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Effect on Maxillary Arch Development of Early 2-Stage Palatoplasty by Modified Furlow Technique and Conventional 1-Stage Palatoplasty in Children With Complete Unilateral Cleft Lip and Palate
J Oral Maxillofac Surg 67:2210-2216, 2009
Effect on Maxillary Arch Development of Early 2-Stage Palatoplasty by Modified Furlow Technique and Conventional 1-Stage Palatoplasty in Children With Complete Unilateral Cleft Lip and Palate Tadashi Yamanishi, DDS, PhD,* Juntaro Nishio, DDS, PhD,† Hiroshi Kohara, DDS, PhD,‡ Yoshiko Hirano, DDS, PhD,§ Michiyo Sako, SLP,储 Yukiko Yamanishi, DDS, PhD,¶ Tadafumi Adachi, DDS, PhD,# Shigenori Miya, DDS, PhD,** and Takao Mukai, DDS, PhD†† Purpose: The purpose of this study was to evaluate the palatal morphology of patients with complete
unilateral cleft lip and palate after early 2-stage palatoplasty (ETS) consisting of soft palate closure by a modified Furlow palatoplasty at 12 months of age and hard palate closure at 18 months of age. We compared the result with the palatal morphology obtained by Wardill-Kilner push-back palatoplasty (PB) at 12 months of age with that of children with noncleft palate. In the present study we investigated whether ETS can result in better palatal development than conventional PB. Materials and Methods: Thirty subjects were treated by ETS and 42 underwent PB. We also included cross-sectional data obtained from 66 children with noncleft palate as control. We measured the arch length, width, and cleft width using dental cast models that were consecutively taken at 3 months to 4 yrs of age and compared the results among the 3 groups. Results: At 4 years of age, the anteroposterior palatal length of ETS was significantly longer than that of PB by 9.8%, and the transversal palatal width of ETS was also markedly wider than that of PB at every point measured. Furthermore, ETS showed potential catch-up growth in the anteroposterior palatal length from 12 months to 4 years of age. Conclusion: These results demonstrate that ETS has a considerable benefit for the palatal development of patients with complete unilateral cleft lip and palate compared with PB. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:2210-2216, 2009 The primary goal of cleft palate surgery is to provide children with cleft palate with adequate velopharyngeal function for normal speech development.1 However, surgical intervention to the palate interferes with maxillofacial growth.2,3 For the acquisition of favorable Received from the Department of Oral and Maxillofacial Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan. *Clinical Fellow. †Chief and Professor. ‡Oral and Maxillofacial Surgeon. §Orthodontist. 储Speech Pathologist. ¶Resident. #Clinical Fellow.
speech and maxillary development, there has been considerable debate on the most suitable technique and timing of cleft palate repair. The “2-stage operation” concept, which was introduced by Gillies4 in the early 1900s, has long been **Resident. ††Resident. Address reprint requests and correspondence to Dr Nishio: Department of Oral and Maxillofacial Surgery, Osaka Medical Center for Maternal and Child Health, 840 Murodocho Izumi, Osaka 5941101, Japan; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6710-0020$36.00/0 doi:10.1016/j.joms.2009.04.038
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applied by subsequent clinicians with substantial modifications. The principal concept of 2-stage palatoplasty is to postpone hard palate closure until maxillary development has proceeded sufficiently to become resistant to surgical interference to the hard palate. As first argued by Slaughter and Brodie,5 hard palate closure performed at 12 to 14 years of age provides patients with cleft palate with favorable maxillary development (delayed hard palate closure).6,7 However, because previous studies have also consistently shown that speech development is disturbed after delaying hard palate closure past the age of integrated speech development,8-10 investigators have started to consider early 2-stage palatoplasty (ETS) in which hard palate closure is performed at a relatively young age, such as 1.5 to 2.5 years. Recently, Rohrich et al11,12 advocated ETS with hard palate closure at 15 to 18 months of age, based on their longitudinal studies in which hard palate closure at a young age (11 months) resulted in a significant improvement in speech development, yet no significant difference in maxillary growth was observed compared with delayed hard palate closure performed at 4 years of age.13 Subsequent studies have supported the observations of Rohrich et al,14,15 indicating that early 2-stage treatment protocols may be a preferable