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

386
S. Berkowitz
Institute, Northwestern University Dental School,
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16 The In fl uence of Conservative Surgery on Growth and Occlusion
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389
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_17, © Springer-Verlag Berlin Heidelberg 2013
17
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 pal-
ate has been traditionally based solely on the
age of the patient and the onset of speech (usu-
ally between 6 and 8 months) irrespective of the
physical assets and defects of the affected tis-
sue and not on 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 pal-
atal casts of patients starting at birth and extend-
ing into adolescence as well as a proper
instrument to measure the palatal cast’s surface.
The premise of this investigation is that data
extrapolated from serial cast records will estab-
lish the relationship of the cleft defect to the
palatal size and shape under the in fl uence of cor-
rective 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 surgi-
cally close the cleft space to avoid growth-
inhibiting scarring.
With the advent of advanced technology to
perform 3D spatial-temporal measurements and
CAD/CAM computer software for in-depth anal-
yses, extrapolated surface data from palatal casts
can now be subjected to highly sophisticated
quantitative analyses to perform differential diag-
nosis and treatment planning.

• Hypothesis to be tested : The hypothesis that
a relationship exists between cleft size and
palatal size to achieve good facial-palatal
growth and speech will be tested; also, there
is more than one physiological surgical pro-
cedure and the Hotz presurgical orthopedic
protocol does not increase palatal size in
velocity.
Choosing the Best Time for Palatal
Surgery
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

390
S. Berkowitz
Table 17.1 Number of clinics and patients involved in study
Clinics
Timing of surgery
Palatal closure
procedure
Lip adhesion
Lip-nose
Second alveolar
bone graft
Hard and soft
palate
Miami
3 months
6–8 months
8–10 years
12–24 months
Von Langenbeck + vomer
fl ap
Illinois
2–4 months
6–8 months
Seldom
12–18 months
Various procedure
Wardil-Kilner, Von
Langenbeck
Nijmegen
1–2 months
udp 6 months
10 years
SP 12–18 months Von Langenbeck
bdp 9 months
HP 6–9 years
Goteborg-
delayed
udp 1–2 months
6–9 months
9–11 years
SP 6–8 months
Vomer fl ap
bdp 2–4 months
HP 9–11 years
Goteborg-
vomer
2 months
18–20 months
Average 14 years 2 months
Arterior vomer fl ap,
posterior push back
9 months
Northwestern
6–8 weeks
primary bone
graft
6 months
12 months
Intravelar – veloplasty
Table 17.2 Treatment protocol and sequence
Controls = (Miami)
Soft palate + 5
Lip/alveous + 5
Soft palate lip alveous 8
Clinics
CBCLP
CUCLP
Presurgical orthopedics
Miami
18
26
None
Illinois
0
12
None
Nijmegen
10
0
Hotz 3–4 weeks for 2–3 years
Goteborg-delayed
8
24
1 weeks to 1–1.5 years
Goteborg-vomer
10
23
1 weeks
Northwestern
0
23
Posterior 1/2 palate
17.1
Method and Material
(Tables 17.1 and 17.2 )
Employing the palatal casts of 242 male and
female individuals from eight institutions in
the USA and Western Europe, separate serial
analyses were conducted of well-growing cases
with excellent aesthetics, dental occlusion, and
speech and a palatal control series of 18 nonpal-
atal cleft cases to access the growth changes in
size and velocity from birth through adolescence.
These control cases consisted of various clefts of
the lip and alveolus and/or soft palate but with
no clefts in the hard palate. The various complete
cleft lip and palate series were compared to this
series. Malcom Johnson (personal communica-
tion) has con fi rmed that this control sample is an
appropriate one for the palatal growth compari-
sons. In this group, the midpalatal suture, extend-
ing anteriorly to the incisal papilla at the anterior
alveolar ridge, served as the medial border divid-
ing the palate into right and left segments. With
the exception of the excellent sample of cases
from Goteborg, the vomer series had poor occlu-
sion, facial aesthetics, and poor speech. This
series was included in order to determine what
timing and type of surgical procedure had pro-
duced favorable or unfavorable outcomes and
also whether the outcomes varied with the rela-
tionship of the size of the cleft defect to the size
of the palatal segments medial to the alveolar
ridges at time of surgery.
The participating institutions were selected
on the basis of their excellent records and

391
17 Choosing the Best Time for Palatal Surgery
varied treatment protocols and different racial
and mixed gender populations. The Miami
sample of nonorthopedically treated cases was
selected at random from a larger number of
similarly treated cases.
Twelve different groupings of cases were
established depending on their institutional
location and type of cleft (complete unilat-
eral cleft lip and palate, CUCLP, and com-
plete bilateral cleft lip and palate, CBCLP),
with each group consisting of both males and
females. The number and type of cases were
as follows: University of Miami: 26 CUCLP
and 18 CBCLP; University of Illinois: 12
CUCLP; Northwestern University: 22 CUCLP;
Nijmegen: 10 CBCLP; Goteborg-delayed
Closure: 24 CUCLP, 8 CBCLP; Goteborg-
vomer: 23 CUCLP, 10 CBCLP; Amsterdam:
26 CUCLP, 4 CBCLP; and Rotterdam: 60
CUCLP. The statistical analyses of the CUCLP
and CBCLP cases were carried out separately.
The Amsterdam and Rotterdam cases, which
had been treated with the Hotz presurgical protocol
(PP), were followed from birth for 48 months, per-
mitting a determination of the PP on palatal growth
effects differed due to presurgical orthopedics.

• Analysis to be made : Comparative effects of
treatment of (1) the palates surface area’s
rate of change (velocity) and growth (size in
2 mm), (2) size of the posterior cleft space
and the velocity of its change, and (3) ratio
of cleft size to the palate’s size before and
after surgery (total surface area). Each of
the subsamples of cleft children will be
compared to each other and to the age-
appropriate control samples.

• Data extrapolation from the surface of palatal
casts (Fig. 17.1 ): A highly accurate, 3D, elec-
tromechanical palatal cast measuring instru-
ment which gave a measurement error of less
than 5 % made possible a spatial-temporal
(4D) analysis of palatal form and size changes,
M
P
P′
E
E′
D
D′
C
C′
B
B′
A
M
IP
Alveolar
crest
L
CAP
P
PC
PC′
P′
IP
V.
A′
B
a
b
c
d
e
A
A′
B′
C′
C
D
D′
E
P
M
alv.cf
R
P
PC
PC′
L
Alveolar
crest
P′
M′
PMC
PMA
PML
PMR
PMP
M
Right
AC
M′
AC′
PC
P
PC′
P′
I
AC′
AC
P′
E′
IP
Fig. 17.1 ( a – e ) Various palatal forms being measured.
( a ) Normal palate, ( b ) posterior view of normal palate
showing position of teeth landmark points: middle of
incisal edge and central fossa of molars, ( c ) isolated cleft
palate, ( d ) complete unilateral cleft lip and palate, and ( e )
complete bilateral cleft lip and palate

392
S. Berkowitz
permitting an in-depth study of how the cleft
space and palatal segments of each clinic’s
cases changed in relationship with each other
over time (Figs. 17.2a and 17.3 ).

• Features to be measured and analyzed
(Figs. 17.1 , 17.2 , and 17.3 ): The sizes of the
palatal segments are measured serially start-
ing at birth and divided into two treatment
periods. The fi rst period ends at surgery to
close the palatal cleft. The second period is
after palatal cleft closure: it includes adding
the remaining cleft space with the changing
size of the palatal segments (total surface
area). In CUCLP (Fig. 17.2a , b ), the sizes of
the palatal segments are limited laterally by
the alveolar ridges and anteriorly by a line
connecting the most anterior point on the
alveolar ridge (AC and AC1). Posteriorly, a
line is drawn from point gingival (P and P1)
which are equivalent to the pterygomaxil-
lary fi ssure seen on cephalo radiographs
which marks the posterior limits of hard pal-
ate. When this transpalatal line makes con-
tact with the cleft, points PC and PC1 are
created. PC to PC1 measures posterior cleft
space width. Medial border of the palatal
segments (AC-PC, AC1-PC1) is limited by
the cleft space. In CBCLP (Fig. 17.3 ), the
premaxilla’s surface area is limited anteri-
orly by its alveolar ridge (PML-PMR).
17.1.1 Method Used for Analyses
Cleft Subjects : The subjects had unequal num-
bers of observations and were observed at dif-
Fig. 17.2 ( a ) Twelve serial digital images of a complete
unilateral cleft lip and palate from 13 days of age to
14 years and 2 months of age. The 2D images generated
from 3D casts are accurate in form but are not related in
size to each other. The image at birth (13 days) is followed
by (0.3 and 1.6) that had undergone molding as a result of
muscular contractive forces created by lip adhesion at
14 months of age. Palatal cleft closure using a von
Langenbeck with modi fi ed vomer fl ap was performed at
14 months of age. A secondary alveolar bone graph was
placed at 8 years and 3 months of age after some minor
orthodontics to align the anterior teeth. No presurgical
orthopedics was performed
#AE-32 (USA)
a
13 days
0-3
1-6
2-0
2-6
3-0
4-4
4-11
5-4
5-6
8-9
9-0
9-11
11-9
13-4
14-2
12-2
12-7

393
17 Choosing the Best Time for Palatal Surgery
ferent ages. In order to compare the responses
of the different groups, the data was recoded
into new age intervals of 2, 8, 18, 36, 60, 84,
120, 168, and 192 months. The groups from
Amsterdam to Rotterdam were observed only
for 4 years and were coded as 2, 8, 18, and
48 months. Infrequently, especially in the early
months, subjects would have two observations
in a recoded age interval. When this happened,
the mean values of the observations were used.
The within-group variances were compared
during subsequent analyses to ensure that the
equal-variance requirement of the analysis of
variance was maintained and not biased by the
use of mean values in some instances.
Controls : Serial casts from 18 patients who
had only clefts of the lip and/or alveolus (CLA),
with or without clefts of the soft palate (SP), or
clefts of the lip and soft palate (CLA and SP)
alone. All of these patients did not have a cleft in
the hard palate. One case series had no cleft at all.
The data from the control series was handled
exactly as that from the cleft series.
Statistical Analysis : A preliminary analysis
of palatal area was performed using a random
effects model in the SAS Proc Mixed software.
This preliminary analysis showed not only
group differences but, more importantly, het-
erogeneity in group responses over time (i.e., a
signi fi cant group x time interaction). Because
of the signi fi cant interaction, overall differ-
ences among groups or times are not directly
interpretable. Consequently, the simple effects
of differences between groups at each time
point were investigated. The SAS Proc GLM
software was used to test the fi xed effects model
2,500.00
2,000.00
1,500.00
1,000.00
500.00
0.00
0−0−13
R.S.A...............................Right surface area
L.S.A...............................Left surface area
Cleft space
CAE: AE-32
Source: USA
Right + left S.A.
Right + left S.A. + Cleft spaces
0−3
1−6
2−0
2−6
3−0
4−4 4−11
5−4
5−6
8−9
9−0 9−11 11−9 12−2 12−7 13−4 14−2
Suface area palatal and cleft space
changes
b
( b ) Graph depicting serial palatal
3D bony growth changes and the size of the cleft space of
case 2A. The combined surface areas of the large and
small palatal segments changed from 689 mm 2 at 13 days
to 1,121 mm 2 at 1 year and 6 months (an increase of
39.5 %) at the time of palatal surgery. The cleft space
reduced from 365 to 202 mm 2 at 3 months due to molding.
Additional molding and palatal growth further reduced
the cleft space prior to palatal surgical closure. Palatal
growth occurred gradually up to 5 years and 6 months.
The continued marked increase in palatal sizes up to
10 years and 8 months re fl ects posterior palatal growth to
accommodate the developing molars. This posterior pala-
tal area appears not to be affected by the palatal surgery
Fig. 17.2 (continued)

394
S. Berkowitz
among groups at each time, followed by a pair-
wise comparison among mean values. At each
time point, it was sometimes possible to com-
pare among eight groups, which would lead to
28 comparisons (some time points had fewer
groups because not all groups were observed at
every time point). A strict control for multiple
comparisons, say by the Bonferroni procedure,
would severely decrease the power to detect
differences. Therefore, the alpha level for each
#WW-9 ( USA )
0-1
0-4
0-8
1-1
1-4
1-9
2-6
4-2
4-6
5-0
5-6
6-1
8-0
15-5
10-5
13-8
14-5
Fig. 17.3 Digitized serial 2D cast images of a one side
incomplete and the opposite side complete bilateral cleft
lip and palate. The serial form cast’s serial changes are
accurate but not so as it relates to their relative size. At
0–1 (1 month) palatal segments are laterally displaced. At
0–4 (4 months), this image shows medial movement
(molding) of the palatal segments, as a result of lip adhe-
sion. The premaxilla is positioned forward of the lateral
palatal segments with marked closure of the cleft space.
At 0–8 and 1–1, these images show further spontaneous
closure of the palatal cleft space as a result of palatal
growth. At 1–4, palatal closure was performed 1 month
earlier using a von Langenbeck with a modi fi ed vomer
fl ap. Note that the following cast images show the gradual
incorporation of the premaxilla within the palatal arch
with orthodontic treatment

