the results regard-
less of the fi ndings is also increased by the
conventions of trial registration and funding.
However, randomised trials are not for the
faint hearted! Trials that compare treatments that
are currently in common use must comply with
the same codes of governance concerning the
integrity of data, ethics and con fi dentiality
required for high-risk drug trials and so involve a
high level of bureaucracy and administration.
There are efforts to correct this (Academy of
Medical Sciences 2011 ) . If the challenge is met,
they remain the surest way of singling out the
in fl uence of surgical protocols on facial growth
and other outcomes. They are feasible in large
centres or in large collaborative groups, but they
require high levels of goodwill and commitment.
15.8.5.1 Scandcleft Trials
Ten centres in Denmark, Finland, Norway,
Sweden and the UK are currently participating in
a set of three randomised trials where groups of
teams are testing their traditional local protocols
against a common protocol (Semb 2001 ) . The
sample size requirements of 450 infants with
UCLP, 150 per trial, were attained, and the
planned initial follow-up to age 5 has been com-
pleted. The principle outcomes are speech and
dentofacial relationship at age 5 years. Only 7 %
of the parents declined participation in the trials,
and follow-up rate at 5 years is 96.5 %. In each
trial, each surgeon has performed the two trial
protocols on an equal number of infants.
Three groups of centres are testing their tradi-
tional local protocols against a newly de fi ned
common method. In the common method, the lip
was repaired simultaneously with soft palate

338
G. Semb and W.C. Shaw
closure at 3–4 months, followed by hard palate
closure at 12 months. In Trial 1, this was com-
pared with hard palate closure delayed till 3 years.
In Trial 2, the common leg was compared to clo-
sure of the lip at 3–4 months followed by closure
of the hard and soft palate together at 12 months.
In Trial 3, the common leg was compared to lip
and hard palate closure at 3–4 months followed
by soft palate closure at 12 months.
At the time of writing, the principal outcomes,
speech and dentofacial development are being
analysed. It is hoped that the results will shed
light on the delayed closure controversy, the
in fl uence of variations in sequence of closure, the
in fl uence of learning curve and the in fl uence of
surgical skill.
15.9
Conclusions
15.9.1 Craniofacial Development
Craniofacial development associated with cleft
lip and palate and the impact of surgery have
been well described in the literature. But mecha-
nisms that can explain normal and post-surgical
development and how surgery interferes with
growth are not well understood. Progress in these
areas has been negligible in recent decades as
craniofacial biology has shifted focus from struc-
tural histology to aetiology and the role of signal-
ling molecules and growth factors in orofacial
embryogenesis.
15.9.2 Limitations of Current Research
Clinical research in cleft care is challenging. Low
prevalence and the variety of cleft subtypes make
it dif fi cult to gather adequate samples, collabora-
tive working between cleft centres and nations
has barely begun and the timescale of most proj-
ects is daunting. The font of current knowledge is
largely composed of potentially fl awed, under-
powered retrospective studies. Not surprisingly,
this overview has found no good evidence to
resolve
the
counter
claims
reviewed
in
Sect. 15.6 .
15.9.3 In fl uence of Surgical Skill
A recurring theme arising from the slightly more
dependable intercentre studies cited in Sect. 15.6.4
is that satisfactory growth outcomes can be
achieved by very different protocols. These
include one-stage closure, three-stage closure,
use or non-use of vomer fl aps, delayed or early
hard palate closure, use or non-use of presurgical
orthopaedics and highly demanding or simpler
protocols. All this strongly suggests that surgical
skill may be the primary factor in determining
ultimate success.
15.9.4 Making a Choice
So there is much to be said for a centre adhering
to a familiar surgical protocol where satisfactory
results across the range of relevant outcomes
have been con fi rmed by critical evaluation, such
as that gained by participation in a formal inter-
centre study. On the other hand, if a centre’s
current protocol is especially burdensome, it
would be reasonable to consider changing to a
well-proven mainstream protocol that is easier on
the child and family.
Where a change is being considered or a new
service is about to be established, the literature
reviewed in this chapter could be summarised as
follows:
Delayed hard palate closure : There is no evi-
dence that delayed closure systematically sur-
passes early closure in achieving satisfactory
growth results and, given the potential harm to
speech development, may not be justi fi ed.
Efforts to minimize trauma and scarring : There is
inconsistent evidence regarding techniques
that may leave large areas of denuded palatal
bone and restrain growth. However, it would
seem wise to adopt mainstream methods
designed to limit scarring.
Vomer fl ap : Theoretical objections to vomerplasty
have been repeatedly contradicted by intercen-
tre and other studies. It deserves its place as a
safe mainstream method in UCLP and BCLP.
Extensive orofacial muscle dissection : There is
no evidence that this procedure is bene fi cial to
growth.

339
15 Facial Growth Related to Surgical Methods
Single-stage or multiple-stage repair : One, two
or three stage and closure of UCLP are com-
patible with good growth, and the burden of
care should be considered.
Early bone grafting : The balance of evidence is
fi rmly against early bone grafting.
Presurgical infant orthopaedics : This is neutral to
growth and other outcomes. Rejecting it will
reduce the burden on the child and family.
The Latham appliance : This is probably harmful
to growth, and it certainly would ease the bur-
den on the child and family to abandon it.
Nasoalveolar moulding : Despite its usage for
almost two decades, there is inadequate evi-
dence to judge whether its bene fi ts outweigh
its disadvantages. Proper research is overdue.
Gingivoperiosteoplasty : There is some evidence
that GPP presents a risk to growth, and little
evidence that it reliably obviates the need for
later grafting.
BCLP surgery : Diverse protocols can achieve
satisfactory growth outcomes, and it appears
appropriate to select one that minimises the
burden on child and family.
Setback of the premaxilla : There is no evidence
that this technique is justi fi ed, but some evi-
dence that it is harmful.
High-volume surgeons : Con fi ning surgery to high-
volume surgeons provides some assurance of
better outcomes and allows meaningful clinical
audit to be conducted over a shorter time span.
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Part VI
Lip and Palate Surgery:
Millard–Berkowitz Protocol

347
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_16, © Springer-Verlag Berlin Heidelberg 2013
16
The collected serial data will provide the clinician
in training with an overview of the variations that
can be encountered in each cleft type, the
signi fi cance of genotype differences that in fl uence
growth and response to surgery, and the natural
history of each cleft entity.
Serial records of cleft lip and/or palate provide
useful data in studying morphologic growth
changes in the head (evaluating dentofacial
abnormalities) and assessing responses to surgi-
cal and orthodontic treatment. The data have been
particularly useful in determining the timing and
type of procedure selected to treat individual
problems. The measurements and analyses uti-
lized are primarily pro fi le-oriented and reveal
both anteroposterior and vertical relationships of
the various parts of the dentofacial complex.
The anteroposterior and vertical growth of the
midface is not yet completely understood. The stim-
ulus or growth force is still being debated. However,
it is essential to understand the basic maxillary
growth concepts to appreciate the in fl uence of pala-
tal and facial surgery on midfacial growth.
Enlow ( 1982 ) states that:
Growth is not “programmed” within the calci fi ed
part of the bone itself. The “blueprint” for the
design, construction, and growth of a bone lies in
the functional matrix: the composite of the mus-
cles, tongue, lips, cheeks, integument, mucosa,
connective tissue, nerves, blood vessel, airways,
pharynx, the brain as an organ mass, tonsils, ade-
noids, and so on. Growth fi elds (growth sites) for
example, a suture and the alveolar bone housing
teeth, throughout a bone do not have the same rate
of growth activity. Some “ fi elds” grow much more
rapidly or to a greater extent than others. The same
is true for resorptive fi elds. All surfaces are sites of
growth; relocation of the bone, going from one
location to another, is the basis for remodeling.
In the maxilla, the palate grows downward
(i.e., becomes relocated interiorly) by periosteal
resorption on the nasal side and periosteal deposi-
tion on the oral side. The nasal mucosa provides the
periosteum on one side, and the oral mucosa pro-
vides it on the other side; together, growth remodel-
ing is paced by the composite of soft tissue housing
the palate. This results in a downward relocation of
the whole palate-maxillary arch composite.
The bone tissue that comes to house the teeth
at older age periods is not the same actual bone
enclosing them during the succession of former
growth levels.
Depending on the extent of palatal surgery and
the resulting scar tissue, the stability of a region can
be disrupted if the results negatively affect the pat-
tern of resorptive and depository fi elds on bone and
at the suture; that is, scarring can work against
growth. As the midface grows, bone is laid down in
the sutures surrounding the maxillary complex. Any
The In fl uence of Conservative
Surgery on Growth and Occlusion
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

348
S. Berkowitz
damage to one of these sutures can interfere with the
direction and amount of growth. For example, an
excessive amount of scarring at the pterygomaxillary
suture (PTM), or at the premaxillary vomerine suture
(PVS), will interfere with anteroposterior and verti-
cal maxillary and premaxillary growth (Fig. 16.1 ).
Growth movement of the premaxilla is pro-
duced by the growth expansion of all the bones
behind and above it and by growth in other parts
of the maxilla, especially at the premaxillary
vomerine suture (PVS). The premaxilla itself
contributes a major part of its own forward growth
movement through changes at the PVS. These
displacement growth movements are a result of
the “carry effect,” as Enlow calls it, which is pro-
duced by the expansion of the soft tissues associ-
ated with the bones, not a “pushing effect” of
bones against bones. Scarring of the palatal
mucoperiosteum, therefore, acts to interfere with
the “carry effect,” thus preventing the change in
position of the maxilla within the face.
Berkowitz speculates that pressure forces cre-
ated by the uniting of the cleft orbicularis oris are
directed posteriorly through the maxilla and nasal
septum to the maxillary sutures and premaxillary
vomerine suture, respectively. This action is similar
to that of a headgear (cervical traction) used to con-
trol midfacial growth in orthodontics. These forces
interfere with the ability of the premaxillary vom-
erine suture and the pterygomaxillary suture to
function properly and lead to some degree of midfa-
cial retrusion. Berkowitz’s clinical fi ndings support
the concept that maxillary growth can be restrained
by a variety of force systems. Marked deformation
and gross changes can result when large forces are
used over long periods of time. Maxillary maldevel-
opment is three-dimensional, resulting in a decrease
in midfacial height, length, and width.
16.1
Surgical Closure of the Cleft
Lip and Palate
Enthusiasm for a particular form of therapy
should not be regarded as scienti fi cally estab-
lished when, in fact, it has not been subjected to
critical scienti fi c analysis. Treatment fads come
and go. Unfortunately, in cleft palate surgery, it
takes at least a decade to determine the effective-
ness of a procedure. A prior belief in a particular
therapy often determines the biased selection of
evidence to support a concept currently in vogue;
some clinicians show a select sample of cases to
prove the theory only in part, if at all.
The following chapters will present our under-
standing of the cleft defect and the face in which
it exists. These chapters are designed to answer
some basic questions: What is the natural history
of the cleft defect? How do similarly classi fi ed
clefts differ from each other? What should be
done for a child with a cleft lip and palate, and
when should it be done? And fi nally, how does
the treatment vary from child to child?
Although selected cases will be shown to
develop our treatment philosophy, it must be
Fig. 16.1 Complete bilateral cleft lip and palate cast
( top ). Occlusal x-ray fi lm ( bottom ). ‘ a ’ indicates premax-
illary vomerine suture ( PVS )