alternative to delayed hard palate closure for rendering favorable facial growth and speech development. However, because the timing of hard palate closure is at a younger age and the expected benefit of the 2-stage treatment on palatal growth is thus less, a question remains; that is, does an early 2-stage protocol induce better palatal development than conventional 1-stage palatoplasty, and if so, how much better is it? Although this is an important question, it has not yet been well documented. Wardill-Kilner push-back palatoplasty (PB), developed in 1937,16 is one of the most widespread surgical techniques for cleft palate repair. We performed WardillKilner PB for patients with complete unilateral cleft lip and palate (CUCLP) at 12 months of age until 1997. Although it consistently provided patients with satisfactory speech, many patients (about 30%) operated on by 1-stage PB exhibited maxillary ankylosis with the collapse of the dental arch. This figure is consistent with previous findings.17,18 Furlow19 designed a unique procedure for cleft palate repair, which attempts to obdurate the defect and lengthen the soft palate by double opposing Z-plasty. One of the most significant features of this technique is that the soft palate is lengthened and retropositioned by the tissue of the soft palate itself. This means that this procedure does not produce major bone denudation on the hard palate, which causes palatal ankylosis. Furthermore, it is possible for us to adopt this technique in a 2-stage protocol. Together with these findings, Nishio et al20 designed a procedure for ETS, which consists of soft
palate closure at 12 months of age by a modified Furlow palatoplasty and hard palate closure at 18 months of age. We have practiced this protocol for patients with CUCLP since 1997. The aim of this article is to discuss the maxillary arch morphology of children with CUCLP after ETS and compare it with the morphology of patients with CUCLP treated by conventional Wardill-Kilner PB and children with noncleft palate.
Patients and Methods SUBJECTS
Of the patients with CUCLP who have been treated in Osaka Medical Center and Research Institute for Maternal and Child Health (Osaka, Japan), 72 cases without any associated malformations were enrolled in this study. The patients were divided into 2 groups by their treatment protocol: 30 patients born from 1996 to 1999 had been treated by ETS (ETS group), and 42 patients born from 1990 to 1996 had undergone PB (PB group). Cross-sectional control records were obtained from 66 healthy children with noncleft palate (control group). TREATMENT PROCEDURE
Treatment protocols for the CUCLP subjects were as follows (Fig 1). All subjects with CUCLP underwent early presurgical orthopedic treatment advocated by Hotz and Goninski.21 Lip repair was carried out by a modified Millard technique at 3 months of age. In ETS, soft palate closure was performed by a modified Furlow palatoplasty at 12 months of age (Fig 2) and hard palate closure at 18 months of age. For several cases we used the Veau (for narrow clefts) or the bridge flap technique (for wide clefts) to close the hard palate. Subjects in the PB group underwent Wardill-
FIGURE 1. Treatment protocols of subjects with CUCLP. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
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Detailed measurements of the subjects (Tables 1, 2) showed significant differences in gestation period and timing of soft palate closure between the ETS and PB groups, but body weight showed no significant differences. DENTAL CAST ANALYSIS
Maxillary dental casts were taken at ages 3 months (before primary lip repair), 12 months (before soft palate closure), 18 months (before hard palate closure), and 2, 3, and 4 years for the ETS and control groups. For the PB group, these were taken at 3 months, 12 months, and 4 years of age. All measurements of these maxillary casts were carried out by 1 examiner using a contact measurement device (QM Measure, Mitsutoyo Co, Osaka, Japan) at the reference points shown in Figure 3. Each cast was measured 3 times and the mean value was used. Means and SDs were calculated for the measurements. Multiple statistical tests among the 3 groups were performed with the Bonferroni test, in which each pair of measurements was compared by unpaired t test, and P less than .017 (.05 for 3 comparisons) was considered statistically significant. Comparisons between the ETS and PB groups were analyzed by paired or unpaired t test with P less than .05 as the critical region. Statistical tests were not available between the control and the ETS or PB groups in developmental analyses because the control group comprised cross-sectional data (Figs 4-8).