395
17 Choosing the Best Time for Palatal Surgery
pair-wise test was set at 0.01. No statistical
comparisons were made across time points, but
the consistency of the signi fi cant differences
found in the pair-wise tests was noted. In this
way, biologically consistent differences could
be elucidated with suf fi cient power.
17.2
Treatment Protocols at Each
of the Centers (Table 17.2 )
17.2.1 Miami Craniofacial Anomalies
Foundation, South Florida
Cleft Palate Clinic (Figs. 17.1 , 17.2 ,
and 17.3 )
All of the lip and palate surgery was performed
by D. Ralph Millard Jr., M.D., secondary alveolar
bone graft by S.A. Wolfe, M.D., and all staged
orthodontics procedures were performed by
Samuel Berkowitz, D.D.S.
All cases studied from the participating insti-
tutions had similar graphs created.
17.3
Results: Comparison of Total
Surface Area in Unilateral
Cases
The mean values, standard errors, and sample
sizes for the unilateral data are shown in Table 17.3
and Fig. 17.2a , b . From Table 17.3 , it appears that
all other groups are below the controls and that
the Goteborg-vomer group and the Northwestern
group behave somewhat differently from the rest.
Both are lower. The results of the statistical com-
parisons are shown in various tables which are set
up as a matrix to be read as follows: In the cell
de fi ned by the intersection of a row for one group
and the column for another group, the times where
the two groups are signi fi cantly different are indi-
cated. As an example, following the Miami row
and the Goteborg-V column, we see that these
two groups had signi fi cantly different total areas
at 36, 60, and 84 months. That this is reasonable
can be determined by inspecting Fig. 17.6 , unilat-
eral cleft lip and palate data, or looking at the
mean values in Table 17.4 .
The most striking feature in Tables 17.3 and
17.4 is that all of the groups differ from controls
over time (see note* ). The differences decrease
over time due to growth changes in the posterior
molar area. This growth area is associated with the
developing permanent molars. The other feature is
that the Goteborg-vomer group seems to be con-
sistently low over the period of 36–84 months.
17.3.1 Growth Velocity in the
Unilateral Cases (Fig. 17.5 )
In order to compute the rate of growth (velocity)
of total surface area, the slope of the growth
between time points was computed for each sub-
ject by dividing difference in area by the differ-
ence in time. The slope was then assigned the
midpoint of the two time observations for analy-
sis and plotting.
The Northwestern and Illinois groups show
the highest initial velocities, with Amsterdam,
Miami, Goteborg-vomer, and Rotterdam show-
ing very similar intermediate velocities.
The Goteborg-delayed group and the controls
show very similar but lower initial velocities.
Interestingly, the controls show a slight increase in
velocity between week 8 and week 18. Between 18
and 60 months, the vomer group drops in velocity
and stays constant. The other groups level off and
stay approximately constant after 36 months. The
plot of the mean velocities is shown in Fig. 17.4 .
Some of the purposes of the Amsterdam and
Rotterdam studies were to investigate growth
velocity before surgery. The data on the velocity
changes are plotted in an expanded graph in
Figs. 17.5 , 17.6 , and 17.7 . This plot substantiates
the observations made above.
These data show that the controls have a
substantially higher growth velocity than the
*corresponds with the *at the end of Table 17.3

396
S. Berkowitz
Table 17.3 Total palate surface area [mean ± std. error (sample size)] of unilateral clefts by data source and age in months
Months
Source
2
7.2
17.2
36
60
7.24
120
192
Amsterdam
7.217.2 ± 19 (33)
1,003 ± 25 (33)
1,157.2 ± 22 (31)
1,396 ± 29 * (33)
Miami
7.211 ± 22 (27.2)
1,001 ± 24 (22)
1,142 ± 25 (24)
1,237.2 ± 23
(30)
1,402 ± 32 (30)
1,616 ± 40 (27.2)
17.206 ± 52 (27.2)
2,144 ± 7.25 (17.2)
Controls
930 ± 34 (11)
1,066 ± 34 (13)
127.23 ± 40 (12)
1,496 ± 36 (14)
17.226 ± 57.2
(15)
17.27.21 ± 65 (17.2) 2,060 ± 7.27.2 (12) 2,337.2 ± 123 (7.2)
Goteberg (D)
7.27.22 ± 27.2 (24) 97.26 ± 21 (22)
1,126 ± 37.2 (17.2) 1,220 ± 33 (21)
137.24 ± 37.2
(20)
1,599 ± 45 (20)
17.230 ± 50 (24)
2,247.2 ± 46 (23)
Goteberg (V)
7.242 ± 21 (23)
1,013 ± 27.2 (22) 1,052 ± 26 (19)
1,109 ± 27.2
(20)
117.29 ± 32 (20) 1,406 ± 45 (22)
17.217.2 ± 37.2 (23) 2,119 ± 57.2 (21)
Illinois
7.292 ± 31 (11)
1,012 ± 49 (11)
1,107.2 ± 32 (19)
1,242 ± 37.2
(17.2)
1,309 ± 53 (11)
167.21 ± 52 (9)
17.27.29 ± 7.22
(10)
2,293 ± 61 (9)
Northwestern
7.230 ± 21 (27.2)
999 ± 36 (12)
107.24 ± 30 (11)
1,126 ± 37.2 (9) 1,316 ± 61 (7.2) 147.20 ± 56 (6)
1,653 ± 57.2 (21)
2,265 ± 95 (6)
Rotterdam
7.27.29 ± 13 (60)
949 ± 17.2 (59)
107.25 ± 23 (59)
1,251 ± 25 * (59)
* Measurements made at 47.2 months
Table 17.4 Statistically signi fi cant differences in unilateral total surface area ( p < 0.01) at speci fi c time points by sample source
Amsterdam Miami
Controls
Goteberg D
Goteberg V
Illinois
Northwestern
Rotterdam
Amsterdam
–
2
2
Miami
–
2, 17.2, 36, 60,
7.24, 120
36, 60, 7.24
2
Controls
2
2, 17.2, 36, 60,
7.24, 120
–
17.2, 36, 60, 7.24 17.2, 36, 60, 7.24, 120 17.2, 36, 60
2, 36, 60, 7.24,
120
2, 7.2, 17.2, 36
Goteberg D
17.2, 36, 60, 7.24
–
36, 60
7.24
2
2
Goteberg V
36, 60, 7.24
17.2, 36, 60, 7.24,
120
36, 60
–
36, 7.24
2
Illinois
17.2, 36, 60
7.24
36, 7.24
–
2
2
Northwestern
2
2
2, 36, 60, 7.24, 120
2
2
2
–
Rotterdam
2, 7.2, 17.2, 36
2
2
–

397
17 Choosing the Best Time for Palatal Surgery
Amsterdam
50
45
40
35
30
Growth velocity of total area
25
20
15
10
5
0
0
24
48
72
Months
96
120
144
168
Berkowitz
Controls
Goteberg(D)
Goteberg(V)
Illinois
Northwestern
Rotterdam
Fig. 17.5 Unilateral cleft
palate data
2,500
2,250
Total surface area (mm2)
2,000
1,750
Amsterdam
Berkowitz
Controls
Delayed
Rotterdam
Vomer
Ilinois
Northwestern
1,500
1,250
1,000
750
500
0
24
48
72
96
120
Months
144
168
192
Fig. 17.4 Unilateral cleft
palate data
other groups after the very early period. The
vomer group shows consistently low velocities.
Interestingly, the Amsterdam and Rotterdam
groups do not differ from Miami, Goteborg-
delayed, Illinois, and Northwestern. The
velocity data showed rapid growth early except
for the controls and the Goteborg-delayed
groups. During the period 8–18 months,
the Amsterdam, Miami, Goteborg-delayed,
Illinois, and Rotterdam groups came together
and showed constant growth thereafter. The
Goteborg-vomer group and the Northwestern
group both showed a lower growth velocity
than did the other groups. After the period of
8–18 months, the controls showed a consis-
tently higher growth velocity.

398
S. Berkowitz
×
×
×
×
×
0
0
5
10
15
20
25
30
35
40
45
50
Growth velocity of total area
6
12
18
24
Months
30
36
42
48
54
Amsterdam
Berkowitz
Controls
Goteberg(D)
Goteberg(V)
Illinois
Northwestem
Rotterdam
Fig. 17.7 Unilateral cleft
palate data
×
×
×
×
×
+
+
+
+
+×
+×
+×
+×
400
0
6
12
18
24
Months
30
36
42
48
Amsterdam
Berkowitz
Controls
Delayed
Rotterdam
Vomer
Illinois
Northwestem
600
800
Total surface area (mm 2)
1,000
1,200
1,400
1,600
Fig. 17.6 Unilateral cleft
palate data
17.3.2 Comparison of Unilateral
Posterior Cleft Areas
(Figs. 17.8 and 17.9 )
The outstanding feature of these data is that Illinois
started out lower than the others and Northwestern
started out higher than the others, but neither showed
decreasing posterior cleft areas after 8 months.
They actually increased in size to 18 months then
slowly decreased. The other groups showed patterns
similar to each other, becoming smaller in size at
different rates and to different degrees.

399
17 Choosing the Best Time for Palatal Surgery
300
250
200
150
100
Posterior cleft area (mm2)
50
0
0
6
12
Months
18
24
30
36
Amsterdam
Berkowitz
Goteberg D
Goteberg V
Illinois
Northwestem
Rotterdam
Fig. 17.8 Unilateral cleft
palate data
Amsterdam
Berkowitz
Goteberg D
Goteberg V
Illinois
Northwestem
Rotterdam
40
35
30
25
20
15
10
5
0
0
6
12
18
Months
Ratio of posterior area to total area (%)
24
30
36
Fig. 17.9 Unilateral cleft
palate data
17.3.3 Comparisons of the Ratio
of Posterior Cleft Area
to Total Surface Area
in Unilateral Cases (Fig. 17.9 )
At month 18, there were no signi fi cant differ-
ences between groups. These data have almost
exactly the same pattern as the posterior cleft
space plots shown in Fig. 17.8 .
17.3.3.1 Tracking of the Large and Small
Segments in Unilateral Cases
(Fig. 17.10a–h )
The large and small segments tracked each other
closely in all groups. Plots of the two segments
for each unilateral group are found in the full-
page plots. In early adulthood, although the
data are sparse in this region, it appears that all
four groups achieve similar total palate surface

400
S. Berkowitz
Small segment
Large segment
Small segment
Large segment
Small segment
Large segment
Small segment
Large segment
Small segment
Large segment
Small segment
Large segment
1,200
a
b
c
d
e
f
1,100
1,000
900
800
700
600
500
400
300
1,200
1,300
1,100
1,000
900
800
700
600
500
400
300
300
350
400
450
500
550
600
650
700
750
800
1,200
1,200
1,300
1,100
1,100
1,000
1,000
900
900
800
800
700
700
600
600
500
500
400
400
300
300
1,200
1,300
1,100
1,000
900
800
700
600
500
400
300
200
Surface area (mm2)
Surface area (mm2)
Surface area (mm2)
Surface area (mm2)
Surface area (mm2)
Surface area (mm2)
0
24
48
72
96
Months
Months
Months
Months
Months
120 144 168 192
0
24
48
72
96
120 144 168 192
Months
0
24
48
72
96
120 144 168 192
0
0
6
12
18
24
30
36
42
48
24
48
72
96
120 144 168 192
0
24
48
72
96
120 144 168 192
Fig. 17.10 ( a – h ) Unilateral cleft palate data. ( a ) Goteborg-vomer sample, ( b ) Goteborg-delayed sample,
( c ) Northwestern sample, ( d ) Amsterdam sample, ( e ) Illinois sample, ( f ) Miami sample