349
16 The In fl uence of Conservative Surgery on Growth and Occlusion
stressed at the start that the concepts being pre-
sented are supported by fi ndings from many lon-
gitudinal facial growth studies already published
by our clinic and others worldwide. The cases
from our center are unique to the extent that they
represent the results of only one surgeon who is
considered a master at his craft. Treatment fail-
ures as well as successes will be presented to
develop and stress the physiological principles
that are the basis of this treatment philosophy.
Improvements in surgical and orthodontic treat-
ment methods, coupled with a better understand-
ing of the natural history of cleft palate growth and
development, have led to different yet frequently
successful treatment protocols. Although some
readers may be concerned that variations in suc-
cessful treatment strategies interfere with compar-
isons and eventual standardization of treatment
outcomes, nothing could be further from the truth.
The one conclusion that should be drawn from
these reports of clinical innovations is that there is
more than one successful treatment protocol.
If the sample populations are large enough,
any statistical evaluation of a generally successful
treatment approach will show a certain proportion
of failures. Obviously, a number of different phys-
iological surgical procedures can be successful,
provided that other dependent variables, such as
the facial growth pattern and geometric form of
the cleft defect, are complementary.
There is no reason to think that, by standard-
izing treatment protocols (as to type and timing),
the same surgical procedure invariably will be suc-
cessful. Certainly the skill employed is equally
important. Moreover, it is a well-known fact that
the same surgery, performed by the same surgeon
on the same cleft type, can yield different results.
Why? To fi nd an answer to this question, it is neces-
sary to change one’s primary focus from solely the
surgery employed to the cleft defect itself and the
face in which it exists. Doing so enables the clini-
cian to take into account three mutually dependent
critical variables: (1) the cleft defect, (2) the facial
growth pattern, and (3) the surgical procedure (see
Chap. 16 , Changing Philosophy of Surgery of the
Cleft Lip and Palate in Goteborg, Sweden).
16.2
Lip Surgery
In a comprehensive evaluation of maxillary growth
and development, the principles and techniques of
tissue repair are of paramount importance as an
integral part of any maxillary surgery. The basic
requirement of any soft tissue closure, whether in
unilateral or bilateral clefts of the lip, is that the
full width of the lip be maintained. Clinical obser-
vations have shown that a moderately tight lip will
hamper, to some extent, maxillary growth and pro-
duce some deformity with subsequent malocclu-
sion of the permanent dentition. Skoog ( 1974 ) has
written that, in the cleft deformity, there is a vari-
able but absolute tissue shortage. He concludes
that, to be effective and achieve an anatomically
correct and aesthetically pleasing result, recon-
struction must therefore preserve and utilize all
available tissue. Millard ( 1980 ) has stressed that,
in bilateral clefts of the lip, the prolabium – regard-
less of its size – should always be positioned to the
vermilion border (Fig. 16.2 ).
Fig. 16.2 ( a , b ) Incomplete
bilateral cleft lip and palate.
( a ) Presurgery. ( b ) 1 year
and 6 months (1–6) after the
lip is united. The prolabium
extends to the vermilion
borders

350
S. Berkowitz
16.2.1 Lip Adhesion
The cleft lip can be closed at any time from the
fi rst day of life, but the rule of “over ten” is usually
followed. At 10 weeks of age, 10 lb, and 10 g of
hemoglobin,
elective
surgery
is
generally
considered safe, and the lip and nose have
increased enough in size to facilitate the detailed
surgery. Thus, most surgeons recommend surgical
repair of the cleft lip at about 3 months of age.
Incisions in the sulcus and undermining of
the soft tissues on the external surface of the
maxillary segments were once commonly used
to facilitate lip closure and decrease lip tension,
especially in wide clefts (Fig. 16.3 ). Walker
et al. ( 1966 ) , Bardach and Eisbach ( 1977 ) ,
Bardach et al. ( 1979, 1982 ) , and Collito ( 1974 )
questioned the advisability of performing this
procedure because they observed clinically
that it contributed to secondary maxillofacial
deformities and midfacial growth inhibition
because of excessive scarring. This objection
led Walker et al. ( 1966 ) to present their con-
cept of the Collito–Walker (C-W) technique
of uniting the cleft lip (i.e., the use of lip adhe-
sion without undermining; Figs. 16.4 and 16.5 ).
Bardach et al. ( 1982 ) , using rabbits, showed
that lip repair with soft tissue undermining
led to signi fi cant shortening of the maxillary
complex. There is no reason to believe that the
same negative effect would not also occur on
children with lip/alveolar clefts, and therefore
Bardach et al. ( 1982 ) concluded that the lip
adhesion procedure is preferred even though
the posterior-directed pressure of the united lip
potentially can slow down midfacial growth.
Fig. 16.3 Surgery to unite the lip over a large cleft space
in one procedure. Undermining the soft tissue on the
buccal alveolar surface posteriorly to the maxillary
tuberosity prior to uniting the cleft lip has led to scarring
and maxillary deformity. This surgery is no longer being
performed and has been replaced with a lip adhesion or
the use of external elastics as the fi rst procedure of choice
(Courtesy of Bardach ( 1990 ) )
Fig. 16.4 ( a – d ) Lip adhesion. ( a ) Complete unilateral cleft lip and palate at birth. ( b ) Lip adhesion at 3 months. ( c ) After
de fi nitive lip repair at 7 months. ( d ) Symmetrical lip at 11 months

351
16 The In fl uence of Conservative Surgery on Growth and Occlusion
16.3
Palatal Cleft Surgery: Type,
Timing, and Sequence
(Figs. 16.6 , 16.7 , and 16.8 )
16.3.1 What to Do and When to Do It:
Speech and Palatal Growth
Considerations
16.3.2 False Premise 1/2 Wrong
Conclusions 1/2 Therapeutic
Folly
At the turn of the last century, surgeons involved
in cleft palate treatment usually performed
surgical procedures whose sole purpose was to
“close the hole” as early as possible without con-
sidering the ultimate effect of the surgery on
palatal, facial, or speech development. These
procedures, Millard ( 1980 ) reports, fall into
three categories:
1. The use of various kinds of fl aps from
other parts of the body to cover the cleft
space.
2. Treating the edges of the cleft so that they
could be sutured together by pulling the muco-
periosteum over the cleft. Failure of a lasting
union led to the use of laterally positioned
relaxation incisions by Dieffenback in 1826
Fig. 16.5 ( a – c ) Lip adhesion in
an incomplete bilateral cleft lip
and palate. ( a ) At birth. ( b ) At
3 years, after lip adhesion and
de fi nitive lip surgery at 8 months.
( c ) Full face at 3 years, showing
good “cupid’s bow” and lip and
nose symmetry
15 days
31 days
1 month to 15 days
6 months to 10 days
5 months to 6 days
4 months to 0 day
Fig. 16.6 An example of molding of overexpanded
lateral palatal segments. In CUCLP, a lip adhesion was
performed at 3 months of age without prior presurgical
orthopedics. The alveolar cleft gradually closed with the
alveolar segments overlapping

352
S. Berkowitz
and von Langenbeck in 1862 (Lindsay 1974 )
(Figs. 16.9 , 16.10 , and 16.11 ).
3. Staged surgical treatment.
Gillies ( 1920 ) , an early proponent of staged sur-
gical treatment procedure, mistakenly believed
that the maxillary and mandibular arches were in
a normal occlusal relationship at birth. He did
not appreciate the distorting effect of aberrant
muscle forces on the geometric relationship of
the palatal segments to each other. He did, how-
ever, suggest that the lip be united soon after
birth and that the soft palate be detached from
the hard palate and “pushed back” to increase its
length. The cleft in the hard palate was to be
closed before speech generally began at 2 years
of age. For some surgeons, this is still the best
surgical sequence to follow.
In the 1920s, William Wardill (Veau 1922 )
focused his interest on controlling air fl ow
through the nose. He appreciated the value of the
velum along with the levators as a part of
the sphincteric muscle system. Because uniting
the soft palate alone often did not bring good
speech, many surgeons (e.g., (Veau 1922 ; Veau
and Borel 1931 ; Wardill 1937 ; Dorrance 1933 )
believed, as Gillies ( 1920 ) did, that the velar
length was insuf fi cient in the von Langenbeck
procedure and advocated “pushback” procedures
(Calnan 1971 ) .
In 1937, Kilner ( 1937 ) in London and Wardill
( 1937 ) in New Castle, publishing independently,
described a technique of palatal repair that ulti-
mately came to be known as the V-Y retroposition
operation. Wardill ( 1937 ) and Kilner ( 1937 ) both
adopted the Veau technique for anterior repair,
and the resulting “Veau–Wardill–Kilner” opera-
tion consisted of (1) lateral relaxing incisions, (2)
bilateral fl aps based on posterior palatine arteries,
(3) nasal mucosa closed as a separate layer, (4)
fracture of the hamulus, (5) separate muscular lay-
Fig. 16.7 ( a ) Lip adhesion causes premaxillary ventro-
fl exion. Class II malocclusion with severe overjet. Anterior
cleft space remains after 3 years and 10 months. No deci-
sion about correction of the overjet should be made at this
age. An obturator closing off the cleft space will improve
speech and feeding. Palatal growth needs to be considered
for future treatment