FIGURE 2. Surgical design of modified Furlow palatoplasty. Top, Schematic drawings represent incision and suture lines for soft palate closure. Middle, Drawings correspond to hard palate closure. Bottom, Drawings show coronal sectional view at the black horizontal lines on the hard palate. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
Kilner PB at 12 months of age. All cleft surgeries were performed by a single surgeon (J.N.). No patient developed postoperative complications or wound infections.
Results Table 3 presents a summary of the measured parameters.
Table 1. DETAILED RECORDINGS OF SUBJECT WITH CUCLP
At birth Body weight (g) Gestation period (wk) Hotz plate set (d after birth) Primary lip repair Age (mo) Body weight (kg) Soft palate closure (ETS), palatoplasty (PB) Age (mo) Body weight (kg) Hard palate closure (ETS) Age (mo) Body weight (kg) Age 4 yrs Body weight (kg)
ETS
PB
P
3.2 ⫾ 0.5 39.7 ⫾ 1.1 16.0 ⫾ 18.3
3.1 ⫾ 0.4 38.8 ⫾ 1.6 12.0 ⫾ 13.9
⬍.05
2.7 ⫾ 0.8 6.0 ⫾ 0.7
2.9 ⫾ 0.6 5.9 ⫾0.6
11.0 ⫾ 0.7 8.9 ⫾ 1.1
12.1 ⫾ 1.7 9.1 ⫾ 0.9
17.4 ⫾ 1.0 10.3 ⫾ 1.0
— —
16.8 ⫾ 0.8
16.5 ⫾ 0.5
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
⬍.05
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Table 2. DETAILED RECORDINGS OF CONTROL SUBJECTS
Stage
Primary Lip Repair
Soft Palate Closure
Hard Palate Closure
2 yrs
3 yrs
4 yrs
Cases Age (mo) Body weight (kg)
3 5.3 ⫾ 0.6 7.6 ⫾ 0.4
16 11.3 ⫾ 1.9 9.5 ⫾ 0.8
12 18.4 ⫾1.2 10.1 ⫾ 0.8
15 25.0 ⫾ 1.5 13.5 ⫾ 0.2
10 35.9 ⫾ 1.6 15.1 ⫾ 0.3
10 48.6 ⫾ 1.1 17.2 ⫾ 0.7
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
COMPARISON OF MAXILLARY ARCH MORPHOLOGY AT 3 AND 12 MONTHS OF AGE
There was no significant difference in each measured value between the ETS and PB groups at 3 and 12 months of age. CHANGE IN CLEFT WIDTH
Cleft widths at ages 3 and 12 months showed no significant difference between ETS and PB. A decrease in the size of the cleft width was observed in the ETS group after soft palate closure. The average reduction in cleft width was 3.9 mm at MM= and 1.8 mm at CC= from 12 to 18 months of age. The ratio of cleft width to arch width (cleft width/arch width) significantly decreased during this period (paired t test, P ⬍ .05; Fig 4), implying that a considerable reduction occurred in cleft width. MAXILLARY ARCH MORPHOLOGY AT AGE 4 YRS
A-TT= at 4 years of age was 37.2 ⫾ 0.9 mm in the control groups, 33.6 ⫾ 1.7 mm in the ETS group, and 30.6 ⫾ 2.4 mm in the PB group, indicating significant differences among the 3 groups (Bonferroni, P ⬍ .017). Similarly, C=-TT= of the control group was the largest among groups, whereas the PB group had the smallest C=-TT= (Bonferroni, P ⬍ .017).