401
17 Choosing the Best Time for Palatal Surgery
areas. The clinical decision to effect a relative
early (18–24 months) closure of the unilateral
cleft based on the Miami model appears to have
had the same results as delaying the closure in
the Goteborg-delayed series until approximately
5–9 years of age. Both groups show a tendency
for growth to start increasing at 5–6 years, coin-
ciding with permanent molar development,
and continue through adolescence and early
adulthood.
17.3.4 Comparisons of Surface Area in
the Bilateral Cases (Table 17.5 )
The statistical methodology for the bilateral com-
parisons was the same as that for the unilateral
comparisons. The mean values for the bilateral
cases are shown in Table 17.5 . Clearly, the sam-
ple sizes are smaller than in the unilateral cases,
but the standard errors re fl ect statistically stable
observations. A plot of these values is shown in
Fig. 17.11 . The most striking feature of these data
is that the control group and the Miami group are
behaving similarly with respect to the other
groups, although the Miami group shows lower
growth until approximately 84 months. To show
early differences more clearly, an expanded plot
is shown in Figs. 17.12 , 17.13 , and 17.14 . These
plots show clearly that the two Goteborg groups
start off slowly.
17.3.4.1 Growth Velocity in the Bilateral
Cases (Fig. 17.12 )
The Miami and Nijmegen groups show the high-
est initial velocities, with Goteborg-delayed and
Goteborg-vomer showing very similar intermedi-
ate velocities. The Amsterdam group and the con-
trols show very similar but lower initial velocities.
Interestingly, the controls show a slight increase
in velocity between week 8 and week 18.
Overall growth velocities are shown in
Fig. 17.14 . This plot substantiates the observa-
tions made above. Figure 17.12 shows that there
is very little difference in growth velocities
among the bilateral cases.
17.3.5 Comparison of Bilateral
Posterior Cleft Areas
(Fig. 17.15 )
The posterior cleft areas up to 36 months are shown
in Fig. 17.15 . All the groups had similar patterns
for the closure of the posterior cleft space.
17.3.6 Comparisons of the Ratio of
Posterior to Total Surface Area
in Bilateral Cases (Fig. 17.16 )
At month 8, Nijmegen is signi fi cantly different
from each of the other groups. There are no
Small segment
Large segment
Months
Months
0
300
400
500
700
g
h
690
1,200
1,100
1,000
900
800
700
600
500
400
300
Surface area (mm2)
Surface area (mm2)
6
12
18
24
30
36
42
48
0
24
48
72
96
120 144 168
192
Small segment
Large segment
( g ) Rotterdam sample, and ( h ) control sample
Fig. 17.10 (continued)

402
S. Berkowitz
Table 17.5 Surface area growth velocity [mean ± std. error (sample size)] of unilateral clefts by data source and age in months
Months
Source
5
13
27.2
47.2
7.22
102
156
Amsterdam
31.0 ± 2.9 (33)
17.2.0 ± 1.6 (34)
7.2.7.2 ± 0.7.2 a (31)
Miami
30.9 ± 2.5 (22)
14.7.2 ± 1.9 (19)
6.1 ± 0.7.2 (23)
6.0 ± 0.6 (27.2)
9.3 ± 0.7.2 (26)
5.3 ± 0.7.2 (26)
4.9 ± 0.6 (16)
Controls
19.2 ± 5.7.2 (10)
23.7.2 ± 2.7.2 (12)
11.3 ± 1.4 (11)
9.9 ± 1.7.2 (13)
7.2.6 ± 1.3 (15)
6.7.2 ± 1.1 (12)
4.5 ± 0.5 (7.2)
Goteberg (D)
17.2.9 ± 3.2 (22)
16.1 ± 3.5 (17.2)
5.0 ± 1.4 (16)
7.2.2 ± 0.9 (17.2)
9.3 ± 1.0 (17.2)
6.1 ± 1.1 (20)
5.9 ± 0.6 (23)
Goteberg (V)
29.4 ± 3.1 (21)
7.2.7.2 ± 1.9 (17.2)
1.9 ± 0.7.2 (16)
3.9 ± 0.7.2 (17.2)
9.2 ± 1.2 (17.2)
7.2.5 ± 1.0 (22)
5.7.2 ± 0.6 (20)
Illinois
37.2.2 ± 7.2.6 (7.2)
13.0 ± 4.2 (10)
9.1 ± 2.6 (9)
4.5 ± 1.6 (6)
10.5 ± 5.3 (4)
5.6 ± 1.5 (5)
5.1 ± 1.5 (4)
Northwestern
47.2.1 ± 5.2 (7.2)
7.2.5 ± 2.7.2 (5)
4.6 ± 1.7.2 (4)
4.3 ± 0.7.2 (5)
7.2.6 ± 1.0 (3)
6.4 ± 0.7.2 (4)
6.7.2 ± 0.4 (4)
Rotterdam
29.2 ± 2.0 (50)
12.7.2 ± 1.3 (57.2)
5.9 ± 0.4 a (57.2)
a Estimate made at 33 months

403
17 Choosing the Best Time for Palatal Surgery
2,400
2,200
2,000
1,800
1,600
Total surface area (mm2)
1,400
1,200
1,000
800
600
0
24
48
72
96
120
Months
Amsterdam
Miami
Controls
Goteberg-D
Goteberg-V
Nijmegen
144
168
192
Fig. 17.11 Bilateral cleft
palate data
0
0
10
20
Growth velocity of total area
30
40
24
48
72
96
120
Months
Amsterdam
Miami
Goteberg-D
Goteberg-V
Nijmegen
Controls
144
168
Fig. 17.12 Bilateral cleft
palate data
further statistically signi fi cant differences. These
data have almost exactly the same pattern as the
posterior cleft space plots shown in Fig. 17.15 .
Bilateral Cases: The bilateral total surface
growth curves revealed that both Goteborg groups
grew slowly throughout the complete time period
while the Nijmegen group showed slowed growth
after 60 months. The Miami group showed a pat-
tern similar to the controls but with somewhat
lower total growth between 18 and 84 months.
The velocity pro fi les for the bilateral cases were
very similar to those for the unilateral cases.

404
S. Berkowitz
Total surface area (mm2)
Months
Amsterdam
0
1,600
1,400
1,200
1,000
800
600
400
6
12
18
24
30
36
42
48
Miami
Goteberg (D)
Goteberg (V)
Nijmegen
Controls
Fig. 17.13 Bilateral cleft
palate data
Months
Amsterdam
0
0
50
100
150
200
250
300
350
400
Surface area, posterior cleft space (mm2)
24
48
72
96
120
144
168
192
Miami
Nijmegen
Goteberg-D
Goteberg-V
Fig. 17.14 Early growth
velocity by group and time
The closure of the posterior cleft spaces and
the ratio of posterior cleft space to palatal sur-
face area before surgery and to total surface area
after surgery was also similar to that in the uni-
laterals. The only noteworthy feature was that the
Nijmegen group had larger posterior cleft spaces
and consequently higher ratios from month
3 through month 36. This may be due to the
longer and more constant use of the presurgical
orthopedic appliance which prevented the palatal
segments from moving together (molding).
17.3.7 Conclusions for the Bilateral
Series
The different practices showed similar results in
palatal growth in that growth curves paralleled

405
17 Choosing the Best Time for Palatal Surgery
controls but never entirely caught up. The only
exception was that the Miami bilateral group did
overtake the controls. Early (18–24 months) or
later closure had similar results.
17.3.8 Clinical Signi fi cance
of the Results
This study highlights that differences in palatal
•
osteogenesis is re fl ected in differences in cleft
space size at the same age at birth and for the
next 12 months.
The vomer series, where the palatal cleft
•
was closed before 1 year followed by a velar
pushback, showed that extensive pushback
procedures interfered with palatal growth.
This fi nding was reported by the clinic staff
and was the reason for discontinuing this
surgical protocol and changing to delayed
closure without vomerine fl aps and palatal
pushbacks.
Months
Amsterdam
0
0
50
100
150
Surface area, posterior cleft space (mm2)
200
250
300
350
400
24
48
72
96
120
144
168
192
Miami
Nijmegen
Goteberg-D
Goteberg-V
Fig. 17.15 Bilateral cleft
palate data
Ratio (%) posterior to total area
55
50
45
40
35
30
25
20
15
10
5
0
0
10
20
30
Months
40
50
60
Amsterdam
Miami
Goteberg-V
Goteberg-D
Nijmegen
Fig. 17.16 Bilateral cleft
palate data

406
S. Berkowitz
The small modi fi ed vomer fl ap with a von
•
Langenbeck procedure used in the Miami
series did not cause palatal growth retardation
or cause an excessive number of posterior
crossbites.
CBCLP cases appear to have more osteogenic
•
de fi ciency than CUCLP cases at birth.
All cleft palates are smaller than noncleft hard
•
palates (controls).
There is more than one physiological surgical
•
procedure which can be used to close palatal
clefts.
In all cases, the most common age for the
•
smallest velocity of growth was between 18
and 24 months of age.
The best time to close the palatal cleft is when
•
palatal growth change has signi fi cantly slowed
down so that cellular growth activity can pro-
ceed without interference.
Physiological surgery (the procedure that
•
interferes least with normal cellular activity)
allows for catch-up palatal growth.
It is now possible to mathematically determine
•
the “best time” to close the palatal cleft, other
than have it based solely on the age of the
patient.
It appears that the effect of cleft closure sur-
•
gery involves only that part of the palate ante-
rior to the fi rst permanent molars. Subsequent
palatal growth is necessary to accommodate
the second and third molars, and this area
seems to grow independently of the effect
from early palatal surgery.
The lateral palatal segments in the CBCLP
•
and CUCLP cases grow at a similar rate.
17.3.9 Discussion
Recent trends in the study of human biology
generally and cleft palate research in particular
exhibit an increasingly emphatic recognition of an
important fact: that mass cross-sectional studies
of large groups can be signi fi cantly less valuable
than studies made of groups of single individuals
over lengthy periods of time. Mass studies tend to
smooth out signi fi cant individual differences and
to obscure them, while consistent and prolonged
serial studies focusing on individual areas tend to
emphasize such variations by bringing them out
in high relief. To date, investigating the growth of
the palate has been studied only so far as it is dis-
played in the super fi cial soft structures overlying
the bony palate.
All measurements in this chapter, therefore,
unless otherwise stated, refer to the soft struc-
tures of the palate and not to the skeletal palate.
For purposes of convenience, whenever neces-
sary, we shall hereafter in our series speak of the
fl eshy palate as distinguished from the bony
palate.
The design of this study would have been bet-
ter if it included test cases treated with the same
palatal surgery at 6–12 months as well as at
18–24 months of age. This comparative growth
study would demonstrate the importance of using
surgery based on the size of the cleft space rela-
tive to total palatal size and eliminate any resul-
tant growth differences due to the type of surgery
used. Unfortunately, we only had a small sample
of these early closure cases. Since they developed
excessive scarring with poor dental occlusion and
midfacial growth, we did not accrue enough cases
to perform valid statistical comparisons. Knowing
that many organ systems in neonates grow very
rapidly within the fi rst 24 months, it was decided
to use the same range of 12–24 months as the sus-
pected ideal period for palatal cleft closure. A
modi fi ed vomer fl ap was added to the von
Langenbeck procedure to create a normal vault
space. Since some cases had extremely large cleft
palate spaces that re fl ected an excessively high
degree of osteogenic de fi ciency, we focused on
this factor rather than the age of the patient to
avoid creating excessive scarring. The palatal
growth velocity measurements showed that our
reasoning as to when best to perform palatal sur-
gery was supported by the subsequent analyses.
Surgical Goals : In 1938, Kilner listed the pri-
mary objectives of cleft palate treatment in order
of importance to speech, followed by chewing
and aesthetics (Millard 1986 ) . Unfortunately, this
priority of goals still seems to be preferred by
many plastic surgeons due to the in fl uence of
speech-language pathologists who fear the con-
sequences of an open palate. Thus, they favor

407
17 Choosing the Best Time for Palatal Surgery
palatal cleft closure before 1 year of age. As a
result, the surgical history of cleft palate repair is
replete with varied attempts to close the cleft
space as if it was “a stagnant hole,” with minimal
concern as to the surgical effects on palatal and
facial growth (Kaplan 1981 ) .
Clinicians in all specialties have criticized the
poor long-term aesthetic and dental occlusion
results created by nonphysiological surgical pro-
cedures (as to type and timing) that did too much
mucoperiosteal undermining too soon, creating
excessive scarring.
Unfortunately, the speech argument for early
palatal cleft closure before 12 months still pre-
vails and with it the hunt for the “magical cut”
that will answer all aesthetic problems at birth
and in the future. Slaughter and Brodie ( 1949 ) ,
commenting on poor midfacial growth, stressed
that reduction in blood supply and constriction
by scars would jeopardize palatal growth, yet this
message was disregarded. In addition, they stated
that unwarranted trauma to hard and soft tissue,
due to the fracturing of bone and stripping of
mucoperiosteum, would cause permanent dam-
age to growth sites that were active until 5 years
of age. There was no criticism of the timing of
surgery, only the procedures being performed.
Not having appropriate records, they could not
relate the surgical outcome to the disproportion-
ately small palatal segments to cleft size that
existed before 1 year of age (Maisels 1966 ) .
What surgical procedures to use and when to
close the palatal cleft were questions that had no
universally acceptable answers. While surgeons
such as Veau ( 1934 ) and Brophy ( 1923 ) believed
that early closure of the cleft palate improved
speech development, there were many who took
a contrary position. Koberg and Koblin ( 1983 )
favored palatal cleft closure between 2 and
3 years of age to achieve both good midfacial
growth and speech.
Delaying Palatal Closure : There were many
European cleft palate clinics which emphasized
in the 1960s to the present time the achievement
of good midfacial, palatal development, and
speech. They recommended that cleft palate clo-
sure be postponed until the eruption of either the
deciduous or as late as the permanent dentition
( Hotz and Gnoinski 1976 ; Hotz 1979 ; Weil 1988 ;
Friede 1998 ) .
Why Presurgical Orthopedics : The rationale of
the four European centers in this study for using
presurgical orthopedics within 2 weeks after birth
is based on their speculation that this treatment
may aid speech development and feeding. The
Goteborg clinic uses the PSO appliance solely
as an obturator to aid feeding. The Goteborg,
Amsterdam, Rotterdam, and Nijmegen centers
usually performed delayed, staged palatal closure
between 5 and 9 years of age. Children’s Memorial
Medical Center, Northwestern University Cleft
Palate Institute, employs presurgical orthopedics
with primary bone grafting while closing the pala-
tal cleft at approximately 1 year of age. In some
instances, PSO is also used to manipulate the lat-
eral palatal segments to aid surgical closure of
the lips and establish an alveolar butt relationship
prior to primary bone grafting.
Advocates of delayed palatal closure (5+
years) wanted to avoid secondary malformations
of the palate and severe deformities of the max-
illa caused by scarring created by extensive
mucoperiosteal undermining with transposition-
ing of the tissue. This occurred when surgery cre-
ated exposed lateral areas of denuded bone due to
stripping off of the overlying mucoperiosteum.
Similar malformations were created in animals
by Kremenak CR, et al. ( 1970 ).
To avoid the consequences of early surgery,
Hotz ( 1979 ) and Weil ( 1988 ) advocated the use
of an obturator in the interim until additional pal-
atal growth occurred which reduced cleft space
width. They believed that postponing palatal cleft
closure would not jeopardize speech develop-
ment. Bzoch ( 1964 ) stated that early speech ther-
apy, between 1 and 3 years of age, corrected early
speech problems. Speech-language pathologists
and surgeons have mistakenly disregarded the
possibility that signi fi cant speech problems can
be corrected with therapy.
Many bene fi ts were claimed for the use of pre-
surgical orthopedics, such as the stimulation of
palatal growth, aiding speech development, and
the reduction of middle ear disease. However, in
a state-of-the-art report on orofacial growth, no
supporting literature was reported (Berkowitz 1978 ).