353
16 The In fl uence of Conservative Surgery on Growth and Occlusion
( b ) CBCLP. Serial cast of two cases (Figs.
16.7a, b and 16.8 ) demonstrates that the premaxilla and pala-
tal shelves may react differently during the fi rst years to the
forces created by a lip strap attached to a head bonnet fol-
lowed by lip surgery. In this fi gure, slow reduction of the ante-
rior cleft space characterized this case. Although ventro fl exion
occurs, the anterior cleft space (the space between the
premaxilla and the lateral palatal segments) remained until
3 years and 10 months of age with a severe premaxillary
overjet and overbite. No surgery to the premaxilla was neces-
sary other than alveolar bone grafting at 8 years. The follow-
ing series of casts show the attainment of excellent aesthetics,
occlusion, and speech. Palatal surgery using a von Langenbeck
with vomer fl ap was performed at 23 months of age
Fig. 16.7

354
S. Berkowitz
Fig. 16.8 Serial BCLP casts
showing a rapid reduction in
the anterior cleft space. The
premaxilla made contact
with the palatal shelves by
12 months of age while being
positioned forward of them.
Palatal surgery at 20 months
of age resulted in excellent
premaxillary overbite and
overjet by 5 years of age.
Good speech and aesthetics
resulted

355
16 The In fl uence of Conservative Surgery on Growth and Occlusion
Fig. 16.9 Von Langenbeck
(simple closure) palatoplasty
for isolated cleft palate
Fig. 16.10 ( a – c ) von Langenbeck (simple closure)
palatoplasty for bilateral complete cleft lip-cleft palate.
The con fi guration of this deformity varies tremendously,
and line drawings can be misleading. ( a ) The incision
lines. The inferior border of the vomer is incised, and
mucous membrane is elevated from both sides. ( b )
Mucoperiosteal fl aps are elevated without anterior detach-
ment, keeping the posterior palatine arteries intact.
Extensive dissection is frequently necessary in the lateral-
release incision area for this anomaly when the cleft is
usually wide and there is usually considerable hypoplasia.
The timing of surgical closure is delayed until there is
additional palatal growth at the expense of the palatal cleft
space. The nasal mucosa is closed. Two suture lines are
necessary anteriorly because of the two vomer fl aps. ( c )
Oral mucosa closure. It is impossible to close the anterior
portions of the cleft with this operation. The amount of
denuded palatine bone is less, however. Anterior cleft clo-
sure is performed simultaneously with a secondary alveo-
lar bone graft. Depending on the occlusion and extent of
the anterior cleft space, the premaxilla and/or the lateral
palatal segments are repositioned at the time of anterior
cleft closure (Reprinted from Lindsay ( 1975 ) , with
permission from WB Saunders Co.)
Fig. 16.11 ( a – c ) von Langenbeck (simple closure)
palatoplasty for complete unilateral cleft lip-cleft palate.
( a ) The incision lines. ( b ) Mucoperiosteal fl aps have been
elevated, although this is not well shown in this diagram.
The nasal mucosa is closed. In this anomaly, the nasal
mucosa on the noncleft or medial side is continuous with
the septum and vomer. More is available to manipulate.
( c ) Oral mucosa closure. Note that it is impossible to
obtain a two-layer closure of the alveolar portion of the
cleft with this operation. Lateral raw areas are relatively
smaller because the mucoperiosteum is not detached ante-
riorly. The anterior cleft space is closed simultaneously
with a secondary alveolar bone graft (Reprinted from
Lindsay ( 1975 ) , with permission from WB Saunders Co.)

356
S. Berkowitz
ered closure, and (6) V-Y type of palatal lengthen-
ing (Figs. 16.9 , 16.10 , 16.11 , and 16.12 ).
Soon various pharyngeal fl ap techniques were
introduced when it was suspected that the velum
was still too short even after it was moved back
(Curtin 1974 ) .
In 1958, Kilner ( 1958 ) listed what he believed
should be the aims of cleft palate treatment, in
order of importance, as: speech, chewing, and
aesthetics. This order of priorities is still preferred
by many plastic surgeons, as well as speech-
language pathologists. As a result, the surgical
treatment concepts have been slow to change.
To “close the hole as early as possible” with or
without velar pushback is still a widely prevailing
concept.
“What to do and when to do it” were ques-
tions that had no universally accepted answers.
Although surgeons such as Veau ( 1922 ) and
Veau and Borel 1931 ) , who appreciated the
morphological differences in cleft types, still
believed that closing the cleft palate early
would improve speech development, many
others began to think differently and empha-
Fig. 16.12 ( a – h ) The three- fl ap
Wardill-Kilner pushback modi fi ed
after Braithwaite. ( a ) The margins of
the soft-palate cleft have been pared,
and the cleft of the hard palate
incised along the junction of oral and
nasal mucoperiosteum. The lateral
incision has been made inside the
alveolar ridge from opposite the
canine anteriorly to a point just
behind the hamulus posteriorly. An
oblique incision joins the anterior
end of the lateral incision to the cleft
margin. ( b ) The mucoperiosteal fl ap
has been elevated from the hard
palate. ( c ) The oral mucoperiosteal
fl ap has been turned back, showing
the greater palatine vessels passing
from the greater palatine foramen to
the fl ap. The mucosa has been
elevated from the septum (the vomer)
which is attached to the margin of the
palate on this side. ( d ) The muscles
have been detached from the back of
the hard palate. The soft palate is
falling away from the hard palate and
becoming elongated. This is the
“pushback.” ( e ) The muscle has been
freed from the overlying mucosa. ( f )
The muscle has been freed laterally
and has been rotated medially. ( g )
The two muscle bundles have been
overlapped and sutured under slight
tension to construct the muscle sling.
The nasal mucosa has been sutured.
( h ) Suturing of the oral layer is
completed. The tips of the oral
mucoperiosteal fl aps are sutured to
the apex of the anterior fl ap,
indicating the degree of palatal
lengthening (Reprinted from
Edwards and Watson ( 1980 ) , with
permission)

357
16 The In fl uence of Conservative Surgery on Growth and Occlusion
sized the need for normal midfacial and pal-
atal development. They recommended that
cleft palate closure be postponed until either
the deciduous or the permanent dentition had
erupted. Advocates of delaying palatal closure
were in fl uenced by Graber ( 1950, 1954 ) and
also by Slaughter and Brodie ( 1949 ) , who were
disturbed by the results of Brophy’s ( 1904 ) and
other procedures in vogue at that time. They
wanted to avoid secondary malformations to
the palate and severe deformities of the max-
illa caused by extensive mucoperiosteal under-
mining with wide lateral areas of denuded bone
which led to severe scarring. Similar malfor-
mations were created in animals by Kremenak
et al. ( 1970, 1971, 1977 ) .
16.4
The Effect of Surgery
on Maxillary Growth
Kremenak and his colleagues ( 1967, 1971, 1976 )
reported a series of follow-up studies on beagles,
based on earlier work, showing that surgical
denuding of palatal bone adjacent to deciduous
teeth resulted in inhibiting maxillary growth.
More recent efforts by this group have focused
on the contraction phase of early healing of sur-
gical wounds on the canine palate. Olin and
associates ( 1974 ) presented data based on mea-
surements between tattoo points on wound mar-
gins on hard palates of young beagles. They
noted that major interruptions in the increase of
arch width coincided with the period of soft tis-
sue contraction. This led Olin et al. ( 1974 ) to
suggest that the contraction of wounds following
surgery could be the fi rst link in a causal chain
leading
eventually
to
secondary
skeletal
deformities.
Kremenak and associates ( 1970 ) reported
related evidence that the contraction seen in pala-
tal mucosa was analogous to that reported in the
healing of skin wounds. Transplanting autoge-
nous grafts from other oral mucosa into mucope-
riosteal excision wounds of the hard palate
resulted in a reduction in contraction and was fol-
lowed by normal or “supranormal” increases in
maxillary arch width. They concluded that more
research in this area was warranted.
It is becoming apparent that the factor of
contractility in some types of nonmuscular con-
nective tissue cells may be a common denomi-
nator for research on surgical wound healing, as
well as for research on normal and abnormal
growth and function in the craniofacial com-
plex. There is a large body of literature dealing
with advances in the understanding of contrac-
tile phenomena. Much of it is collected in a bib-
liographic review by Morris and Kremenak
( 1976 ) . The report by Madden and associates
( 1974 ) also provides an excellent overview of
this area of inquiry.
Is surgery for the repair of cleft lip and pal-
ate to be determined by the age of the patient
or by the palate’s morphological characteris-
tics and the effects of surgery on the subse-
quent growth of the face? This was one of the
driving questions being asked by surgeons in
the 1940s. Slaughter and Brodie ( 1949 ) and
Graber ( 1950, 1954 ) deserve historical credit
for bringing this issue to the world’s attention.
Their condemnation of the results of cleft pal-
ate surgery, as mentioned, led to a new conser-
vatism and forced a reexamination of surgical
practice.
The beginning of serial facial growth studies,
Graber’s ( 1950, 1954 ) cross-sectional study of 60
cases of mixed cleft palates of various types at
various ages, had a profound effect on surgical
planning. He compared jaw development of 46
operated cases with 14 cases that had had no sur-
gery and found that the unoperated palates resem-
bled normal palates more than they did the
operated palates. He noted that the growth of the
operated palates was retarded in all three dimen-
sions. It should be understood that it was not
unusual in those days to encounter patients with a
history of 35 operations. A common operation of
the day involved wiring compression of the cleft
segments (Brophy 1904 ) . As already noted, this
procedure was notorious for its mutilating effects.
Dental neglect was common, resulting in rampant
caries, and the associated malocclusions were
often so severe as to discourage orthodontic
treatment.