The control group had the largest CC= and MM=, whereas the smallest values were observed in the PB group. Significant differences among the 3 groups were demonstrated in CC= (Bonferroni, P ⬍ .017). In MM=, there were significant differences between the ETS and PB groups and between the PB and control groups (Bonferroni, P ⬍ .017), yet there was no significant difference between the ETS and control groups. TT= was the largest for the ETS group, whereas the smallest TT= was in the PB group, but there was no significant difference between the ETS and control groups. CHANGE IN MAXILLARY ARCH MORPHOLOGY FROM 12 MONTHS TO 4 YRS OF AGE
In this period, increases in A-TT= and C=-TT= in the ETS group were 28.3% and 31.2%, respectively, whereas they were 12.3% and 22.0% in the PB group (Fig 5; unpaired t test, P ⬍ .05 for A-TT= and C=-TT=). During the same period, the control group showed an 18.1% increase in A-TT=; thus, A-TT= in the ETS group showed a greater increase than that in the control group. The periods during which the ETS group showed a more rapid increase in A-TT= than the control group were 12 months to 2 years and 3 to 4 years of age (Fig 6).
FIGURE 3. Mucosal reference points on maxillary cast models and measurements. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
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FIGURE 6. Change in arch length during each period.
FIGURE 4. Changes in the ratio between cleft width and alveolar width (cleft width/alveolar width) from 12 to 18 months of age. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
The increase in arch width from 12 months to 4 years of age was largest in the control group and smallest in the PB group at every point measured (Fig 7; unpaired t test, P ⬍ .05 between ETS and PB groups). MM= and CC= of the PB group at 4 years of age were 5.0% and 2.7% smaller, respectively, than those at age 12 months (paired t test, P ⬍ .05). In contrast, MM= and CC= in the ETS group increased by 3.8% and 5.4%, respectively, and increased in the control group by 9.5% and 10.3%, respectively (unpaired t test, P ⬍ .05 between ETS and PB groups for each parameter). Precise analysis of arch width development in the ETS and control groups (Fig 8) showed that a rapid increase in CC= occurred from 18 months to 2 years of age in the control group, whereas the ETS group showed decreases in arch width during the same period.
Discussion
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
the result with that of patients with CUCLP treated by conventional PB and children with noncleft palate. The main results are as follows. 1) The anteroposterior palatal length of the ETS group was significantly greater than that of the PB group by 9.8% at 4 years of age. 2) At 4 years of age, transversal palatal width of the ETS group was markedly greater than that of the PB group at every point measured. 3) The ETS group showed potential catch-up growth in palatal length from 12 months to 4 years of age. Those results clearly demonstrate that ETS by modified Furlow technique results in better palatal development than PB. To show the negative influence of a treatment regimen for cleft on maxillary development, we must consider several factors such as cleft type, surgeon, individual intrinsic growth potential, and timing and technique of cleft surgery. The subjects enrolled in this study possessed the same cleft type (CUCLP) and ethnic background (Asian Japanese) and were adjusted for age, surgeon, and consecutive treatment protocol. Maxillary arch morphology at ages 3 and 12
In this study, we measured the palatal morphology of patients with CUCLP treated with ETS and compared
FIGURE 5. Changes in arch length from 12 months to 4 years of age.
FIGURE 7. Changes in arch width from 12 months to 4 years of age.