408
S. Berkowitz
The same failure of having any supporting
literature is in evidence even today.
The fi ndings by the Amsterdam, Nijmegen,
and Rotterdam prospective studies, which used
presurgical orthopedics (PSOT) for 30-plus years,
state that PSOT has a very limited effect on feed-
ing and have recently concluded that it has no
lasting effect on palatal arch form. Therefore, the
cost/bene fi t ratio may not warrant its further use
(Prahl et al. 2001 ) . They are beginning to ques-
tion whether earlier palatal surgery may be
warranted.
Berkowitz ( 1996 ) believes the timing pendu-
lums had swung too far to the opposite extremes:
from early to very late closure and is now swing-
ing back again to early closure, between 6 and
12 months of age. Berkowitz ( 1985 ) states that
those who favor either extreme timing periods are
still not focusing, as Berkowitz and Millard did,
on the size of the cleft defect but continue to be
fi xated on the patient’s age alone. Some surgeons
have found a “middle of the road” treatment plan,
around 12–18 months of age, but not on the size
of the cleft space.
17.4
Good Speech Is Dependent
on a Normal Palate
Sally Peterson-Falzone et al. ( 2000 ) have written
that malocclusion needs to be considered during
the early speech-learning years. She points out
that the dental and orthodontic literature con-
tains 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 (Berkowitz 1985 ) .
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 (Berkowitz 1985 ) . Children with clefts
are obviously vulnerable to restriction in size of
the palatal vault and the possibility of class III
occlusions due to the 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 den-
tition 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.
This study has demonstrated that a scienti fi c
basis for selecting the best time to close the pala-
tal cleft, in both CUCLP and CBCLP, is when the
cleft space surface area is 10 % or less of the sur-
rounding palatal surface area bounded by the
alveolar ridges.
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.
The overarching thesis of this report favors
consideration of the total emotional and physical
health of the child with a cleft, based on the
desired attainment of a cosmetically attractive
face, adequate dental function and respiration, as
well as speech. Many surgical, medical, and den-
tal therapies may be necessary in the best-treated
cases. As long as the surgeon individualizes the
treatment plan, taking care to do no harm to
growing structures, all goals are obtainable.
17.5
Conclusions
1. When the ratio of posterior cleft space to the
total palatal surface area medial to the alveolar
ridges is no more than 10 %, it is the best time
to surgically close the palatal cleft space.
Therefore, one need not wait until 5–9 years

409
17 Choosing the Best Time for Palatal Surgery
of age to close the cleft space in order to maxi-
mize palatal growth.
2. Presurgical orthopedics does not stimulate pala-
tal growth beyond its normal growth potential.
3. There is more than one physiological surgical
procedure to achieve good palatal growth.
4. Extensive velar fl aps with or without palatal
pushback surgery are detrimental to palatal
growth.
17.6
Participating Treatment
Programs and Coinvestigators
Principal Investigator:
Miami Craniofacial Anomalies Foundation,
•
South Florida Cleft Palate Clinic, Samuel
Berkowitz, D.D.S., M.S., F.I.C.D.
Coinvestigators:
University of Miami, School of Medicine,
•
Robert Duncan, M.D.
Center for Craniofacial Anomalies, University
•
of Illinois College of Medicine, Carla Evans.,
D.D.S., D.M.Sc.
Children’s
Memorial
Medical
Center,
•
Northwestern University Cleft Palate Institute,
Sheldon Rosensteim, D.D.S., M.S.D.
Cleft Palate Center, Sahlgrenska University
•
Hospital, Goteborg Sweden, Hans Friede,
D.D.S., O.DR.
University Hospital of Nijmegen Cleft Palate Center,
•
Anne Marie Kuijpers-Jagtman, D.D.S., Ph.D.
Free University of Amsterdam Cleft Palate
•
Center, Birte Prahl-Andersen, D.D.S, Ph.D.
Academic Hospital (Dijksigt/Sophia) Rotterdam
•
Cleft Palate Center, M.L.M. Mobers, D.D.S
References
Berkowitz S (1985) Timing cleft palate closure-age should
not be the sole determinant. J Craniofac Genet Devel
Biol 1(Suppl):69–83
Berkowitz S (1978) State of the art in cleft palate, orofa-
cial growth. Am J Orthod 84:5, 564–586
Berkowitz S (1996) Cleft lip and palate and craniofacial
anomalies perspectives in management. Singular
Press, San Diego
Brophy TW (1923) Cleft lip and palate. Blakiston’s,
Philadelphia, pp 131–132
Bzoch KR (1964) Clinical studies of the ef fi cacy of speech
appliances compares to pharyngeal fl ap surgery. Cleft
Palate J 35:285–286
Friede H (1998) Growth sites and growth mechanisms at
risk in cleft lip and palate. Acta Odontol Scand 56:
346–351
Hotz MM (1979) 22 years of experience in cleft palate
management and its consequences for treatment plan-
ning. In: Kherer B, Slongo T, Graf B et al (eds) Long-
term treatment in cleft lip and palate with coordinated
approach. Hans Huber, Bern, pp 208–211
Hotz M, Gnoinski W (1976) Comprehensive care of cleft
lip and cleft palate children at Zurich University: a
preliminary report. Am J Orthod 80:481–504
Kaplan EN (1981) Cleft palate repair at three months.
Ann Plast Surg 8:189–190
Koberg W, Koblin I (1983) Speech development and max-
illary growth in relation to technique and timing of
palatoplasty. J Maxillofac Surg 1:44
Kremenak CR, Huffman WC, Olin WM (1970) Maxillary
growth inhibition by mucoperiosteal denudation of
palatal shelf bone in noncleft beagles. Cleft Palate J 8:
818–825
Maisels DO (1966) The timing of various operations
required for complete alveolar clefts and their in fl uence
on facial growth. Br J Plast Surg 20:230–243
Millard DR (1986) Cleft craft: the evolution of its surgery,
part I: the unilateral deformity. Little Brown, Boston
Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP
(2000) Cleft palate speech, 3rd edn. Mosby, St. Louis,
pp 123–148
Prahl C, Kuijpers-Jagtman AM, Van’t Hof MA, Prahl-
Andersen B (2001) A randomized prospective clinical
trial into the effect of infant orthopaedics on maxillary
arch dimensions in unilateral cleft lip and palate. Eur J
Oral Sci 109:298–305
Slaughter WB, Brodie AG (1949) Facial clefts and their
surgical management in view of recent research. Plast
Reconstr Surg 4:311–332
Veau V (1934) Le Sequalette due bec-de-lievre. Ann Anat
Pathol 11:883
Weil J (1988) Orthopaedic growth guidance and stimula-
tion for patients with cleft lip and palate. Scand J Plast
Reconstr Surg 21:58–64

Part VII
Another Tested Good Surgical Procedure

413
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_18, © Springer-Verlag Berlin Heidelberg 2013
18
Abbreviations
A-P
Anterior-posterior
CLP
Cleft lip and palate
HPR
Hard palate repair
RCT
Randomized controlled trial
SPR
Soft palate repair
UCLP Unilateral cleft lip and palate
VPC
Velopharyngeal competence
VPF
Velopharyngeal fl ap
VPI
Velopharyngeal incompetence
18.1
Introduction
The surgical protocol is the most important factor
for subsequent outcome of cleft lip and palate (CLP)
treatment. Today, there is general consensus that,
particularly, the protocol for repair of the palate is
crucial for normal speech development and adequate
long-term midfacial growth. In this chapter, we will
describe experiences from protocols, where the pal-
ate has been repaired in two stages: early soft palate
repair (SPR), at ages from 3 to 24 months, followed
by delayed hard palate repair (HPR) at varying ages
during the fi rst decade of life up to adolescence.
Statistics from the year 2000 indicated that this sur-
gical regimen was used in Europe by more than a
third of the cleft teams (Shaw et al. 2000 ) . (Another
type of two-stage palatal surgery would be initial
HPR, followed by later SPR, but this variant of two-
stage surgery is not considered here.)
This chapter is written by three members of
the cleft team from Gothenburg, Sweden, where
two-stage palatal repair has been advocated for
about 35 years. During this rather long time, we
have gained considerable clinical experience in
addition to signi fi cant knowledge through
research covering many different aspects of the
surgical method. The major reason for our change
to this protocol was dissatisfaction with occlu-
sion as well as midfacial growth in CLP patients
treated according to our previous regimen (Friede
and Johanson 1977 ) . In a later follow-up study,
we learnt that also the patients’ speech had not
developed as optimally as expected after our ear-
lier protocol (Lohmander-Agerskov et al. 1993 ) .
Two-Stage Palatal Surgery with
Early Veloplasty and Delayed Hard
Palate Repair: A Balanced View
on Speech and Midfacial Growth
Outcome
Hans Friede, Jan Lilja, and Anette Lohmander
H. Friede , DDS ()
Department of Orthodontics ,
Sahlgrenska Academy at University of Gothenburg ,
Gothenburg , Sweden
e-mail: hans.friede@gu.se
J. Lilja , M.D., DDS, Ph.D.
Department of Plastic Surgery,
Sahlgrenska University Hospital ,
SE-41345 Gothenburg , Sweden
A. Lohmander , SLP, Ph.D.
Division of Speech and Language Pathology ,
Karolinska Institute , SE-14186 Stockholm , Sweden
Previously af fi liated with Sahlgrenska
Academy at University of Gothenburg , Sweden

414
H. Friede et al.
18.2
Historical Background
In 1921, Gillies and Fry published a paper, crucial
to the development of the two-stage palatal repair
method. They outlined a new, what they called
“revolutionary principle” to improve treatment out-
come in patients born with wide clefts of the palate.
They suggested that the two halves of the soft pal-
ate, after being partly separated from the hard pal-
ate, should “be united in as far back a position” as
possible (Fig. 18.1a ). This procedure enlarged the
remaining cleft of the hard palate, which in their
opinion, should not be surgically repaired. They felt
that a dental prosthesis, covering the hard palatal
defect, would enhance possibilities to achieve
treatment goals such as “perfect speech, perfect
mastication, normal nasal respiration, and normal
bony contour” of the midface. A later long-term
outcome study reported encouraging results for
facial and occlusal development, while speech out-
come was judged as less satisfactory (Walter and
Hale 1987 ) .
18.2.1 The First Pure Surgical
Two-Stage Protocols for
Palatal Repair
It was Herman Schweckendiek ( 1955 ) from
Marburg, Germany, who, in the early 1950s, fi rst
described a true surgical two-stage palatal repair
Fig. 18.1 Illustrations of early methods for SPR. ( a )
Obtained from Gillies and Fry ( 1921 ) (With permission
from BMJ Publishing Group Ltd) and ( b ) drawings illus-
trating details in the SPR method used by Schweckendiek
( 1978 ) . See text for further explanations