358
S. Berkowitz
Graber ( 1950 ) concluded that “to minimize
interference with growth centers, it seemed advis-
able to postpone surgical correction at least until
the end of the fourth year of life, when fi ve-sixths
of the total maxillary width has been accom-
plished.” As a result, early surgical repair of the
palate fell into disfavor, and prosthodontists came
to dominate the rehabilitation of cleft palate.
Graber ( 1950 ) suggested that the following
questions should be asked:
1. How does the pattern of growth and develop-
ment of a cleft palate individual compare with
that of a noncleft person?
2. What is the effect of early and repeated surgi-
cal intervention on this pattern?
3. What happens to a tissue that has been manip-
ulated and traumatized?
4. Does increased tension of soft tissue stimulate
or depress cellular proliferation?
5. What is the growth potential of fi brous bands
of scar tissue?
6. Can cicatricial (scar) bands in fl uence the
normal growth and development of the sur-
rounding soft tissue structures and the bony
skeleton?
7. How do cleft palate individuals with surgi-
cally closed clefts compare with those who
have had no surgery?
Pruzansky, in 1969 at an international symposium
on cleft palate held at Northwestern University
Dental School, recognized the important contribu-
tions of Graber ( 1950, 1954 ) and Slaughter and
Brodie ( 1949 ) for their condemnation of the delete-
rious effects of traumatic surgery on midfacial
growth (Gruber 1969 ) and recommended that sur-
gery on the palate should be delayed until 5 or
6 years of age to minimize facial growth malforma-
tions. In questioning the validity of their conclusion
on the timing of surgery, Pruzansky goes one step
further, citing fi ndings from his longitudinal palatal
and facial growth studies (Gruber 1969 ) .
I saw patients whose palates had been repaired
early and yet their faces developed well and their
speech was free of the stigma associated with the
stereotype. On the other hand, some children, for
whom palatal surgery had been delayed, did not do
well at all. Their midface did not develop normally
and their speech was hypernasal and unintelligible.
I saw all kinds of permutations and combinations.
He went on to explain that the faultless error
was in not recognizing the heterogeneity that
exists within a single cleft type. Pruzansky ( 1953,
1955 , 1974 ) stressed that morphological and
physiological variants in the individual child
should provide the rational basis for therapeutic
design, not age alone.
In the early 1920s, the cleft space was consid-
ered a “hole” that needed immediate closing
either by orthopedics and surgery. Early surgical
closure in the fi rst 6 months led to disastrous
results. As a reaction, the timing pendulum was
to swing to the opposite extreme to favor surgical
closure at 5–9 years of age, when the hard pal-
ate’s growth was 90 % completed. To satisfy the
speech-language pathologists, obturators were
worn until the cleft was closed. Based on theo-
retical and anecdotal evidence, many surgeons
chose 18–24 months for closure without the use
of obturators as a compromise between speech
and growth requirements.
Many variations in surgical procedures
arose. Gillies and Fry ( 1921 ) and Slaughter and
Pruzansky ( 1954 ) believed it was important to
delay hard-palate closure to 2 or 3 years of age
and chose to close the lip and soft palate fi rst to
aid speech development (Fig. 16.13 ). Others (e.g.,
Robertson and Jollys 1968 ; Hotz 1973 ) delayed
midpalatal closure to the deciduous dentition, and
Schweckendiek ( 1978 ) went to the extreme and
delayed closure into adolescence, favoring the
Fig. 16.13 Palatal view showing the lip and soft-palate
closure as a primary procedure. The hard-palate cleft is
closed at a later date, usually between 18 and 30 months
according to the size of the cleft space

359
16 The In fl uence of Conservative Surgery on Growth and Occlusion
need to maximize palatal growth above all else.
The Slaughter and Pruzansky ( 1954 ) method was
associated with good speech development; the
Schweckendiek delayed palatal closure procedure,
and although producing satisfactory midfacial
growth, it left the patients with very poor speech.
16.5
Speech Considerations
Some surgeons believe that good speech requires
palatal cleft closure between 6 and 9 months,
the child’s stage of phonemic development of
articulation, and are willing to accept the trade-
off of creating some maxillary growth inhibition
(Dorf and Curtin 1982 ) . Other surgeons believe
that good speech development is not related to
the age of cleft closure but depends on the
growth integrity of the entire midface: the pala-
tal vault space, the size and shape of the pharyn-
geal space, and the size and neuromuscular
action of the soft palate and pharyngeal muscles,
along with hearing and the patient’s phenotype
(Bzoch 1979 ) .
Blocksma et al. ( 1975 ) , Lindsay ( 1971 ) , Kaplan
et al. ( 1978 ) , Krause et al. ( 1976 ) , and Musgrave
et al. ( 1975 ) found good speech with the von
Langenbeck procedure in most cases. This repair
gave slightly better speech results than the length-
ening procedures in soft-palate clefts, but the
V-Y pushback was superior in the more extensive
clefts. However, the authors do not discuss the
effects of the procedures on palatal growth and
dental occlusion. Dryer and Trier ( 1984 ) com-
pared the speech results when three different pal-
atal surgeries were performed: (1) V-Y or island
pushback, (2) von Langenbeck method utilizing
two bipedicled mucoperiosteal fl aps advanced
to the midline, and (3) von Langenbeck proce-
dure with the addition of levator reconstruction
(intravelar veloplasty). The speech results after
palatoplasty revealed no signi fi cant difference
between children with simple von Langenbeck
closure and those undergoing palatal lengthening
procedures. Children with levator reconstruction
demonstrated superior speech results.
As to maxillofacial development, Jolleys
( 1984 ) found better speech results in his patients
who had surgery prior to age 2 and found no dif-
ference in maxillofacial development. Koberg
and Koblin ( 1973 ) suggested that 2–3 years old is
the best age for surgery without damaging maxil-
lary development. Friede et al. ( 1980 ) and
Berkowitz’s ( 1985 ) facial and palatal growth
studies do not support Ross’s ( 1987a, b ) conclu-
sion that early (before 18 months) palatal repair
provides better facial growth than does delayed
hard-palate repair. The opposite appears to be
true because deformed palates are more closely
related to early (within the fi rst year) surgery than
delayed (4–9 years of age) surgery. For example,
Graber ( 1950 ) reported:
In various studies of facial growth and development,
it is seen that the lateral width of the maxilla is
accomplished quite early in life, but the downward
and forward growth is not complete until the
second decade of life. Any growth disturbance
induced by environmental interference would be
possible in the sutural sites of proliferation for a
number of years, but any appreciable withholding
of the palate in width would require speech
interference during the fi rst 4 years of life.
All goals of a good speech, speech occlusion,
and facial aesthetics are possible. Most orthodon-
tists and surgeons now agree that the skills of the
surgeon need to be considered when evaluating
all surgical procedures, but the timing of palatal
closure to avoid scarring is equally important.
Attainment of normal speech, facial and pala-
tal development, and dental occlusion is possible
without compromising one objective for another.
Although speech development may bene fi t from
early palatal closure, there are instances when the
cleft space is very wide and cleft closure should
be postponed to a later age to permit additional
palatal growth and allow for conservative pala-
tal surgery. Berkowitz’s palatal growth studies,
presented in this text, show that an increase in
palatal size with the spontaneous narrowing of
the cleft space can occur early, late, or not at all,
and in rare instances, the cleft may even widen.
Nonphysiological surgery causes facial and pala-
tal deformation due to the destruction of blood
supply with scar formation. To avoid these con-
sequences, timing of palatal closure should be
related to the anatomical and functional assets in

360
S. Berkowitz
the individual and not determined by age alone.
Berkowitz’s ( 1985 ) serial studies of 36 unilateral
(UCLP) and 29 bilateral (BCLP) cleft lip and
palate cases with good speech demonstrated that
conservative palatal surgery is conducive to good
speech, as well as good palate and facial develop-
ment. Speech appliances, in very rare instances,
may be necessary as an interim device to close
off the cleft space after 2 years of age.
Van Demark and Morris ( 1922 ) found that
early surgery (before 24 months of age – before
the child begins to talk) to close the cleft space
was associated with better articulation skills
when the children were tested at 8 years of age,
but after that age, differences were less often
seen. They believed that other variables, for
example, velopharyngeal competence and cleft
type, were better predictors of eventual articula-
tion skills than was age at surgery.
McWilliams et al. ( 1984 ) , in reviewing the lit-
erature, found better speech to be associated with
earlier palatal repair (before 24 months of age).
However, they noted that design fl aws in the stud-
ies make it dif fi cult to interpret results. Failure to
de fi ne “normal,” “perfect,” or “acceptable”
speech and the omission of information about
cleft type and surgical techniques are signi fi cant
shortcomings in comparing results.
Most speech-language pathologists still advo-
cate closure of the palatal cleft before 1 year of
age, believing that early closure prevents devel-
opment of patterns of speech that would require
prolonged and dif fi cult therapy at a later age
(McWilliams et al. 1984 ) . Most of their studies
and conclusions are based on the use of only two
variables: timing of surgery and speech outcome,
omitting other signi fi cant variables; therefore,
their conclusions must be questioned. The error
in relating speech adequacy to the age that a pala-
tal cleft was closed has only confused the issue of
individualizing treatment planning based on dif-
ferential diagnosis of the cleft defect.
Speech studies of individuals or a small sam-
ple of subjects are often suf fi cient, and sometimes
essential, to fi nding solutions to a particular prob-
lem being investigated; however, the fact that a
“correlation” exists between two variables (speech
pro fi ciency and age) does not indicate or prove
causation. Although the age at which surgery is
performed may be the sole relevant variable stud-
ied, sensory function, genotype, the geometrics of
the original deformity, the facial growth pattern,
and the surgical procedure performed are also
factors that must be considered. It is dif fi cult, and
perhaps impossible, to demonstrate the effective-
ness of a treatment philosophy in a clinical set-
ting, where many variables cannot be identi fi ed,
controlled, or manipulated. Therefore, conclu-
sions drawn from such investigations should be
considered with caution (Berkowitz 1985 ) .
Some past surgical strategies also emphasized
early palatal closure and velar lengthening with the
goal of resolving immediate problems with cleft
space and, hopefully, preventing future speech prob-
lems associated with hypernasality. In addition,
velum lengthening procedures, originally advocated
in the newborn period – often without evidence of
incompetent air fl ow control – to avoid a possible sec-
ond surgical procedure, were found to be ineffective
even when performed at a later age (Millard 1980 ) .
Surgery can either aid in directing the natural
growth into proper channels by establishing mus-
cle balance across the cleft defect, or it can
grossly interfere with the normal developmental
changes by hindering growth through interfer-
ence with blood supply, introducing a scar or
destruction of growth centers. In view of the wide
range of individual variations of the defect, the
surgical procedure must be altered to fi t the par-
ticular case, in terms of both time and technique.
Determining which surgical orthodontic proce-
dures are best utilized for different types of clefts is
the goal of all clinicians. Unfortunately, palatal and
facial growth patterns are not predictable at birth,
and therefore one needs to wait to see the effects of
initial treatment on the developing face before decid-
ing what next needs to be done. When decisions to
act are made under conditions of uncertainty, it is
always appropriate to consider not only the probabil-
ity of success but also the consequences of failure.
16.6
Surgical Orthodontic
Procedures and Sequences
It is impossible to review all of the surgical orth-
odontic approaches to the closure of lip and hard
and soft palatal clefts with or without the use of