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
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FIGURE 8. Change in arch width during each period. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
months demonstrated no significant difference between the ETS and PB groups at any points measured, indicating that the influences of initial treatment and the intrinsic growth potential up to soft palate closure are almost identical between groups. Hence, the subjects enrolled in this study were suitable for this comparative study. During 6 months after soft palate closure, the remaining cleft width in the hard palate narrowed markedly for the ETS group. The ratio of cleft width to arch width significantly decreased during this period, suggesting that this reduction is predominantly caused by
a reduction in cleft width. This is consistent with a previous finding,22 which demonstrated a similar reduction in residual cleft width, which reached a plateau 6 to 12 months after soft palate closure. Because a smaller residual cleft requires less surgical intervention to the hard palate, it is important to know how long it takes for the natural reduction of the residual cleft to reach its plateau. In our subjects, we could not identify the period in each case, but we observed contact between both sides of the anterior tips of the alveolar segments in most subjects in the ETS group at 18 months of age. From the observation that the remaining cleft width in the hard palate is hardly reduced after both sides of the segments come in contact with each other, we believe that the reduction in residual cleft width mostly finishes 6 months after soft palate closure. Berkowitz23 defined “catch-up growth” in patients with cleft palate as a state in which the palatal development in these patients becomes superior to that of a normal person during a given period, and achieving catch-up growth has been one of the most important objectives in cleft treatment. The comparison between the ETS and control groups in the present study showed that the increase in A-TT= of the ETS group from 12 months to 4 years of age exceeded that in the control group (a statistical analysis could not be
Table 3. MEASUREMENT RESULTS
Group Cleft width cc= mm= tt= Anteroposterior length A-TT= C=-TT= Alveolar width CC= MM= TT=
3 mo
12 mo
18 mo
2 yrs
3 yrs
4 yrs
ETS PB ETS PB ETS PB
9.8 ⫾ 31 8.8 ⫾ 3.1 12.8 ⫾ 2.1 12.2 ⫾ 2.4 12.4 ⫾ 1.8 11.8 ⫾ 2.2
4.3 ⫾ 2.8 3.2 ⫾ 2.6 8.4 ⫾ 2.5 7.3 ⫾ 2.7 10.2 ⫾ 1.9 9.2 ⫾ 2.2
2.5 ⫾ 2.1
ETS PB Control ETS PB Control
24.9 ⫾ 1.7 25.0 ⫾ 2.1 27.8 ⫾ 0.6 16.4 ⫾ 1.5 16.2 ⫾ 1.9 19.7 ⫾ 1.4
26.4 ⫾ 1.6 27.3 ⫾ 1.9 31.4 ⫾ 0.8 18.4 ⫾ 1.1 18.6 ⫾ 1.6 20.8 ⫾ 0.3
28.3 ⫾ 1.9 — 32.7 ⫾ 0.9 19.4 ⫾ 1.2 — 21.8 ⫾ 0.9
30.2 ⫾ 2.0 — 33.4 ⫾ 0.9 20.4 ⫾ 1.6 — 22.9 ⫾ 0.3
32.0 ⫾ 16 — 35.8 ⫾ 1.1 22.3 ⫾ 1.4 — 24.8 ⫾ 0.9
33.6 ⫾ 1.7*‡ 30.6 ⫾ 2.4† 37.2 ⫾ 0.9 23.9 ⫾ 1.1*‡ 22.6 ⫾ 1.8† 27.0 ⫾ 1.8
ETS PB Control ETS PB Control ETS PB Control
32.8 ⫾ 2.4 32.2 ⫾ 2.9 31.3 ⫾ 2.2 38.3 ⫾ 2.0 38.9 ⫾ 2.7 37.2 ⫾ 2.9 34.2 ⫾ 1.8 34.2 ⫾ 2.2 32.9 ⫾ 2.6
31.3 ⫾ 2.2 31.3 ⫾ 2.7 31.4 ⫾ 1.4 39.2 ⫾ 2.0 39.8 ⫾ 2.5 38.8 ⫾ 1.7 35.8 ⫾ 1.9 36.6 ⫾ 2.3 33.4 ⫾ 1.1
31.2 ⫾ 2.2 — 32.2 ⫾ 1.4 38.2 ⫾ 2.0 — 39.6 ⫾ 1.3 34.7 ⫾ 1.6 — 34.7 ⫾ 0.8
31.6 ⫾ 2.2 — 33.6 ⫾ 0.8 38.9 ⫾ 2.1 — 39.9 ⫾ 1.3 36.0 ⫾ 1.5 — 35.3 ⫾ 2.3
32.1 ⫾ 2.3 — 33.8 ⫾ 1.2 40.7 ⫾ 2.4 — 41.8 ⫾ 0.3 38.6 ⫾ 2.3 — 37.6 ⫾ 1.7
32.2 ⫾ 2.4*‡ 30.3 ⫾ 2.7† 34.3 ⫾ 1.2 41.2 ⫾ 2.4* 37.8 ⫾ 3.1† 42.8 ⫾ 2.6 40.2 ⫾ 2.1* 38.3 ⫾ 3.1 39.6 ⫾ 1.9
4.5 ⫾ 1.4
P ⬍ .017, Bonferroni test, for *ETS versus PB group, †PB versus control group, ‡ETS versus control group. Abbreviations as in Figure 3. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