415
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
method (Fig. 18.1b ), which, over time, was
employed in a great number of CLP patients.
Even today, the two-stage protocol sometimes is
referred to as the “Schweckendiek method,”
though, presently, important details of the origi-
nal description are no longer advocated and new
features have been added. Follow-up reports from
the German cleft center by the originator’s son,
Wolfram Schweckendiek ( 1978, 1981a, b ) ,
described great satisfaction with the devised regi-
men, both regarding the patients’ speech devel-
opment and their long-term maxillary growth.
However, when an outside team examined some
of the Marburg patients, they could only con fi rm
the highly acceptable facial growth (Bardach
et al. 1984 ) . Regarding speech outcome of the
investigated sample, an unusually high incidence
of velopharyngeal incompetence (VPI) was
found, most likely due to a short soft palate with
poor mobility.
In the 1950s, Slaughter and Pruzansky ( 1954 )
from the United States also reported use of two-
stage palatal surgery, particularly in patients
where the palatal cleft did not lend itself to one-
stage repair. They outlined several factors for the
team to consider before deciding to perform velar
surgery as an initial procedure. Examples of such
determinants were width of the cleft, length and
mobility of velum, and relation of velum to con-
tiguous areas in nasopharynx. No outcome stud-
ies of their method were published, however,
which might suggest that the results did not reach
up to the authors’ expectation. Although a few
American teams began advocating the two-stage
palatal surgery protocol in the mid-1960s
(Blocksma et al. 1975 ; Cosman and Falk 1980 ;
Dingman and Argenta 1985 ) , it was mostly in
Europe the method gained acceptance. Interest in
the protocol was boosted here, in particular after
the Zürich cleft team reported favorable outcome
following change to the two-stage method in
1967 (Hotz and Gnoinski 1976 ) . When members
of the Gothenburg cleft team in the mid-1970s
also contemplated change to the two-stage regi-
men with early SPR followed by later HPR, it
was the excellent short-term result from Zürich,
which was the precipitating factor for us. At this
time, several other Swedish teams began advo-
cating the two-stage protocol as well, while other
cleft centers in Scandinavia did not join the group
using the protocol until more recently.
18.2.2 American Rejection
of the Two-Stage Protocol
In the early 1980s, particularly, speech patholo-
gists from a limited number of American cleft
centers questioned the advisability of introducing
the two-stage method for palatal repair (Witzel
et al. 1984 ) . They maintained that the few papers
published on this subject had demonstrated severe
speech problems, both before and after HPR.
Some surgeons also expressed concerns about the
protocol, which they felt not only jeopardized the
patients’ speech development, but in addition, it
resulted in inferior surgical results. The incidence
of fi stulas in the repaired cleft region increased
signi fi cantly, and furthermore, the patients’
occlusion did not improve as much as hoped for
(Cosman and Falk 1980 ; Jackson et al. 1983 ) .
Though this criticism was built only on short-
term observations with minimal scienti fi c analy-
ses, many surgeons, especially in the United
States, chose to abandon the two-stage method.
Today, very few American teams appear to
advocate the protocol with early SPR and delayed
HPR (Katzel et al. 2009 ) .
18.3
Surgical Details Introduced
During Development of the
Two-Stage Palatal Protocol
Though Gillies and Fry ( 1921 ) had employed sur-
gical separation of part of the soft palate from the
posterior edge of the hard palate, Schweckendiek
( 1955 ) did not include this important surgical
step at the reintroduction of the two-stage proto-
col. With no detachment of velum at SPR, the
repaired soft palate became both short and tight.
The younger Schweckendiek ( 1978 ) presented
schematic drawings, illustrating how tension in
the sutured velum could be alleviated (Fig. 18.1b ).
Before uniting the velar halves, small incisions
were made laterally on both sides. The dissections

416
H. Friede et al.
penetrated the soft palate, where a transverse rub-
ber band was inserted. At the end of SPR, it was
tightened to reduce tension at the midline stitches.
The device was kept in place after surgery for
1–2 weeks. Releasing incisions around the maxil-
lary tuberosities and cutting of hamulus on both
sides were other ways trying to deal with the
increased tension in the repaired velum.
18.3.1 Modern Methods for Velar
Repair
To avoid problems with a short and tight soft pal-
ate, surgeons began realizing that velum had to
be released from the posterior hard palate
(Braithwaite and Maurice 1968 ) . This idea was
supported by studies of Kriens ( 1970 ) , showing
that if there is a cleft of the soft palate, the velar
muscular complex on both sides is running in an
abnormal, anterior-posterior (A-P) direction.
Therefore, it seemed logical, not only to detach
but also to redirect those muscles to their normal
transverse direction. To get access to the attach-
ment of the velar muscles, mucosal/mucope-
riosteal fl aps were dissected from various
positions at or within the posterior hard palate.
The muscles were then cut from the palatal
shelves, reoriented to a transverse course, and
could be joined in the midline in a more poste-
rior position than before. The procedure would
be enhanced by addition of a posterior vomer
fl ap (Malek and Psaume 1983 ) , which was
sutured to the nasal mucosa of the anterior soft
palate (Fig. 18.2 ). With anterior velum attached
to the lower edge of the posterior nasal septum,
the soft palate was lifted up to the level of the
palatal shelves, which, during healing, helped
reduce the size of the remaining cleft of the hard
palate.
18.3.2 Methods for Repair of
Remaining Cleft of Hard Palate
Regarding HPR, Schweckendiek ( 1955, 1978 )
did not suggest any particular method for this
surgery and only mentioned that, preferably, it
should be delayed until around puberty, i.e., when
most of maxillary growth was completed. With
such late repair of the residual cleft, the chosen
method was not as crucial, as if this surgery had
been performed at an early age. When later on
some surgeons elected to close the remaining
cleft already during development of the primary
dentition, or sometimes even earlier, different
repair methods were utilized. Without any direc-
tion from the originators of the two-stage proto-
col, most surgeons chose to use the same surgical
method at HPR, as they were accustomed to in a
one-stage palatal procedure. Examples of meth-
ods varied from use of uni- or bilateral mucope-
riosteal fl aps according to methods of Veau,
Wardill-Kilner, von Langenbeck, Delaire, or oth-
ers. Particularly, after use of methods where
extensive mucoperiosteal fl aps were shifted
medially to cover the palatal cleft, areas of bone
in the hard palate were left denuded. Growth-
restricting palatal scars would then develop,
which, depending on the position and size of
Fig. 18.2 Series of palatal views of a male patient from
preoperatively to age 10 years and 4 months. The picture
from 3 months shows early healing from where the poste-
rior vomer fl ap was raised ( arrow ) and turned backward.
Note narrowing of the residual cleft in the hard palate. The
HPR added only midline scars

417
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
these scars, had a varying negative effect on max-
illary development.
With delay of HPR, the residual cleft usually
would narrow considerably (Owman-Moll et al.
1998 ) , which the surgeon should have taken advan-
tage of. The reduced width of the remaining cleft
would, in many cases, allow primary repair of the
residual opening in the hard palate after mobiliza-
tion of the cleft edges without leaving any palatal
bone denuded. In wider residual clefts, the repair
could be accomplished with a turnover vomer fl ap
or by use of bilateral fl aps taken from the thin pala-
tal mucoperiosteum close to midline. According to
Delaire, inclusion of the thick palatal mucoperios-
teum more laterally would cause bare bone in areas
with increased risk for development of growth
impairing scars (Markus et al. 1993 ) . If the remain-
ing cleft in the hard palate was very wide, it was
suggested to postpone HPR until age 2 or 3 years.
These surgical details were decisive factors for
maxillary development during subsequent growth.
18.3.3 Timing of Palatal Surgery
Timing of repair of the two palatal procedures has
also been characterized by great variation. Reports
from literature have suggested ages varying from
3 to 24 months for SPR, and for HPR, different
papers have proposed ages ranging from 6 months
to 16 years. The timing preferences of the surgeon
and the cleft team most often have been guided by
subjective estimations of how the operations might
affect speech and/or maxillary growth outcome.
18.3.3.1 Surgical Timing and Speech
Development
Regarding speech development, the controversial
debate on optimal age for palatal closure has been
hampered by questionable comparisons between
studies with different timings of surgery without any
consideration to other factors, i.e., staging, sequence,
or technique for the repair, which will in fl uence the
outcome. From theoretical perspective of speech-
language development and particularly in relation to
the sensitive period or state of readiness for speech
development between the ages of 4 and 6 months,
there is no controversy that an early, complete pala-
tal closure is preferable (Kemp-Fincham et al. 1990 ) .
The early age would mean before or at onset of per-
tinent canonical babbling and possibility to close the
oronasal coupling for relevant development of oral
pressure sounds. Both were found to be signi fi cant
predictors of later speech and language performance
(Oller et al. 1998 ; Chapman et al. 2003 ; Lohmander
and Persson 2008 ; Scherer et al. 2008 ) . Recent stud-
ies indicate that these factors can be reached to a
higher degree, if the soft palate is repaired early,
even if the cleft in the hard palate still is unoperated
(e.g., Willadsen and Albrechtsen 2006 ) . According
to opinions published by one of the few American
teams, currently advocating the two-stage repair
(Rohrich et al. 2000 ) , a protocol, with velar repair at
around 3–6 months and delayed hard palate closure
at age 15–18 months, would provide the best oppor-
tunities for normal speech development as well as
favorable maxillary growth outcome.
18.3.3.2 Timing of Surgery
and Maxillary Growth
Considering the growth in fl uence from palatal sur-
gery, our view is that possible effects from various
timings, for SPR as well as HPR, depend upon
whether the employed surgical methods will impair
palatal areas, important for subsequent maxillary
development. If using a method with de fi nite pro-
pensity for growth restriction, an early repair
should be delayed or preferably not be used at all.
But, if surgery can be accomplished with minimal
denudation of palatal bone in sensitive regions
(Markus et al. 1993 ) , the growth outcome of the
procedure can be quite satisfactory even if per-
formed during the patients’ fi rst year of life. These
circumstances have seldom been considered, which
has contributed to controversies about the bene fi ts
of the two-stage method for palatal repair.
18.4
Reported Speech and Growth
Outcome After Some Variants
of the Two-Stage Palatal
Protocol
After introduction of a new philosophy for solving
a speci fi c surgical problem, such as repair of cleft
palate, many surgeons tend to “jump on the

418
H. Friede et al.
bandwagon,” and furthermore, some of them
might devise their own treatment variants. When
the two-stage palatal repair protocol was reintro-
duced in the 1960s and 1970s, many cleft teams
converted to this regimen. Unfortunately, the
majority of those early teams, including the oper-
ating surgeons, did not disclose, whether the new
regimen had ful fi lled their expectations or not. A
few short-term reports were published in the
1980s, where the outcome generally was rated as
poor.
18.4.1 Speech Outcome
Speech development, sometimes appraised before
HPR, was judged as inferior to what was expected.
These young children had signi fi cantly poorer
articulation skills than their noncleft peers.
Posterior substitutions had often developed and
so had frequent VPI (Cosman and Falk 1980 ;
Jackson et al. 1983 ; Noordhoff et al. 1987 ) . From
a methodological point of view, it has to be
remembered that these evaluations were clinical,
live judgements with no possibility for control of
the data. If we believe that, even so, these early
assessments were valuable, we suspect that many
of the speech errors might have had their origin in
missing important surgical details at closure of
the soft palate. For instance, one of the papers
stated, “the soft palate was closed directly with
only minimal division of nasal mucosa and pala-
tine aponeurotic fi bers” (Cosman and Falk 1980 ) .
With no de fi nite separation between the soft and
hard palate, we suspect the surgeon had been
unable to bring back the repaired velum to a posi-
tion needed for achievement of velopharyngeal
competence (VPC) on a regular basis. In other
studies (Noordhoff et al. 1987 ) , it was mentioned
that SPR had been performed according to the
original method of Perko ( 1979 ) , but nothing was
reported about use of a posteriorly based vomer
fl ap. Omission of this crucial surgical step is
likely to have caused reduced velar length in
many cases and also a wider residual cleft in the
hard palate due to less narrowing during early
palatal growth. Tentatively, the short soft palate
would increase the risk for VPI and posterior
substitutions, such as pharyngeal and/or glottal
articulations. In the report by Noordhoff et al.
( 1987 ) , all patients treated with the two-stage
method were said to have increased articulation
errors, particularly those individuals with wide
remaining cleft of the hard palate. A later follow-
up paper (Liao et al. 2010 ) con fi rmed increased
hypernasality and compensatory articulation dis-
orders in these patients.
18.4.2 Maxillary Growth Results
More recently, a number of teams have, in par-
ticular, reported the patients’ maxillary growth
outcome with limited focus on their speech devel-
opment. The majority of the papers described
favorable midfacial growth (Noverraz et al. 1993 ;
Tanino et al. 1997 ; Nollet et al. 2005, 2008 ; Sinko
et al. 2008 ; Liao et al. 2010 ) , while a few of the
reports did not fi nd any maxillary growth advan-
tage of the two-stage protocol (Gaggl et al. 2003 ;
Mølsted et al. 2005 ; Holland et al. 2007 ; Stein
et al. 2007 ) . The fi rst group of papers generally
advocated methods for SPR and especially for
HPR, where closure of the cleft resulted in mini-
mal denudation of bone in the palate. Examples
of such procedures comprised employment of a
turnover vomer fl ap, suturing of the cleft edges,
mobilization of mucoperiosteal fl aps dissected
close to the cleft, or use of a modi fi ed von
Langenbeck operation. On the other hand, in
studies describing no maxillary growth bene fi ts
or inferior maxillary development, the methods
used in these patients had created growth-restrict-
ing scars, mostly from HPR. Examples of surgi-
cal methods included employment of a Veau
pedicle fl ap, a mucoperiosteal pushback proce-
dure, or use of “unipedicled mucoperiosteal
fl aps.” All of them will give rise to signi fi cant
areas of bare palatal bone, which will heal sec-
ondarily, leading to scar tissue development.
Thus, these different opinions about de fi nite
growth advantage or insuf fi cient maxillary devel-
opment after the two-stage palatal protocol can
be explained by the performed repair methods
and, only to a limited extent, by when surgery
was done, as described above. Such explanations