361
16 The In fl uence of Conservative Surgery on Growth and Occlusion
orthopedic plates. Some surgeons will fi rst unite the
lip, followed either by closure of the hard and soft
palate in one stage or fi rst unite the soft palate, and
then the hard palate at a later age. Some even favor
closing the soft palate before uniting the lip. There
are as many different surgical procedures as there
are differences in the timing and surgical sequence
to be utilized. Some surgeons favor a vomer fl ap
with or without a mucoperiosteal fl ap, others with/
without a pushback, still others a mucosal tissue
closure without involving the periosteum. Yet each
clinical report tells of both good and bad results,
usually using the number of buccal and anterior
crossbites in the deciduous dentition to designate
whether the procedures have failed or succeeded.
Unfortunately, most reports do not have fi nal post-
pubertal facial/palatal records, which are more
meaningful in describing the fi nal outcome.
16.6.1 Palate Cleft Closure
Controversies Revisited
Present-day corrective procedures involve sur-
gery, the type and timing of the operation depend-
ing on whether the surgeon is a von Langenbeck
soft tissue descendant, with or without presurgi-
cal maxillary orthopedics, or a Brophy “steel
clamp and silver wire” bony closure man. There
is a basic philosophical con fl ict between the two
major groups. Some surgeons employ staphylor-
rhaphy for closure of the cleft palate, a variation
of the von Langenbeck, Furlow, or Veau–
Wardill–Kilner V-Y pushback procedure using
mucoperiosteal fl aps. They may or may not use
vomer fl aps to line the surface of the mucope-
riosteal fl ap. The soft tissue is repositioned over
what many surgeons consider a normal bony
framework (with the exception of the cleft area)
that had failed for some reason to unite in the
midline. Today, most surgeons are convinced
that aberrant embryonal and fetal in fl uences
force the lateral halves of the maxilla apart, mak-
ing the intramaxillary width excessive. In the
past, it was Brophy; today, it is many McNeil
disciples who utilize presurgical maxillary ortho-
pedics, believing that the fi rst step in habilitation
is to restore what they believe to be a normal
segmental relationship at a very early age. Each
school of thought has intense convictions that
there is only one correct approach – its own.
Four surgical approaches are commonly used
to close the palatal cleft:
1. Early complete palate repair (3–9 months).
Rationale: to achieve maximum speech results
with a possible chance of inhibiting midfacial
growth and creating severe dental occlusion.
This approach favors speech above facial
growth and development.
2. Delayed complete palate repair (12–24 months).
Rationale: Speech results are nearly as good as
with earlier repair, and the facial growth distur-
bance is less.
3. Late complete palate repair (2–5 years).
Rationale: to prevent facial–palatal growth
inhibition, accepting the poorer speech results.
Use of a palatal obturator is needed in most
cases.
4. Early lip and soft-palate repair (2–9 months)
and delayed hard-palate repair (5–9 years).
Rationale: to avoid facial and dental deformity
but perhaps still achieve good speech with the
aid of an obturator.
16.6.2 Scarring Inhibits Palatal
Growth
Surgery to the hard and soft palate with temporary
disruption of the blood supply does not, by itself,
cause damages to the underlying bone. Most
surgeons and orthodontists believe that the prin-
cipal growth inhibitor seems to be the quantity
and distribution of scar tissue that is created after
surgery. When evaluating the effects of surgery
on maxillary growth and development, it is neces-
sary to consider that clefts of the palate can differ
greatly in size and form at the same age due to the
amount of osteogenic de fi ciency in the hard and
soft palate and lip. The great individual variation
in the relationship of the size and form of the cleft
space relative to the size of the palatal segments
is responsible for the differences in the amount of
scar tissue formed even when the same surgical
procedure is performed by the same surgeon.
A review of cleft palate surgical history clearly
shows that a single mode of surgery for all cases
invariably resulted in severe palatal and midfacial

362
S. Berkowitz
deformities, as well as poor speech development.
Unfortunately, the same poor results still occur
despite the timing of surgery and the skill and expe-
rience of the plastic surgeon. This is so because of
failure to de fi ne the criteria for the timing of palatal
surgery and failure to agree on which surgical proce-
dures interfere with normal growth and development
of the structures involved. Poor results were under-
standable when there were no standardized methods
for estimating success or recording the effects of sur-
gery on speech and facial growth and development;
these shortcomings no longer exist. Nonetheless,
some present-day surgical reports still do not ade-
quately describe the original deformity; thus, the
ef fi cacy of the surgical effort cannot be evaluated.
Mapes and coauthors ( 1974 ) , Robertson and
Fish ( 1975 ) , and Berkowitz (unpublished data)
all concluded that nontraumatic palatal surgery
accelerated the growth rate of the maxilla, help-
ing it reach more normal dimensions in the fol-
lowing years. Berkowitz and associates ( 1974 )
demonstrated that, in the patient with complete
bilateral cleft lip and palate, after conservative
palatal surgery, the palatal surface area doubled
from birth to the age of 1 1/2 years. Also, in an
isolated cleft palate of a patient with Pierre Robin
Sequence, there was a 50 % increase in the pala-
tal surface area from birth to 1 year of age. The
acceleration in growth tapered off after palatal
surgery in both instances. Palatal growth acceler-
ates 6–12 months postsurgery in some cases.
Berkowitz found that cases with relatively
small cleft spaces prior to using modi fi ed von
Langenbeck surgery grew the best after surgery.
This can be interpreted to mean that the smaller
the laterally placed areas of denuded bone, the
less scar tissue will result with a better chance of
obtaining “catch-up growth.”
Bardach ( 1990 ) questioned the validity of
claiming that palatoplasty is detrimental to max-
illary growth. He believed there is no adequate
substantiation of this concept from clinical or
experimental studies. However, Berkowitz’s
(1974) clinical report on Millard’s island fl ap
pushback procedure, which creates large areas of
denuded bone, has conclusively shown that this
procedure deforms the palate and causes major
maxillofacial growth aberrations (Figs. 16.14 ,
16.15 , 16.16 , 16.17 , 16.18 , 16.19 , 16.20 , and
16.21 ). However, this study does not fi nd fault with
palatoplasties that produce small areas of exposed
palatal bone. The same palatoplasty can yield dif-
ferent long-term results because all clefts within
the same cleft type are not the same. They may
have different size of cleft spaces. Unfortunately,
Bardach focuses only on the surgery performed
and does not consider the geometric variations in
the cleft deformity as critical factors in predicting
the long-term outcome of surgery.
Research is presently underway in Berkowitz’s
laboratory to determine why “catch-up growth”
occurs in some but not all cases even when sur-
gery is performed by the same surgeon using the
same surgical procedures.
In the course of a set of related experiments,
Latham and Burston ( 1964 ) , Latham ( 1969,
1980 ) , and Calabrese and coworkers ( 1974 ) sug-
gested that new tissue could be induced to form
in the growing face by applying appropriately
controlled physical stress through neonatal max-
illary orthopedics. However, no known support-
ive objective data have ever been presented. This
subject was covered in depth in Chap. 21 .
Viteporn et al. ( 1991 ) , utilizing longitudinal
cephaloradiographs, showed that patients with
extensive cleft palate who had a pushback procedure
reached maximum growth spurt later than patients
with less extensive surgery and that the surgery had
an inhibitory effect on midfacial growth. They con-
cluded that, because the sample was of the same eth-
nic group and received surgical treatment at the same
age by the same surgeon, signi fi cant differences
in midface development between the two groups
should be attributed to the treatment itself. Scar tis-
sue associated with the denuded bone left after the
V-Y pushback technique, they claimed, played a
major role in inhibiting forward displacement of the
maxilla and in distorting dentoalveolar growth.
16.7
Dental Occlusion Associated
with Early Palatoplasty Using
a Vomer Flap
Dahl et al. ( 1981 ) reported on the prevalence
of malocclusion as seen in early mixed denti-
tion with complete unilateral clefts of the lip
and palate. The frequency of posterior lin-

363
16 The In fl uence of Conservative Surgery on Growth and Occlusion
gual crossbite they found was extremely high.
This might be partly an effect of the two-layer
palatoplasty–vomerplasty used for closing of the
cleft in the hard palate at 12 months of age. It
has been shown that bone formation in the pala-
tal cleft is common subsequent to this procedure
(Prysdo et al. 1974 ) . It was supposed that the
newly formed bone might act as a bony ankylosis,
inhibiting the transverse growth of the maxilla.
A longitudinal study, by the implant method, of
patients operated on by this method substantiated
this supposition. To reduce the adverse effects on
transverse maxillary growth, Dahl recommended
the surgical procedure be changed to a one-layer
closure of the cleft in the hard palate by a vomer
fl ap. There has not been a follow-up study to
evaluate the effect of changing the procedure –
whether it is the timing or the surgery that needs
changing. Dahl’s Danish group of treated patients
were characterized by unilateral lingual crossbite,
high frequencies of midline deviation, mesial
molar occlusion, and mandibular overjet. There
were very few cases with an anterior open bite.
A tendency was seen for a difference in the sagittal
molar relationship on the cleft side, as compared
with the noncleft side, with distal molar occlusion
being more frequent on the cleft side. This may
be explained by a primary difference in the sag-
ittal position of the two segments of the maxilla
and also as a result of secondary changes, such as
lateral shifting of the mandible caused by lingual
crossbite on the cleft side, medial rotation of the
cleft segment subsequent to surgery, and tipping
the teeth toward the cleft on the affected side.
Berkowitz’s ( 1985 ) serial occlusal study
of complete unilateral clefts of the lip and pal-
ate, which involved the use of modi fi ed von
Langenbeck procedure with a vomer fl ap between
Fig. 16.14 ( a , b ) “Island fl ap” for a unilateral cleft lip
and palate. ( a ) Outline of incisions at 21 months. ( b ) At
21 months, a V-Y pushback of the palate was achieved,
leaving the V over the anterior closure untouched and tak-
ing a unilateral island fl ap for nasal lining (Courtesy of
Dr. Millard, Jr.). Comments: The island fl ap is a variant of
a V-Y pushback that is very similar to the Wardill–Kilner
V-Y pushback procedure in that a large anterior area of
denuded bone remains. In the “island fl ap,” the anterior
palatal mucoperiosteum is transposed to nasal surface,
creating a mucoperiosteum sandwich. This is the area that
creates the transpalatal scar. Because the denuded bone
heals by epithelialization becoming scar tissue, the larger
the denuded area, the more the resulting scar tissue will
negatively affect maxillary growth in three dimensions.
The maxillary de fi ciency usually becomes apparent in the
late mixed or permanent dentition when facial appearance
is affected. Lateral cephalometric studies have shown that
this or other “pushback” procedures have not resulted in a
net gain in soft-palate length. We speculate that, in most
cases, good velopharyngeal closure would have occurred
even if a “pushback” had not been performed as a primary
palatal cleft closure procedure. The singular lesson to
learn from these longitudinal facial–palatal growth studies
is the need to avoid creating large areas of denuded bone
when performing palatal surgery