2216 carried out). Although this may be partly because of the very short A-TT= in the ETS group at 12 months of age, probably associated with the primary lip plasty, this finding suggests that catch-up growth occurred during this period in the ETS group. We did not observe such rapid palatal development in the PB group. MM= of the PB group at 4 years of age was smaller than that at 12 months of age. This may be caused by scar contraction in the hard palate associated with PB. In contrast, the palatal width for the ETS group constantly increased from 18 months to 4 yrs of age. These findings indicate a disadvantage of intensive surgical intervention to the hard palate by the PB surgery at around 12 months of age. Comparison of CC= between the ETS and control groups demonstrated that the increase in CC= for the ETS group from 18 months to 4 years of age was significantly smaller than that for the control group. A detailed analysis showed that the largest difference in the increase in CC= between the ETS and control groups was from 18 months to 2 years of age. This is most likely because of the hard palate closure performed in the ETS groups at 18 months of age. However, considering that a developmental spurt in palatal width, probably associated with the eruption of the deciduous molars, occurred in control subjects during this period, an additional 3- to 6-month delay (after the subject reaches 18 months of age) in the timing of hard palate closure might result in efficient palatal growth. If we perform hard palate closure after 18 months of age, however, the lateral incisor in the minor segment might erupt at the cleft margin, making hard palate closure difficult. Therefore, we need to carefully observe the development of individual patients when delaying the timing of hard palate closure for another several months when they reach 18 months of age. In conclusion, in the present study, we demonstrated the advantage of ETS on palatal development compared with PB. The results also showed potential catch-up growth in arch length after performing ETS.
References 1. Kilner TP: The management of the patient with cleft lip and/or palate. Am J Surg 93:204, 1958
EARLY 2-STAGE PALATOPLASTY 2. Friede H: Growth sites and growth mechanisms at risk in cleft lip and palate. Acta Odontol Scand 56:346, 1998 3. Semb G, Shaw WC: Facial growth after different methods of surgical intervention in patients with cleft lip and palate. Acta Odontol Scand 56:352, 1998 4. Gillies HD: Plastic Surgery of the Face. London, England, Frowde, 1920 5. Slaughter WB, Brodie AG: Facial clefts and their surgical management. Plast Reconstr Surg 4:311, 1949 6. Liao YF, Mars M: Hard palate repair timing and facial morphology in unilateral cleft lip and palate: before versus after pubertal peak velocity age. Cleft Palate Craniofac J 43:547, 2006 7. Friede H, Enemark H: Long-term evidence for favorable midfacial growth after delayed hard palate repair in UCLP patients. Cleft Palate Craniofac J 38:323, 2001 8. Noordhoff MS, Kuo J, Wang F, et al: Development of articulation before delayed hard-palate closure in children with cleft palate: A cross-sectional study. Plast Reconstr Surg 80:518, 1987 9. Witzel MA, Salyer KE, Ross RB: Delayed hard palate closure: The philosophy revisited. Cleft Palate J 21:263, 1984 10. Cosman B, Falk AS: Delayed hard palate repair and speech deficiencies: A cautionary report. Cleft Palate J 17:27, 1980 11. Rohrich RJ, Byrd HS: Optimal timing of cleft palate closure. Speech, facial growth, and hearing considerations. Clin Plast Surg 17:27, 1990 12. Rohrich RJ, Love EJ, Byrd HS, et al: Optimal timing of cleft palate closure. Plast Reconstr Surg 106:423, 2000 13. Rohrich RJ, Rowsell AR, Johns DF, et al: Timing of hard palatal closure: A critical long-term analysis. Plast Reconstr Surg 98: 236, 1996 14. Noverraz AE, Kuijpers-Jagtman AM, Mars M, et al: Timing of hard palate closure and dental arch relationships in unilateral cleft lip and palate patients: A mixed-longitudinal study. Cleft Palate Craniofac J 30:391, 1993 15. Swennen G, Berten JL, Schliephake H, et al: Midfacial morphology in children with unilateral cleft lip and palate treated by different surgical protocols. Int J Oral Maxillofac Surg 31:13, 2002 16. Wardill WEM: The technique of operation for cleft palate. Br J Surg 