419
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
are easier to embrace than speculation about
effects, e.g., from cleft team organization (Shaw
et al. 1992a, b ) or surgeons’ different operating
skills (Ross 1987a, b ) , as reasons for the patients’
growth results. However, we have to remember
that acceptance or rejection of the two-stage regi-
men might be in fl uenced not only by how well
the repaired maxilla will develop but also by
other factors, such as increased risk for fi stula
formation, poor speech development, and need
for more velopharyngeal fl aps (VPFs); etc.
18.5
Outcome of Maxillary Growth
as Well as Speech from Teams
with Long-Term Records
Only a limited number of publications exist,
where the patients’ maxillary growth as well as
their speech development after two-stage palatal
surgery has been studied up to adolescence or
early adulthood. From this very small group of
papers, we have chosen to report treatment out-
come in unilateral cleft lip and palate (UCLP)
patients from two European cleft teams still prac-
ticing the protocol.
18.5.1 Zürich, Switzerland
In Zürich, Switzerland, the cleft team has used
their version of the two-stage palatal repair proto-
col since the late1960s. It was built on a system-
atic coordination between maxillary orthopedics
and surgical interventions from early infancy
(Hotz and Gnoinski 1976 ; Hotz et al. 1986 ) . The
team initiated preoperative maxillary orthopedic
treatment shortly after birth, not only to help
feeding but also for growth guidance of the max-
illary segments. After lip repair at age 5–6 months,
the infant continued with maxillary orthopedics
until SPR, which was carried out at around
18 months. This surgery included reorientation of
the velar muscles after their separation from the
posterior hard palate (Perko 1979 ) . The covering
fl aps of the oral mucosa were dissected from the
posterior third of the hard palate, and, to reduce
risks for maxillary growth impairment, the dis-
sections were made supra periosteally. A poste-
rior vomer fl ap was also raised, and after turning
it backward, the fl ap was sutured as part of the
anterior nasal layer at SPR (Hotz et al. 1986 ) .
With the nasal mucosa not separated from the
posterior hard palate, inclusion of the vomer fl ap
would not help elongate the soft palate, and there-
fore, a midline Z-plasty was added. At age
5–6 years, HPR was performed. Due to narrow-
ing of the residual cleft, closure was accom-
plished by use of a turnover vomer fl ap for the
nasal layer, and for repair of the oral layer, a
mucoperiosteal fl ap was shifted medially from
the noncleft side.
18.5.1.1 Follow-up Studies
The Zürich cleft team has published several fol-
low-up investigations, particularly about maxil-
lary growth. Roentgencephalometric results from
a group of 10-year-olds born with UCLP indi-
cated satisfactory A-P relationship between max-
illa and mandible in about 80 % of the subjects
(Gnoinski 1990 ) . At age 15–20 years, these
patients showed continuation of the favorable
orofacial development, documented in the
10-year sample (Gnoinski 1991 ; Gnoinski and
Haubensak 1997 ) . Even if the cleft maxilla grew
slightly in length also between 15 and 20 years of
age, the average maxilla was shorter than in non-
cleft subjects. Only about 10 % of the patients
needed maxillary orthognathic surgery to achieve
an acceptable facial pro fi le.
The team from Zürich has also reported cross-
sectional, detailed speech data based on live
assessments. After HPR and speech therapy, the
patients’ glottal or pharyngeal articulations were
eliminated (Hotz et al. 1978 ) . This outcome was
in contrast to what was achieved with the previous
treatment protocol. Nothing was mentioned about
development of retracted articulations of certain
consonants such as anterior plosives. Severe
hypernasality decreased spontaneous with age,
even before HPR was performed. After HPR, this
speech error was claimed by the authors to have
disappeared almost completely, often though,
with help of intensive speech therapy. No pharyn-
geal fl aps were judged by the team to be necessary
in any of the Zürich patients.

420
H. Friede et al.
18.5.1.2 Veri fi cation of the Zürich
Speech Outcome
An outside investigator was recruited to verify
the satisfactory speech development of the cleft
children in Zürich (Van Demark et al. 1989 ) .
Thirty-seven UCLP patients were studied in a
cross-sectional investigation at ages ranging from
6 to 16 years (mean 10.5 years). Oral examina-
tion generally revealed a mobile and fairly long
soft palate, which was ascribed to the surgical
method used for SPR. A comprehensive, inde-
pendent speech analysis from audio recordings
revealed that about 95 % of the patients displayed
adequate or marginal VPC. The majority of sub-
jects did not show speech errors such as glottal
stops and pharyngeal substitutions. Even in the
younger patients, the incidence of other compen-
satory articulations and “nasalizations” was low.
The authors concluded that “good speech results
for unilateral complete cleft lip and palate can
also be achieved with late closure of the anterior
palate, at least as done by the Zürich approach.”
Unfortunately, no further follow-up has been
published.
18.6
Gothenburg, Sweden
When we planned the palatal surgery in our
new protocol, the Zürich group had neither
published any suggested ages nor detailed
descriptions of their surgical procedures. For
velar repair, we opted for an age around
6–8 months, while we wanted to delay closure
of the remaining cleft in the hard palate to the
mixed dentition. Regarding surgical details for
SPR, we chose the approach to separate soft
palate from hard palate right at the border
region (Friede et al. 1980 ) (Fig. 18.3 ). The lat-
eral incisions and denudation of palatal bone
were to be made as minimal as possible. The
velar muscle bundles should be united in the
midline after complete release of the muscular
fi bers from their abnormal insertion at the pos-
Fig. 18.3 Schematic illustration of SPR according to an
early repair version used at Gothenburg Cleft Center.
Incision lines run in the border region between velum and
hard palate. The two halves of the soft palate, with the
muscle bundles reoriented to a transverse course, are
united in the midline ( arrows )

421
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
terior border of the hard palate. The muscles
remained attached to the nasal mucosa. At this
stage of development of our method for velar
repair, no posteriorly based vomer fl ap was
raised and attached to the anterior soft palate.
Therefore, the residual cleft of the hard palate
did not narrow as much as expected. This made
our surgeon dissect the palatal fl aps further
anteriorly, occasionally into the middle of the
hard palate (Fig. 18.4 ). Such change would
reduce the remaining cleft size and thereby
enhance early speech development. However,
after some time, we realized that this change in
surgical detail at SPR also might restrict maxil-
lary growth. It was fi rst after introduction of the
posterior vomer fl ap that the dissection line in
the palatal mucosa returned to its previous posi-
tion close to the edge of the hard palate. The
Zürich surgeon Perko ( 1979 ) did not report in
detail how their two-stage surgical procedures
were carried out until 1979, and then, a posteri-
orly based vomer fl ap at SPR was not yet part
of the Swiss surgical routine. It took another 1
or 2 years before many surgeons, including
those from Zürich and Gothenburg, began uti-
lizing this important addition to SPR.
18.6.1 More Detailed Two-Stage
Palatal Surgery
In 1996, our cleft team published a detailed report
how the two-stage protocol was practiced in
Gothenburg up to 1995 (Lilja et al. 1996 ) . At soft
palate surgery, incisions began around the poste-
rior part of the maxillary tuberosities and then fol-
lowed a zigzag route at the posterior border of the
hard palate (Fig. 18.5 ). A posteriorly based vomer
fl ap was dissected. Anteriorly, the incision was
placed behind the vomero-premaxillary suture,
and the fl ap had its base close to the junction
between vomer and the cranial base. Mucosal fl aps
in the soft palate were raised by blunt dissection.
Hamulus was identi fi ed but not broken. The inser-
tions of velar muscles, including their attached
nasal mucosa, were cut at the posterior border of
the hard palate. A fl ap with the muscles connected
to the nasal layer was then dissected free and
mobilized to a posterior position. After that, the
muscles including the levator were reconstructed
to a transverse course, where suturing could be
performed without tension. The vomer fl ap was
raised and the nasal layer of velum was closed
anteriorly to the level of the muscular sling by use
Fig. 18.4 Anterior-posterior variation in position of scar
line from SPR. In upper patient , the scar line is too far
forward, harming growth in length of the maxillary dental
arch. In lower patient , the scar line is in correct position at
posterior maxilla. The dental arch length is well devel-
oped with space for all teeth

422
H. Friede et al.
of the vomer fl ap. In this way, the vomer bone
became connected to the anterior velum. The pala-
tal closure was then continued over to the oral side,
where a pushback procedure was performed within
the oral layer of the soft palate. Inclusion of the
vomer fl ap as well as the pushback surgery helped
to increase the length of the repaired velum.
The HPR was delayed until the patient had
reached the stage of early mixed dentition
(7–9 years), because, thereby, the procedure
could be combined with bone grafting to the
alveolar cleft. Surgery began with gingival inci-
sions along the neck of the teeth on the palatal
side and in part also labially (Fig. 18.6 ). In the
area of the cleft, incisions were made along the
cleft edges, and gingival and palatal mucope-
riosteal fl aps were raised. On the labial side, a
back-cut was made in the cleft-side molar area.
This facilitated mobilization of the gingival fl ap
as well as the dissection in the cleft area. When
the cleft had been dissected completely free on
both palatal and labial side, suturing in the
Fig. 18.5 Schematic drawings of the soft palate closure.
( a ) The incisions follow a zigzag line between the soft and
hard palate. A posterior vomer fl ap is dissected, which has
its base at the posterior-cranial part of vomer. ( b ) Both
sides of velum are divided into two layers: the oral mucosa
and the nasal mucosa with the forward inserting muscle
bundles attached. The two layers are separated laterally
and posteriorly to the uvula. Medially, the nasal layer with
the muscle bundles is cut bilaterally from the posterior
hard palate. ( c ) The muscles are redirected to a transverse
course, sutured together medially in a posterior position,
and also attached anteriorly to the backward-turned vomer
fl ap. ( d ) The muscles and the raw surface of the vomer
fl ap are covered by the oral fl aps, which are pushed in a
medial-posterior direction

423
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
midline began in the nasal layer and continued
orally in the midline palate. Cancellous bone
was then grafted to the cleft in the alveolar pro-
cess and covered with gingival and palatal fl aps.
The operation was completed with suturing the
gingival and palatal mucoperiosteal fl aps
together in some interdental spaces. We consider
the palatal incisions along the necks of the teeth
very important. Because of the reduced width of
the residual cleft, suturing back of the combined
palatal fl aps along the dental arch could be done
with none or only minimal palatal bone exposed
close to the teeth. In 1996, timing for HPR was
modi fi ed in an effort to prevent development of
typical retracted oral speech deviations noted in
some patients during preschool and early school
age. The repair was then changed to be carried
out around 3 years, which meant an extra opera-
tion, because HPR could no longer be performed
together with the bone grafting procedure. If the
residual cleft of the hard palate was narrow or of
average size, it was closed in one layer by use of
a simple turnover vomer fl ap (Fig. 18.7 ). This
approach did not work so well for wider residual
clefts of the hard palate due to increased risk for
fi stula development. In these cases, a two-layer
repair was necessary. A vomer fl ap was then
sutured to the nasal mucosa on the cleft side, and
the suture line was closed with a mucoperiosteal
fl ap from the cleft side of the palate (Fig. 18.8 ).
18.6.2 Follow-up Studies of Maxillary
Growth
Over the years, the Gothenburg cleft team has
reported several follow-up studies, both regard-
ing maxillary growth and speech development.
An early growth comparison at age 7 years,
before HPR in the two-stage protocol, demon-
strated signi fi cantly improved results in com-
parison to what was achieved with our previous
regimen (Friede et al. 1987 ) . In a more recent
longitudinal follow-up study, we compared 30
consecutive UCLP patients, who had been sub-
jected to our two-stage palatal surgery, to a simi-
lar sample from another center. Those patients
had undergone HPR with a vomer fl ap at age
3 months, which was followed by SPR with a
pushback method at 22 months (Friede and
Enemark 2001 ) . Comparison of roentgenceph-
alograms, obtained during the age span from
prepuberty to adolescence, demonstrated that
our patients with delayed HPR had much better
midfacial development than the other group of
subjects. This difference was also noticed in the
percentage of patients with need for later max-
illary advancement surgery (10 % vs. 30 %).
The favorable maxillary growth outcome in
our patients was, some years later, con fi rmed
in a cast study of 104 consecutive subjects with
UCLP (Lilja et al. 2006 ) . If just considering casts
Fig. 18.6 Illustrations of the method for repair of the
residual cleft in the hard palate in combination with bone
grafting. ( a ) Incisions are made along the necks of the
teeth and along the edges of the residual cleft. Palatal and
gingival mucoperiosteal fl aps are raised. The nasal layer is
closed. ( b ) The palatal mucoperiosteal fl aps are closed in
the palate. Bone grafting is performed to the cleft in the
alveolus. ( c ) The grafted bone is covered by gingival and
anterior palatal mucoperiosteal fl aps, which are sutured
together