364
S. Berkowitz
Fig. 16.15 Case No. DD-96. Serial casts of bilateral cleft
lip and palate show marked palatal scarring following
early “island fl ap” pushback. 0–0–14: At birth. 0–9:
Excellent palatal arch form after the lip was united. The
premaxilla lateral palatal segments are in good relationship.
1–7: Narrow and distorted palatal arch due to island fl ap
scarring performed earlier. 4–3: Bilateral buccal crossbite
with the anterior incisor are in a tip-to-tip relationship.
9–2: The palatal arch width narrowed at the line of the
island fl ap creating an “hourglass”-shaped palate
Fig. 16.16 ( a – d ) Case JB. No. X-16. Serial palatal changes
after “island fl ap” leading to Le Fort I maxillary advance-
ment. ( a ) Serial casts. The island fl ap V-Y procedure was
performed at 5 months. 0–11–13: The palate shows severe
scarring and collapse. 5–6: Even after a dif fi cult attempt at
palatal arch expansion, the buccal and anterior occlusions
are still in a tip-to-tip relationship with the opposing teeth.
13–2: The palatal arch collapsed again due to the strong
medial pull of the transpalatal scar placing the buccal and
anterior teeth in crossbite. Note that midfacial recessiveness
increased as the face grew even with orthodontia and pro-
traction mechanics and by 17–6: a Class III malocclusion
existed. 17–10: After Le Fort 1 maxillary advancement.
18–0: The right maxillary incisor and alveolar labial plate
exfoliated as a result of the severance of the blood supply to
this area. 15–13c: A “roundhouse”- fi xed bridge was utilized
to replace the missing teeth and stabilize the arch form. A
transpalatal removable metal strut helps to maintain the cor-
rected arch by counteracting the medial pull of the severe
scarring. Lip and palate surgery

365
16 The In fl uence of Conservative Surgery on Growth and Occlusion

366
S. Berkowitz
1 Newborn palatal cast. 2
Narrowing of the cleft space due to molding action brought
on by a facial elastic worn over the cleft lip. 3 Palatal seg-
ments are in contact. 4 Further palatal narrowing after
island fl ap pushback. 5 Severe loss of palatal vault space.
6 Right buccal crossbite. 7 Expansion appliance in place.
8 Failure to increase palatal arch width. 9 Right buccal
occlusion still tip to tip. 10 Narrowed palatal arch at
13 years 2 months of age. 11 Class III malocclusion with
bilateral buccal crossbite. 12 , 13 , 14 (17–10) After Le Fort
I advancement. Excellent dental occlusion has been estab-
lished. The scar tissue has been stretched, allowing for the
congruency of the upper and lower arches
Fig. 16.16 (continued)

367
16 The In fl uence of Conservative Surgery on Growth and Occlusion
( b ) Lip and palate surgery. 1 and
2 Prior to Le Fort I surgery. 3 Presurgical orthodontics.
Buccal expansion and anterior advancement are unsuc-
cessful. 4 Right lateral incisor pontic placed on the arch
wire. 5 and 6 (19–3): Facial photographs after placement
of a maxillary bridge and lip–nose revision. ( 6 ) Severe
loss of palatal vault space. 7 (18–0): The labile plate of
bone overlying the right central incisor exfoliated because
of the loss of blood supply. The posterior palatal blood
supply was cut off during the soft-palate pushback proce-
dure. The central incisor had to be extracted. 8 (18–0):
A temporary prosthesis replaces the missing incisors and
maintains the correct arch form
Fig. 16.16 (continued)

368
S. Berkowitz
( c ) Postsurgery after Le Fort I
maxillary advancement to correct a retrusive midface.
This followed the loss of right lateral central incisors due
to blood deprivation to the area. 1 Frontal and 2 lateral
facial photographs. 3 Transpalatal removable cast goal
arch appliance to help maintain maxillary arch size and
form. 4 “Round-house” bridge to maintain a functional
occlusion and improve aesthetics. ( d ) Superimposed
cephalometric tracings, pre- and postmaxillary advance-
ment, show changes to the skeletal and soft tissue pro fi le.
The upper lip is more recessive than the lower lip due to
the lack of maxillary basal bone coupled with additional
mandibular growth. Comment: Growth disturbance caused
by severe palatal scarring is three-dimensional. Although
palatal osteotomies can reposition the bony segments, the
force of scar contracture will prevail, causing arch col-
lapse if it is not counteracted. This can only occur with
dental bridges of various types and/or transpalatal struts
(McNeil 1950 )
Fig. 16.16 (continued)

369
16 The In fl uence of Conservative Surgery on Growth and Occlusion
Fig. 16.17 Case TO X-26. Facial changes from birth to the
mixed dentition do not usually show the effect of midfacial
growth retardation. The effects on facial growth become
more evident after the postpubertal facial growth period. At
birth (1), 10 months (2), 3 years (3), 6 years, and 9 months
(4 and 5). Frontal and lateral views at 17 years (6)

370
S. Berkowitz
Fig. 16.18 Demonstrates the deleterious effects of
excessive scarring associated with an island fl ap on palatal
growth, and arch form in a CUCLP. Palatal casts. 0–10:
After lip surgery which brought the alveolar segment is in
good approximation. A small palatal cleft and good arch
form before the island fl ap. 1–0: After the island fl ap and
resulting collapse of the palatal segments. The child had
to protrude the lower jaw to obtain a comfortable posterior
occlusion. 1–6: Anterior and buccal occlusion. 3–5:
Palatal deformation becomes more apparent, leading to
left buccal crossbite. 6–9: Marked palatal form changes
re fl ecting growth retardation. Further palatal and occlusal
changes between 9 and 3

371
16 The In fl uence of Conservative Surgery on Growth and Occlusion
9–7 and 10–0 are evident. The
strong transpalatal scar contracture narrows the transverse
palatal width and reduces palatal growth leading to severe
dental crowding. 11–11: Orthodontia was able to tempo-
rarily produce good palatal arch changes and improve the
occlusion. 13–4: Both maxillary cuspids were transposed
to the lateral incisor spaces. 13–10: Again the transpalatal
scar tissue caused the arch form to narrow across the
bicuspids and fi rst molars
Fig. 16.18 (continued)

372
S. Berkowitz
Fig. 16.19 Biopsy of transpalatal scar showing acellular
band of fi brous tissue
14–3: The narrowed palatal arch
width stabilized with a good anterior overjet and overbite
remaining. 16–7 to 19–1: The maxillary cuspid was posi-
tioned in the missing lateral incisor space. Millard discon-
tinued using this palatal closure procedure as a result of
the transverse scarring and the problems it created
Fig. 16.18 (continued)

373
16 The In fl uence of Conservative Surgery on Growth and Occlusion
Fig. 16.20 Lateral cephalometric tracings for Case TO
(No. X-26) between 2–5 and 18–0. The mandibular
prominence (SNP) increased from 69° to 75°, while the
midfacial protrusion (SNA) decreased from 82.13° to
72.85° during the same time period re fl ecting the effects
of midfacial growth retardation

374
S. Berkowitz
18 and 24 months of age, lists an absence of dis-
tal molar occlusion with a minimal number of
anterior crossbites and only a few complete buc-
cal crossbites. By comparison with studies that
do not use vomer fl aps, one can conclude that the
obvious cause for the deleterious occlusal results
in the Dahl et al. ( 1981 ) study lies in the timing
and not the surgical procedure utilized because
Millard ( 1980 ) also utilizes a similar vomer fl ap
with success. This conclusion does not mean that
all cleft closure procedures need to be delayed
until 18 months of age since narrow clefts in
the palate can exist before 12 months of age.
A narrow cleft suggests that less scar tissue will
be created. The age of surgery is a primary vari-
able in determining the effect of surgery on pala-
tal development only when the width of the cleft
space is also placed into the equation.
16.7.1 The Fourth Dimension of Time:
Catch-up Growth
Substantial evidence from the many excellent facial
and palatal growth studies (Figs. 16.22 and 16.24 ;
Table 16.1 ) has determined that a “catch-up” poten-
tial exists in children with cleft lip and/or palate,
which allows for reasonably good growth of the
maxillary complex and face. Inherent factors alone,
however, do not determine this growth. Clinicians
are cognizant of the very strong in fl uence – which
quite often is adverse – of extraneous factors (e.g.,
iatrogenic and functional). These factors are com-
plex and varied. It becomes obvious that surgical
skill, the type of surgery, the timing of surgery, and
even the sequence and numbers of surgical proce-
dures all complicate the overall end result of facial
growth in any given situation. It would appear that
just the primary surgical closure of the lip and pal-
ate produces a myriad of sequences and variables
to be dealt with, and they in turn introduce more
sequences and variables.
To take into account both the inherent insult
and extraneous factors, and to recognize and
quantify the extent to which each contributes to
the overall severity of the problem, is a much
needed step in the correct rehabilitative effort.
The inherent problem, such as the anomalous
cleft, should of necessity emphasize rehabilitative
a
b
Fig. 16.21 ( a ) Superimposed polygon tracings for Case
TO (No. X-26) using the Basion horizontal method of
Coben. Changes from 2–5 to 18–0 clearly show retarded
midfacial growth when compared to normal growth of the
upper and lower portions of the face. The soft tissue pro fi le
is able to mask the skeletal discrepancy in this instance.
The upper, middle, and lower parts of the face are growing
normally, creating a very aesthetic face with excellent
occlusion. ( b ) Serial cephalometric tracings with its facial
polygon. Tracings were superimposed on the anterior cra-
nial base (SN) and registered on S . These tracings show
extensive growth at the anterior cranial base and mandi-
ble. There was some midfacial growth up to 8 years but
very little. Therefore, all goals of good facial aesthetics,
occlusion, and speech were achieved

375
16 The In fl uence of Conservative Surgery on Growth and Occlusion
efforts with minimal adverse effects on growth.
At present, there is no consensus as to how this
could be achieved, a fact attested to by the wide
variety
of
successful
treatment
regimens
employed throughout the world. A long-term
assessment of the approach to this problem has
been brought about by the use of objective serial
clinical records, such as serial dental casts, by
research consortium members working together
(Berkowitz et al. 2005 ) .
From Berkowitz’s serial palatal growth
studies, he has deduced that the intrinsic growth
potential of the maxillary processes and basal
bone in cleft palate patients on the whole is
slightly less in all three dimensions than in non-
cleft children. Various cleft types have different
degrees of osteogenic de fi ciency, with bilateral
clefts potentially being the most de fi cient at birth
and remaining that way even as the palatal pro-
cesses grow and develop. It has conclusively been
shown that surgical trauma with developing scar
tissue at an early age can further inhibit palatal
bone growth and its forward translation within
the face (Ross 1987a, b ) .
The structure and function of the physiologi-
cal elements involved in cleft lip and/or palate, as
previously explained, are not static. They exist
not only within a framework of three-dimensional
space but also in a functional continuum of time.
This fourth dimension of time involves the
modi fi cations induced by the processes of growth
and development, which determine the ultimate
nature of the congenital defect. To understand
time–space relationships as they affect the indi-
vidual cleft palate patient requires a longitudinal
study of the patient by means of casts, photo-
graphs, and cephalometric roentgenograms.
Catch-up growth has been de fi ned as growth
with a velocity above the statistical limits of nor-
mality for age during a de fi ned period of time.
Table 16.1 Case CM (AC-33). Surface area of CUCLP from 21 days to 15 years and 5 months of age
Age
Skeletal area
Cleft space total
RLS
LLS
Total
Post
SA + CS
0–0–21
474.7
259.3
734.0
364.9
1,098.9
0–3
567.6
389.6
957.2
223.1
1,180.3
0–7
611.3
407.7
1,019.0
187.5
1,206.5
1–2
682.5
448.4
1,130.9
141.7
1,272.6
1–9
743.2
510.4
1,253.6
75.6
1,329.2
3–0
775.3
552.1
1,327.4
13.9
1,341.3
3–5
809.6
570.8
1,380.4
1,380.4
3–10
814.3
606.5
1,420.8
1,420.8
4–6
825.5
618.9
1,444.4
1,444.4
5–0
855.1
654.4
1,509.5
1,509.5
5–7
890.0
698.8
1,588.8
1,588.8
6–5
917.3
718.4
1,635.7
1,635.7
7–3
1,033.5
857.7
1,891.2
1,891.2
8–4
1,103.6
875.8
1,979.4
1,979.4
8–10
1,116.6
888.7
2,005.3
2,005.3
9–4
1,157.8
918.8
2,076.6
2,076.6
9–9
1,168.0
924.4
2,092.4
2,092.4
11–4
1,204.9
938.8
2,143.7
2,143.7
12–4
1,223.3
962.6
2,185.9
2,185.9
13–5
1,366.9
1,197.5
2,564.4
2,564.4
14–2
1,448.8
1,231.7
2,680.5
2,680.5
15–5
1,575.8
1,357.7
2,933.5
2,933.5
These numbers were used to create the growth chart in Fig. 16.25
Note : RLS right lateral segment, LLS left lateral segment, Tot total surface area, SA + CS bony surface area + cleft space area

376
S. Berkowitz
Such an increase in the rate of growth, before and
after palatal surgery, with or without neonatal
maxillary orthopedics, may allow the palate to
attain greater size, but it may still be smaller than
normal adult size. In the latter case, it is called
“incomplete” catch-up growth. The duration and
severity of the insult (the surgical procedure used
to close the cleft space in the hard palate) may
positively or negatively affect the ability of the
palate to recover and undergo catch-up growth.
Fig. 16.22 ( a – r ) Case CM (AC-33) illustrates excellent
palatal growth in a CUCLP treated conservatively without
presurgical orthopedic treatment. Lip closed with a
Millard rotation advancement at 7 months. Soft palate
united at 16 months, and the hard palatal cleft closed at
24 months of age using a modi fi ed von Langenbeck.
( a ) Newborn: 24 days. ( b ) After lip adhesion at 3 months.
( c ) After de fi nitive lip surgery at 7 months. ( d ) 4 years,
10 months. ( e , f ) 5 years. ( g , h ) 8 years, 4 months

377
16 The In fl uence of Conservative Surgery on Growth and Occlusion
Fig. 16.22 (continued) ( i , j ) Left cuspid crossbite. ( k )
Palatal view showing mesioangular rotation of the left
palatal segment. ( l ) Palatal expander after expansion. ( m )
17 years. ( n ) 18 years. ( o – r ) 17 years. Comments: A man-
dibular central incisor was extracted to allow a proper
overjet-overbite relationship. Even with the extraction of
a mandibular incisor, it was dif fi cult to create more of an
incisor–overbite relationship due to the relative palatal
midfacial recessiveness. Note the short midfacial vertical
dimension with a relatively long lower facial height

378
S. Berkowitz
16.7.2 The Need for Differential
Diagnosis
Diagnosis and surgical treatment planning in
both medicine and dentistry are most frequently
dependent on the patient’s age and nature and
extent of the tissue’s defect. In cleft lip and pal-
ate, the timing for surgically closing a cleft palate
has been traditionally based solely on the age of
the patient and the onset of speech (usually
between 6 and 8 months) irrespective of the
physical assets and defects of the affected tissue,
that is, the relative size of the palatal cleft defect
to that of the surrounding palatal tissue.
The inability to develop quantitative diagnos-
tic criteria to facilitate a differential diagnosis for
proper treatment planning is partially due to cleft
palate research programs having an insuf fi cient
number of investigative data obtained from serial
maxillary and mandibular dental casts of patients
starting at birth and extending into adolescence, as
well as a proper instrument to measure the palatal
cast’s surface. Berkowitz et al. ( 2005 ) formed a
consortium of four European and three American
cleft palate centers to determine the relationship
of the size of the cleft defect to palatal size at
the time of surgery of patients that grew well into
adolescence, yet they all used different surgi-
cal protocols. The premise of this investigation
is that data extrapolated from serial cast records
will establish the relationship of the cleft defect
to the palatal size and shape under the in fl uence
of corrective surgery.
Clinicians who do not have serial cast records
have failed to appreciate the importance of cleft size/
shape variations that exist within each cleft type at
various ages, which may be crucial for making the
proper decision as to when to surgically close the
cleft space to avoid growth- inhibiting scarring.
16.7.3 Timing of Palatal Closure Based
on the Ratio of the Palatal Cleft
to the Palatal Size
A multicenter serial 3D study of the palatal
mucoperiosteum medial to the alveolar ridge
analysis was made of complete unilateral cleft
lip and palate (CUCLP) and complete bilateral
cleft lip and palate (CBCLP) casts’ growth (size
and velocity) changes from birth through adoles-
cence of cases that demonstrated good occlusion,
facial aesthetics, and speech. Only ones showing
good outcomes were selected in order to deter-
mine which surgical protocols (timing and type)
collectively produced these outcomes and what
was the relationship of the size of the cleft defect
to the size of the palatal segments medial to the
alveolar ridges at the time of surgery. Poor out-
come cases were not included because they could
have been due to the surgery performed and not
related to the relative size of the cleft to the pal-
ate medial to the alveolar ridge. This study was
to focus on the two variables, the size of the cleft
space and the size of the palate that supplies the
mucoperiosteum for surgical closure. The source
and number of centers in the retrospective study
were the cleft palate clinic at the University of
Miami School of Medicine (CBCLP, CUCLP);
University
of
Illinois
(CBCLP,
CUCLP);
Nijmegen (CBCLP, CUCLP); Goteborg delayed
series (CBCLP, CUCLP); Goteborg vomer series:
(CBCLP, CUCLP); and Northwestern University
(CBCLP, CUCLP). The Amsterdam cases were
followed from birth for 48 months to eliminate
the effects due to palatal surgery. This study
focused on the in fl uence of presurgical orthope-
dics (PSO) at Amsterdam (CBCLP, CUCLP) and
Rotterdam (CBCLP, CUCLP) which were treated
with the Hotz PSOT protocol.
An exception to the well-growing cases in the
Goteborg series is the Goteborg vomer- fl ap cases
which were included because the palate and faces
developed very poorly. The purpose of including
this series is to compare the in fl uence of vomer
fl ap surgery on the palatal growth rate and size
(2 mm) and to determine if palatal maldevelop-
ment (size and velocity) values are signi fi cantly
different from well-growing palates.
The control series consisted of mixed gender
clefts of the lip and alveolus and/or soft palate
with no palatal clefts. The growth data was the
standard to which all the cleft palatal casts series
were compared.
Serial palatal casts were surveyed using a
highly accurate electromechanical digitizer to

379
16 The In fl uence of Conservative Surgery on Growth and Occlusion
extrapolate surface data in millimeters and to be
analyzed using special CAD/CAM software
(CADKEY). The morphometric palatal growth
(size and rate of change) was compared.
Results: Berkowitz ( 1985 ) concluded that:
1. Goteborg which had delayed palatal closure
and Miami and other institutions which had
closure at an earlier age reported similar palatal
growth rate. The various clinic’s cases growth
(size) were less than that of the control series.
2. The 3D surface area data identi fi ed quantita-
tive palatal parameters before palatal cleft clo-
sure that can be used as criteria for establishing
a scienti fi c basis for determining when to close
the palatal cleft space.
3. Increased palatal scarring, as seen in the
Goteborg vomer series, diminishes palatal
growth.
4. Delaying all cleft closure surgery until 5+
years of age is unnecessary to maximize pala-
tal growth.
5. Based on excellent palatal growth outcomes,
the best time to close the palatal cleft space is
when the palatal cleft size is 10 % or less than
the total palatal surface area bounded laterally
by the alveolar ridges.
6. The 10 % ratio generally occurs between 18
and 24 months but can occur earlier or later in
some instances.
7. There is more than one good type of palatal
cleft closure surgery (Berkowitz 2005 ).
No studies have conclusively shown that palatal
growth can be accelerated by orthopedic appli-
ances as Weil ( 1987 ) claimed that “physiological”
surgery with the establishment of functional occlu-
sion will accelerate bone growth. Yet, Berkowitz
( 1985 ) , Krogman and associates ( 1975 ) , and
Cooper et al. ( 1979 ) suspected that catch-up
growth must happen in some clefts after surgery
due to the amount of additional growth that occurs,
as measured by changes in palatal surface area
(the area between the alveolar ridges and limited
posteriorly by the end of the hard palate).
Berkowitz’s palatal growth charts have shown
a marked increase in palatal surface area in the
fi rst 2 years before palatal surgery. After palatal
cleft closure between 18 and 24 months, there
appears to be a growth hiatus, creating a plateau
in the growth graph; however, 6–12 months post-
surgery, there is frequently a second period of
growth acceleration which extends to 6 years of
age. The palatal surface area continues to increase
as the molars develop and erupt into the arch.
Berkowitz and Millard palatal cleft closure
timing is based on the size of the cleft defect not
fi xated on the patient’s age alone. Some surgeons
have found a “middle of the road” treatment plan
to be around 12–18 months of age and discount
the size of the cleft space.
16.8
Good Speech Is Dependent
on a Palate of Relatively
Normal Size and Shape
Sally Peterson-Falzone et al. ( 2000 ) have written
that malocclusion needs to be considered during
the early speech learning years. They point out
that the dental and orthodontic literature contains
fairly consistent information regarding the
effects of dental problems and malocclusions on
speech.
A Need For Differential Diagnosis and
Treatment Planning: A careful review of cleft
palate surgical history makes it clear that a single
mode of surgery based on age alone for all
cases frequently results in severe palatal and
midfacial deformities, as well as poor speech
development.
In general, this literature tells us that dental
and occlusal problems are more likely to be caus-
ative factors in speech problems (1) when they
occur in combination rather than singly, (2) when
they are present during the speech-learning years
as opposed to later years, and (3) when they
in fl uence the spatial relationship between the tip
of the tongue and the incisors (Peterson-Falzone
et al. 2000 ) . The literature also indicates that
speech problems are fairly common when there is
a restriction in the size of the palatal vault, which
is more apt to be found in Class III occlusions
compared with Class II (Peterson-Falzone et al.
2000 ) . Children with clefts are obviously vulner-
able to restriction in size of the palatal vault and
the possibility of Class III occlusions due to the