424
H. Friede et al.
Fig. 18.7 Composite of drawings illustrating repair of a
small- or average-sized residual cleft in the hard palate at
age 3 years or preferably earlier. At this stage, bone graft-
ing is not performed in connection with the HPR as shown
in Fig. 18.6 . ( a ) The residual cleft in the hard palate. ( b )
Incision lines. On the noncleft side, the incision goes into
the fl at medial part of the palate. On the cleft side, the inci-
sion is made at the cleft border between oral and nasal
mucosa. ( c ) The vomer fl ap is raised. It contains some
millimeters of oral mucosa leaving a raw bone surface in
the medial part of the palate on the noncleft side. On the
edge of the cleft side palatal shelf, a subperiosteal dissec-
tion is performed and a pocket is created between the oral
periosteum and the bone. ( d ) The vomer fl ap is tucked into
the pocket and sutured, which fi nalizes HPR. Thus, this is
a one-layer closure, and the raw surface of the vomer fl ap
is left for secondary epithelialization
Fig. 18.8 Drawings illustrating HPR in an individual
with a somewhat wide residual cleft. Preferably, the
patient should have erupting/erupted upper deciduous
molars, which usually means an age at around 3 years. ( a )
Incision lines. On the noncleft side, the incision goes into
the fl at medial part of the palate. On the cleft side, the inci-
sion is made at the cleft border between oral and nasal
mucosa. ( b ) The vomer fl ap is raised. It contains some
millimeters of oral mucosa leaving a raw bone surface in
the medial part of the palate on the noncleft side. ( c ) On
the cleft side, a subperiosteal dissection is performed,
and the nasal layer is lifted and brought in contact with the
vomer fl ap and sutured. ( d ) Also on the cleft side, an oral
mucoperiosteal fl ap is raised via an incision along the
teeth. The fl ap is brought in contact with the incision on
the noncleft side and sutured. The suture line between the
vomer fl ap and the nasal layer is now covered. The raw
bone surface is left for secondary epithelialization, which
takes place on a surface with thin neighboring wound
edges. Thereby, the risk for bad scar contraction is small

425
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
obtained at around 19 years, an acceptable dental
relationship, reported as GOSLON scores 1, 2,
and 3 (Mars et al. 1987 ) , was found in 97 % of
the subjects. This was rated as an exceptionally
high incidence of satisfactory occlusion at early
adulthood.
For our most recent longitudinal follow-up
study (Friede et al. 2011 ) , we used a consecutive
series of 50 patients born with UCLP. All sub-
jects had lateral roentgencephalograms from
four selected age stages from preschool to
early adulthood. Besides lateral cephalograms,
we also studied maxillary casts from an age
around 1.5 year to score the A-P position of the
mucosal scar line from the dissection between
soft and hard palate at SPR. Interestingly, we
found that those patients with more anteriorly
placed scar lines had de fi nitely reduced maxil-
lary lengths as appraised in their cephalograms
from age 19 years (Figs. 18.9 and 18.10 ). This
illustrates how small details at surgical recon-
struction of the UCLP are important for opti-
mal maxillary development during subsequent
growth. However, the overall favorable midfa-
cial development, noticed in our previous out-
come reports, was con fi rmed in this study. In
early adulthood, the patients’ mean values for
the skeletal pro fi le convexity and for the sag-
ittal jaw relationship were close to or within
the 95 % con fi dence interval of the mean for
noncleft Swedish subjects (Thilander et al.
2005 ) . Generally, the average UCLP patient’s
facial morphology displayed a skeletal pattern
in harmony with the retrognathic maxilla and
mandible characterizing this group of patients
(Segner 1989 ) (Figs. 18.11 and 18.12 ).
18.6.3 Follow-up Studies of Speech
Outcome
Most of the reports on speech development
from Gothenburg cleft center have been retro-
spective, longitudinal, follow-up studies of
individuals born with UCLP and have, by and
large, investigated consecutive series of patients.
It should be mentioned though that particularly
the early reports employed limited patient
samples and, in addition, more than one sur-
geon had carried out the palatal repairs. We are
aware that these facts might, to some extent,
have reduced the reliability of our results.
However, on the positive side, we must mention
that all speech samples were rated using stan-
dardized audio recordings, which were identity
blinded to the investigators and independently
evaluated by two experienced speech-language
pathologists, and in the later studies also by an
external listener.
18.6.3.1 Early Results
Our initial speech results were reported in the
beginning of the 1990s when our fi rst patients,
treated according to the two-stage palatal surgery
protocol, were evaluated during their early child-
hood (Lohmander-Agerskov and Söderpalm 1993 ;
Lohmander-Agerskov et al. 1995 ) . Hypernasality
and audible nasal emission occurred among the
5-year-olds before HPR in a moderate-to-severe
degree in about 40 and 30 %, respectively.
For hypernasality, the prevalence decreased to
about 10 % at age 7, which still was an evaluation
before HPR. For audible nasal emission, however,
in most patients, the occurrence remained the
same until about 1 year after HPR. The preva-
lence for both hypernasality and audible nasal
emission were then reduced to occur in about 6 %
of the patients. The gradual reduction in size of
the remaining cleft was suggested as explanation
for lowering the hypernasality rate even before
hard palate closure. Supposedly, the smaller cleft
size resulted in reduced in fl uence on resonance
from the nasal cavities (Lohmander-Agerskov
et al. 1997 ) . In contrast, there was no relationship
between the aerodynamic-related variable audible
nasal emission and the size of the residual cleft.
The early outcome studies on articulation
errors revealed very rare occurrence of
glottal / pharyngeal misarticulation s. Low inci-
dence of these speech deviances was considered
an indication of adequate VPC in the vast major-
ity of our patients. Instead, we discovered so-
called retracted oral articulation of dental/
alveolar plosives to a palatal or velar place,
which, particularly before HPR, was a rather
common fi nding (Lohmander-Agerskov 1998 ) .

426
H. Friede et al.
In different reports, we recorded prevalences
between 30 and 40 % with little reduction in rate
before HPR and with weak, but signi fi cant, cor-
relation to size of the residual cleft (Lohmander
et al. 2002 ) . The varying degrees of the retracted
articulation errors after our two-stage protocol
occurred up to early childhood in about one third
of the children. However, the speech deviation
was gradually reduced to half of that at age
10 years, and around adolescence, the errors had
disappeared. An interesting fi nding was that chil-
dren who had had a spontaneous, early, func-
Fig. 18.9 Casts and orthopantomograms from two
patients illustrating different development of maxillary
dental arches. The upper patient demonstrates slight
crowding at early adulthood in spite of no permanent lat-
eral incisor on the cleft side. In the lower patient , the den-
tal arch is well developed with space for all permanent
teeth. Note more posteriorly positioned scar line after
SPR in this patient compared to the upper one. See
Fig. 18.10 for midfacial development

427
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
tional closure of the residual cleft (Fig. 18.13 )
(evaluated before age 3 years) did not display
any articulation errors at later ages (Lohmander-
Agerskov et al. 1996 ) . In another early study of
possible factors related to development of
retracted oral articulations, we found that chil-
dren with this speech error at ages 3 and 5 years
were more likely to have been babies prefering to
use a posterior place of articulation at babbling
or maybe, more correctly, lacking anterior articu-
lation at this stage of speech development
(Lohmander-Agerskov et al. 1998 ) .
Tracings 5,10,16, and 19years
Patient #4, female
19–0
19–4
Tracings 5,10,16, and 19years
Patient #5, male
Fig. 18.10 Superimposed tracings at four age stages in addition to cephalograms at young adulthood of the two
patients illustrated in Fig. 18.9 . Notice better development of the maxilla of patient #5 compared to patient #4

428
H. Friede et al.
When we in 1996 made an effort to deal with
noticed speech concerns, particularly the retracted
oral articulation, we chose to lower the age for
HPR. The timing of this surgery was gradually
changed from a previous mean age of 8 years down
to 3 years. Interestingly, a follow-up investigation
did not reveal any signi fi cant speech improvements
in spite of the earlier HPR (Lohmander et al. 2006 ) .
The same prevalence of retracted articulation errors
was found in these patients as in previous individu-
als, who had been subjected to HPR after age
8 years. Therefore, we concluded that if repair of
the residual cleft was to have any potential for
improvement of the patients’ speech outcome,
palatal surgery should be completed before age
3 years.
Fig. 18.11 Composite of casts, photographs, and cepha-
lometric records from two typical patients treated accord-
ing to the Gothenburg two-stage palatal surgery protocol.
No orthognathic surgery have been performed. Upper
patient showed satisfactory sagittal growth of the maxilla
but, partly due to missing laterals, developed bilateral
crossbite. Patient declined further surgery of her upper lip.
Good speech developed already from early age. Lower
patient displayed excellent maxillary growth, both in sag-
ittal and transverse dimension. Treated with a velopharyn-
geal fl ap at around 3 years due to short velum. In spite of
narrow residual cleft, the patient developed retracted oral
articulation. It turned out to be a phonological backing
process, which disappeared with speech therapy after
some years. Still some audible nasal emission at age
19 years

429
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
Fig. 18.12 Illustration of records from two representative
patients treated with the two-stage method for palatal repair
at Gothenburg cleft center. Outcome obtained without max-
illary orthognathic surgery. Upper patient displays an over-
all acceptable intermaxillary relationship in spite of slight
maxillary de fi ciency, compensated for by proclination of
the upper incisors, and also causing a tendency to bilat-
eral crossbite. Good speech development since early ages.
Lower patient demonstrates good maxillary development
despite congenitally missing lateral incisor on the cleft side.
Quite satisfactory early speech but has developed moderate
hypernasality during postpubertal years
Patient #10; male
0-2
0-8
1-7
Fig. 18.13 Spontaneous functional closure of the cleft in
the hard palate from a series of casts from the same patient.
The fi rst cast at age 2 months was obtained before lip
adhesion surgery, the second model from before velar clo-
sure, and the third cast from before fi nal lip/nose repair

430
H. Friede et al.
18.6.3.2 Longitudinal Long-Term
Follow-up Results
A longitudinal study of a consecutive series of 55
patients with UCLP, obtained from a total cohort
of 65 individuals, completed our follow-up of
speech development after the Gothenburg original
two-stage palatal protocol as used up to 1995 (SPR
at 6–8 months and HPR at 7–9 years) (Lohmander
et al. 2011, 2012 ) . Based on obtained standardized
audio recordings, blindly analyzed at ages 5, 7, 16,
and 19 years, and clinically assessed at 10 years of
age, we were able to verify previous fi ndings, both
the positive and the compromised ones, regarding
our patients’speech development. Hypernasality,
audible nasal emission, and retracted oral articula-
tion occurred in about 30 % of the 5-year-olds, i.e.,
when their cleft in the hard palate still was unoper-
ated. Generally, all those three speech errors were,
however, markedly reduced during the following
years, and their prevalence was low at age 16 and
19 years. As a result of these enhancements and
other spontaneous speech improvements, the prev-
alence of VPC was judged as quite satisfactory
with a recorded prevalence of 82 % at age 16 and
87 % at age 19 years; at both ages, the patients’
speech intelligibility was judged as normal. It
should be added that secondary VPF surgery had
been performed in six of the 55 patients (11 %).
Our main conclusion was that speech improved in
children treated according to our two-stage palato-
plasty protocol even before HPR. In addition, fur-
ther small improvements occurred until early
adulthood. An added advantage was that the prev-
alence of other, more severe cleft speech charac-
teristics, such as symptoms related to VPI and
particularly the occurrence of glottal misarticula-
tions, was very low. An almost similar picture can
be seen in Fig. 18.14 , which displays cross-sec-
tional data for the same ages but with inclusion of
twice as many patients at ages 5, 7, and 10 years as
investigated in the longitudinal, long-term follow-
up. In addition, information at 3 years of age is
also incorporated. Our longitudinal results
(Lohmander et al. 2011, 2012 ) together with these
cross-sectional data give a trustworthy picture of
the long-term speech outcome after the original
palatal repair procedures at the Gothenburg cleft
center.
Hypernasality
Retracted oral articulation
Reduced intelligibility
Audible nasal airflow errors
100
90
80
70
60
50
40
30
20
10
0
3 y
5 y
7 y
10 y
16 y
19 y
100
90
80
70
60
50
40
30
20
10
0
3 y
5 y
7 y
10 y
16 y
19 y
100
90
80
70
60
50
40
30
20
10
0
3 y
5 y
7 y
10 y
16 y
19 y
100
90
80
70
60
50
40
30
20
10
0
3 y
5 y
7 y
10 y
16 y
19 y
Fig. 18.14 Prevalences (%) of hypernasality, audible
nasal air fl ow errors, retracted oral articulation, and
reduced intelligibility in a cross-sectional series of patients
born with UCLP. The number of patients included at
each age were: 3 years = 45; 5 years = 93; 7 years = 101;
10 years = 88; 16 years= 50; 19 years = 46. A majority of
the fi nal patients (37) were included longitudinally from
age 5 years (Lohmander et al. 2011 ). Green no/normal;
Yellow Mild; Red Moderate-Severe

431
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
18.6.3.3 Retracted Oral Articulations
The speech deviation coined as “retracted oral artic-
ulation of anterior pressure consonants,” occasion-
ally called “backing,” was the most common speech
error affecting about one third of our preschool chil-
dren born with UCLP (Lohmander et al. 2011,
2012 ) . Similar speech problems have been reported
from other centers and is sometimes considered an
atypical phonological process (e.g., Timmons et al.
2001 ) . However, if there still is a coupling between
the oral and the nasal cavities, consonants normally
produced in a place anterior to the communication
may be retracted to a place behind the oronasal
opening. With this in mind, the process should be
regarded as a compensatory strategy for the inabil-
ity to create suf fi cient intraoral pressure to produce
high-pressure consonants (Fig. 18.15 ). This speci fi c
speech error is not necessarily incorporated in the
child’s internal phonological system and will quite
often recede without speech therapy.
18.6.3.4 Results Related to Early Speech
Development
An important rationale for early SPR would be
that it makes it possible for the patient to achieve
increased velopharyngeal activity and oral place
of articulation already during the early babbling
stage. As an example of such achievements, it
can be mentioned that a proportionally high
occurrence of oral stops at 12 and 18 months has
been reported in studies, which have described
outcomes associated with early SPR at our center
(Lohmander et al. 2004, 2011, 2012 ) as well as in
another Scandinavian center practicing the same
surgical method (Willadsen and Albrechtsen
2006 ) . The continuity between early consonant
production and later speech has been described to
occur in noncleft children (e.g., McCune and
Vihman 2001 ) as well as in patients born with
cleft palate and treated according to different sur-
gical protocols (Chapman et al. 2003 ; Lohmander
and Persson 2008 ; Scherer et al. 2008 ) . A high
number of consonant types and plosives, particu-
larly with anterior placement during early speech
development, were related to articulation accu-
racy, measured as percentage of correct conso-
nants (Fig. 18.16 ) (Lohmander and Persson
2008 ) , as well as with the vocabulary develop-
ment (Scherer et al. 2008 ) . Thus, in babbling,
certain characteristics are important for later
speech and language development. Early SPR
seems to enhance this development.
18.7
The Scandcleft Study
At
the
Zürich,
Switzerland,
International
Symposium on Early Treatment of Cleft Lip and
Palate in 1984, there were intense discussions
regarding the advantages and disadvantages of
different surgical procedures for treatment of
patients with cleft lip and palate. Generally, these
a
b
Fig. 18.15 ( a ) Correct place of articulation for dental/
alveolar consonants and ( b ) retracted to velar placement,
behind the oronasal opening. With adequate velopharyn-
geal function, the place of articulation is posterior to the
oronasal opening but in front of the velopharyngeal port,
i.e., a compensatory strategy for the inability to create
suf fi cient intraoral air pressure to produce high-pressure
consonants in front of the opening

432
H. Friede et al.
debates triggered growing interests in multidisci-
plinary inter-center research comparing outcome
after different surgical protocols used for CLP
treatment. As examples of the new trend, surgical
results in four Scandinavian centers were ana-
lyzed, especially with regard to maxillofacial
development (Friede et al. 1991 ; Enemark et al.
1993 ) . Members of six European cleft centers
made similar efforts (Shaw et al. 1992a, b ; Mars
et al. 1992 ; Asher-McDade et al. 1992 ; Mølsted
et al. 1992, 1993a, b ; Morrant and Shaw 1996 ) ,
but here also, aspects on speech development
were included in the outcome analyses (Grunwell
et al. 2000 ) . However, soon it became obvious
that it would be impossible to separate and com-
pare single elements of treatment protocols used
at the different centers. Therefore, Scandinavian
cleft teams from Helsinki, Stockholm, Linköping,
Gothenburg, Copenhagen, Oslo, and Bergen
together with two teams from the UK, Manchester
and Belfast, decided to start randomized con-
trolled trials (RCTs) regarding effects of primary
surgery (particularly palatal repair) in UCLP.
These prospective RCT studies were designed as
a set of three parallel trials, where groups of
teams would test their local protocols against a
common protocol.
This was how the Scandcleft study was initi-
ated ( Semb 2001). The common protocol was a
modi fi cation of the Gothenburg two-stage method
for palatal repair. The modi fi ed surgical detail
was that the palatal muscles were dissected free
from the nasal mucosa and moved posteriorly.
The muscles were sutured together in this posi-
tion to form a posteriorly placed muscular sling.
The nasal layer was left intact and closed with
help of the posterior vomer fl ap. This is an early
form of intravelar veloplasty, where the levator
muscle was not identi fi ed and, consequently, not
completely released. In the common protocol
14
12
10
8
6
4
2
0
100
90
80
70
60
50
40
30
20
10
0
10
20
30
40
50
60
70
80
90
100
0
0
10
20
30
40
50
60
70
80
90
100
Number of consonant types
versus PCC
Number of dental / alveolar plosives
versus PCC
Fig. 18.16 ( Upper chart ) A
high number of consonant
types (inventory) and ( Lower
chart ) a high number of
dental/alveolar plosives at 18
months of age (= y -axis); both
correlated signi fi cantly with a
high percentage of conso-
nants correct (PCC) at age
3 years (= x -axis) (Rho = .57,
p < .05; Rho = .68, p < .01) in
both UCLP ( black ) and
comparison group ( gray )
(Lohmander and Persson
2008 )

433
18 Two-Stage Palatal Surgery with Early Veloplasty and Delayed Hard Palate Repair
used by all teams, the residual cleft in the hard
palate was closed at age 1 year. Inclusion of new
patients to the Scandcleft study was stopped
5 years ago and evaluation of the results began
in 2012.
The local protocol in Gothenburg will be com-
pared to the common protocol, and the parameter
to be studied will be timing of surgery. Therefore,
we had to use the modi fi ed procedure also in the
local protocol, where the residual cleft was closed
at 3 years. This leg of the study was performed in
Copenhagen and Gothenburg, with the majority
of the patients operated in Copenhagen.
18.8
Final Comments
and Re fl ections
As a summarizing evaluation of the Gothenburg
two-stage platal surgery regimen, we have to
judge the protocol as quite successful. Both from
midfacial growth point of view and regarding
speech development, the chosen surgical method
has exceeded the expectations we had when the
protocol was initiated in 1975.
During the early years after our change of
palatal protocol, we introduced several surgical
details, which proved important for later out-
come. One such feature was where to separate
velum from the hard palate at SPR. Preferably, it
should be done right at the level of the posterior
palatal shelves. Separation further anteriorly
would often leave denuded areas of bone, where
growth-restricting scar tissue would form. A sur-
gical procedure related to HPR should also be
mentioned. It has been described in many papers
dealing with so-called pushback palatal surgery.
Wide palatal fl aps, raised for medial and poste-
rior displacement at repair of the cleft, will often
include parts of the thick oral mucoperiosteum
covering the maxillary body. Scars in these lat-
eral parts of the palate seem to be especially
harmful for later maxillary growth. Such wide
fl aps should not be used at HPR in a two-stage
protocol, because the remaining cleft in the hard
palate has usually narrowed substantially after
SPR. Therefore, it can be repaired, e.g., by sutur-
ing the cleft edges after their mobilization, by
employment of a simple turnover vomer fl ap, or,
alternatively, by use of small fl aps, raised in the
thin mucoperiosteum close to the cleft. Shifting
of these fl aps medially, to cover the residual cleft,
will result in scars with minimal maxillary growth
restriction. Using such an approach would there-
fore allow for HPR at an early age (15–18 months)
in most patients without jeopardizing subsequent
maxillary development.
Inclusion of a posteriorly based vomer fl ap at
velar repair seems to be an essential factor to
facilitate narrowing of the remaining cleft during
subsequent palatal growth and thereby enabling
early HPR. In addition, the fl ap appears to
improve the patient’s ability to achieve adequate
VPC. A likely explanation might be that the
repaired velum can attain a more posterior and
upward position than if this surgical detail is
omitted.
A good velar function after early, successful
veloplasty together with substantial reduction in
size of the residual cleft in hard palate has been
the most important factor to explain a satisfactory
speech outcome after two-stage palatal surgery
(Van Demark et al. 1989 ; Persson et al. 2002 ;
Lohmander et al. 2006 ) . Studies at Gothenburg
cleft center of 3-year-old patients have revealed
that speech developed typically (= as in individu-
als without a palatal cleft) in about 50 % of the
children with UCLP in spite of an unoperated
cleft in the hard palate. This outcome compares
as good as or even favorably to what have been
reported in the literature after any palatal surgery
protocol (Lohmander 2011 ) . The typical speech
error among our patients at this early age was
“retracted oral articulation,” which occurred in
about 40 % of the 3-year-old subjects. However,
occurrence of compensatory articulations related
to VPI was very low and absent in the absolute
majority of patients, which indicated satisfacory
VPC, before the residual cleft in the hard palate
had been repaired. Some researchers and experi-
enced clinicians have expressed convictions that
such a remaining open cleft would have a nega-
tive impact on the patient’s velopharyngeal func-
tion and make it dif fi cult or impossible to achieve
VPC. These beliefs have not been veri fi ed though,
neither in studies from Zürich nor from

434
H. Friede et al.
Gothenburg. Actually, a high occurrence of plo-
sives, although retracted to velar place beyond
the opening in the hard palate, presupposes VPC.
Although not wanted, we consider this oral artic-
ulation error (retracted oral articulation) much
less severe than non-oral misarticulations (glottal
and/or pharyngeal) because of its only minor
impact on speech intelligibility. Furthermore, a
signi fi cant number of children with retracted oral
articulation improve their speech before school
age spontaneously.
Early soft palate closure seems to give a bet-
ter condition for early consonant development
than if the entire palatal cleft is left unoperated
until around 12 months of age. Early use of pala-
tal obturators before and after early soft palate
repair (6 months) in a two-stage regimen or
before palatal closure in a one-stage protocol
does not appear to enhance this process (Hardin-
Jones et al. 2002 ; Lohmander et al. 2004 ) . Early
hard palate closure at 12 to 18 months of age
would possibly reduce the prevalence of the oral
speech errors and together with early soft palate
closure give the best conditions for speech devel-
opment taking other aspects of treatment into
consideration.
The Gothenburg two-stage surgical protocol
as described here is easy to teach and also easy to
learn. The fi rst stage, SPR, is based on open dis-
sections of wide and thick fl aps without any
closed undermining. This makes the procedure a
simple, fast, and predictable method with few or
no dehiscences postoperatively. In developing
countries with limited resources of cleft surgery,
orthodontics, or speech therapy, we believe the
2-stage regimen, described by Kontos et al.
( 2001 ) , will result in better outcome than what is
achievable with other standard surgical protocols.
If our initial surgery is performed during the
patient’s fi rst year of life, the outcome will usu-
ally be very adventageous. Lip closure and SPR
can be combined in one primary operation with
good result in a great number of patients, even if
the hard palate never is repaired. However, about
one-third of the children are likely to need HPR
to develop acceptable speech. As the residual
cleft is surrounded by virgin tissue, this surgery
will be easier and give a predictable, better result
than after closure of a palatal fi stula. In most
cases, the dental arch will develop with only
minor irregularities, such as one or sometimes
two deciduous teeth in crossbite on the cleft side,
a narrow remaining cleft in the palate and alveo-
lar ridge, and some rotation of the permanent
central incisor on the side of the cleft.
The Gothenburg procedure with combined lip
closure and SPR has been tested in cooperation
with Universities of Campinas and Rio de Janeiro
in Brazil, where patients with UCLP were oper-
ated on at different ages. The advocated Gothenburg
protocol produced good occlusal development and
acceptable narrowing of the residual cleft, if the
Brazilian children had their surgery done early
during their fi rst years of life. However, if patients
were older than 3 years, the residual cleft of the
hard palate did not narrow very much over time.
Therefore, in these cases, HPR could just as well
be performed already 6 months after SPR.
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