380
S. Berkowitz
Fig. 16.23 Case CM (AC-33) serial dental casts. 0–1–6
at birth, 0–3–13, 0–7–16, 1–2–0, and 1–9–0. With lip clo-
sure, the palatal segments moved together with a slight
overlap of the smaller cleft segment by the noncleft seg-
ment. 3–4–17, 5–0–6, and 5–7–0. Only the left deciduous
cuspid is in crossbite

381
16 The In fl uence of Conservative Surgery on Growth and Occlusion
Fig. 16.23 (continued) 6–1–2. Excellent vault space to
accommodate the tongue, as attested by the good dental
occlusion. The deciduous cuspid crossbite did not cause a
functional problem nor did it inhibit palatal growth of the
lesser segment. 13–5–0. The left lateral incisor and cuspid
erupted through the secondary alveolar bone cranial bone
graft performed at 8 years and 5 months of age. Tip-to-tip
anterior occlusion. A lower central incisor was extracted
to permit a proper overjet–overbite relationship to be
established. 16–0 and 17–8–0. Excellent anterior and buc-
cal occlusion with ideal palatal vault space

382
S. Berkowitz
presence of dental or occlusal problems (possibly
several at one time) during the speech learning
years. The question is will the speech problems
diminish as the dentition or occlusion improves?
This statement convincingly acknowledges
that good speech development is contingent on
good tongue–teeth relationships within a normal
vault space of proper volume.
Early palatal surgery (before 1 year of age in
most instances) may not always jeopardize pala-
tal and facial development provided conservative
surgical methods are employed when the cleft
space is suf fi ciently small.
There are no longitudinal palatal growth studies
which show that overlapping palatal segments in
CBCLP and CUCLP are incapable of growing and
developing normally. The reverse is true! Many
longitudinal palatal and facial growth studies show
that overlapped palatal shelves have the potential
of growing well when there is minimal scarring of
the palatal mucosa. Why is such a big fuss being
made by those who perform presurgical orthope-
dics about the need to prevent “collapsed” arches?
The use of the word “collapse” has a strong nega-
tive connotation which infers that a problem exists
which should be prevented from occurring, and if
it does happen, it needs correction.
In fact, there are some bene fi ts associated
with the narrowing of the cleft space due to the
unimpeded medial movement of palatal seg-
ments. They are: (1) the perpendicular plates
of the sphenoid, which are displaced laterally
in the pharyngeal space at birth, become more
normally positioned after lip surgery, and (2) a
reduced cleft space may encourage better tongue
posturing and with it improved speech develop-
ment and feeding. This still needs to be proven.
Should a dental crossbite result; it can be eas-
ily corrected in the deciduous dentition using
simple orthopedic forces although necessitating
prolonged retention. Curiously, in many cleft
palate centers, prevention of maxillary constric-
tion (collapse) is still a major focus of attention,
despite the fact it has never been shown to cause
long-term dif fi culties associated with growth
inhibition.
Unfortunately, when the clinician’s treat-
ment protocol is designed to prevent “collapse,”
the team’s focus is diverted, and less attention is
given to appreciating the heterogeneity of sur-
gical procedures employed, different standards
for selection of patients, and lack of standard-
ization of evaluation techniques. Indeed, with
a change in focus to conservative treatment
planning, most surgeons now believe there will
be a greater chance for improved long-term
outcomes.
The developmental age of the infant at the
time of the insult and the nature of the insult itself
(extent of denuded bone left after surgery) will
affect the ability of the infant to achieve com-
plete catch-up growth. The case in Figs. 16.22 ,
16.23 , 16.24 , and 16.25 demonstrates the catch-
up growth phenomenon. Berkowitz suggests that
the effects of accelerating or restricting growth
are not seen in all dimensions throughout the pal-
ate. He suggests that the features most likely to
be affected have very strong clinical implications
in deciding at what age the palatal cleft should be
closed. It is expected that morphometric analysis
of the changing form and size of the palate will
permit some insight into the appropriate surgi-
cal procedures (age and type) to prevent growth
retardation.
When asked at what age he operated, Pruzansky
( 1969 ) replied:
We still hear the same question today. Is chrono-
logic age the parameter that really matters, or is it
morphologic age and physiologic fi tness? We
should be asking whether the tissues are adequate
in quantity and quality. Is the geometric relation-
ship of the malformed cleft parts to the contiguous
anatomy favorable or unfavorable for reconstruc-
tion? What is the relationship of the malformed
cleft parts to the contiguous anatomy which, in
turn, may be anomalous? What are the changes
incident to growth? Are the parts static in their
de fi ciency or does this de fi ciency diminish in
time?
LaRossa ( 2000 ) , State of the Art in Cleft
Palate Surgery, a two-layered, tension-free clo-
sure of the hard palate is advocated using a vomer
fl ap for nasal lining and mucoperiosteal fl aps that
leave minimal amounts of exposed palatal bone.
This approach seems to result in the least amount
of growth retardation and a reduced incidence of
fi stula formation.

383
16 The In fl uence of Conservative Surgery on Growth and Occlusion
a
b
0–1–6
AC – 33
0–3
0–9
1–3
1–9
4–6
5–0
AC 33
0–1–6
0–9
6–6
5–9
6–6
3–0
3–6
4–0
Fig. 16.24 ( a , b ) Case CM (AC-33) from 0–1–6 to 6–6.
( a ) Computer-generated outlines of serial casts drawn to
scale. Three-dimensional serial palatal growth representa-
tion using an electromechanical digitizer and CAD/CAM
software shows the degree and location of growth changes
and the relative changes in cleft space size. ( b )
Superimposing computer-drawn cast tracings taken at
0–1, 0–9, and 6–6 on the palatal rugae and registered on
the vomer point ( V ) as it crosses the P–P1 (postgingival
point) line which is posterior limit of the hard palate. This
graph demonstrates the great increase in palatal size and
direction of palatal growth that occurs when physiological
surgery is performed. P and P ¢ : Postgingival. This land-
mark is comparable to point PTM (pterygomaxillary
fi ssure) which is found between the maxillary tuberosity
and the perpendicular plate of the sphenoid. Pc and Pc ¢ –
Landmark on line PP ¢ at the cleft space. Ac and Ac ¢ –
Landmark at the anterior most point of the alveolar ridge
of the cleft space. V – Point at which the vomer crosses the
PP ¢ line. This fi gure shows palatal molding changes that
follow lip adhesion. Most of the growth occurs posteriorly
to accommodate the developing molars

384
S. Berkowitz
16.9
Facial Changes in Successfully
Treated Cases
16.9.1 Lateral Cephalometric Results
from the Oslo Team
Semb’s group (Semb and Shaw 1990 ; Semb
1991a, b ) conducted a serial lateral and frontal
cephalometric study of 90 cases from the Oslo
archives with bilateral cleft lip and palate. Since
1962, the treatment procedure has involved unit-
ing the lip and hard-palate cleft space closing in
two stages. No presurgical orthodontics were uti-
lized since the surgeons and Bergland, an ortho-
dontist and past director of the program, believe
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-palate 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 perma-
nent canine teeth (Abyholm et al. 1981 ) . Twenty-
fi ve percent of the updated cases needed
superior-based pharyngeal fl aps which were per-
formed, if possible, before the child started
school. No orthodontics were utilized in the
deciduous dentition. Protraction headgear in the
mixed dentition was used in one-third of the
cases. Fixed retention was necessary in all cases.
Results showed that (1) the maxilla progressively
receded over time; (2) the mandible was retrusive
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 dif-
ferent from the normal Bolton standards: (a) male
and female facial growth patterns were similar
except that the males’ linear dimensions were
larger; (b) the prominent premaxilla would grad-
ually realign in the preschool years; and (c) surgi-
cal premaxillary setback was never required.
3,060
Right lateral segment
Left lateral segment
Premaxilla
Total surface area
Anterior cleft space
Posterior cleft space
Total cleft space
Total surface area + cleft space
Surface areas
case ac-33
Lip closure
Soft palate closure
2,880
2,700
2,520
2,340
2,160
1,980
1,800
1,620
1,440
1,260
Source (millimeter)
1,080
900
720
540
360
180
0
0
8
16
24
32
40
48
56
64
72
80
88
Months
96
104
112
120
128
136
144
152
160
168
176
184
Hard palate closure
Fig. 16.25 Case CM (AC-33). The palatal growth chart
shows a very rapid period of acceleration occurring the
fi rst year. During the fi rst 8 months, the palatal surface
area (bordered by the alveolar crests) increased by 45 %.
Growth gradually slowed down after 20 months. Comment:
Note that both lateral palatal segments grew at parallel
growth rates. The growth acceleration curve after palatal
surgery was the same as that before surgery. The cleft
palatal segment shows two growth periods, at 80 and
152 months. Since rapid palatal growth occurs in all cleft
palate children during the fi rst year, caution should be
exerted when closing the cleft spaces at this age period to
avoid creating excessive scar tissue when its negative
effect would be greatest