25:117, 1937 17. Friede H, Persson EC, Lilja J, et al: Maxillary dental arch and occlusion in patients with repaired clefts of the secondary palate. Influence of push back palatal surgery. Scand J Plast Reconstr Surg Hand Surg 27:297, 1993 18. Ross RB: Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J 24:5, 1987 19. Furlow LT Jr: Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 78:724, 1986 20. Nishio J, Adachi T, Hirano Y, Sako M: A new designed twostage palatoplasty using Furlow’s veloplasty. Transactions of the 9th International Conference of Cleft Palate and Related Craniofacial Anomalies. Göteborg, Sweden, 2001, p 173 21. Hotz MM, Gnoinski WM: Effects of early maxillary orthopaedics in coordination with delayed surgery for cleft lip and palate. J Maxillofac Surg 7:201, 1979 22. Lohmander-Agerskov A, Friede H, Söderpalm E, et al: Residual clefts in the hard palate: Correlation between cleft size and speech. Cleft Palate Craniofac J 34:122, 1997 23. Berkowitz S: Lip and palatal surgery, in Cleft Lip and Palate: Perspectives in Management. London, Singular, 1996, pp 65-82
Effect on Maxillary Arch Development of Early 2-Stage Palatoplasty by Modified Furlow Technique and Conventional 1-Stage Palatoplasty in Children With Complete Unilateral Cleft Lip and Palate Tadashi Yamanishi, DDS, PhD,* Juntaro Nishio, DDS, PhD,† Hiroshi Kohara, DDS, PhD,‡ Yoshiko Hirano, DDS, PhD,§ Michiyo Sako, SLP,储 Yukiko Yamanishi, DDS, PhD,¶ Tadafumi Adachi, DDS, PhD,# Shigenori Miya, DDS, PhD,** and Takao Mukai, DDS, PhD†† Purpose: The purpose of this study was to evaluate the palatal morphology of patients with complete
unilateral cleft lip and palate after early 2-stage palatoplasty (ETS) consisting of soft palate closure by a modified Furlow palatoplasty at 12 months of age and hard palate closure at 18 months of age. We compared the result with the palatal morphology obtained by Wardill-Kilner push-back palatoplasty (PB) at 12 months of age with that of children with noncleft palate. In the present study we investigated whether ETS can result in better palatal development than conventional PB. Materials and Methods: Thirty subjects were treated by ETS and 42 underwent PB. We also included cross-sectional data obtained from 66 children with noncleft palate as control. We measured the arch length, width, and cleft width using dental cast models that were consecutively taken at 3 months to 4 yrs of age and compared the results among the 3 groups. Results: At 4 years of age, the anteroposterior palatal length of ETS was significantly longer than that of PB by 9.8%, and the transversal palatal width of ETS was also markedly wider than that of PB at every point measured. Furthermore, ETS showed potential catch-up growth in the anteroposterior palatal length from 12 months to 4 years of age. Conclusion: These results demonstrate that ETS has a considerable benefit for the palatal development of patients with complete unilateral cleft lip and palate compared with PB. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:2210-2216, 2009 The primary goal of cleft palate surgery is to provide children with cleft palate with adequate velopharyngeal function for normal speech development.1 However, surgical intervention to the palate interferes with maxillofacial growth.2,3 For the acquisition of favorable Received from the Department of Oral and Maxillofacial Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan. *Clinical Fellow. †Chief and Professor. ‡Oral and Maxillofacial Surgeon. §Orthodontist. 储Speech Pathologist. ¶Resident. #Clinical Fellow.
speech and maxillary development, there has been considerable debate on the most suitable technique and timing of cleft palate repair. The “2-stage operation” concept, which was introduced by Gillies4 in the early 1900s, has long been **Resident. ††Resident. Address reprint requests and correspondence to Dr Nishio: Department of Oral and Maxillofacial Surgery, Osaka Medical Center for Maternal and Child Health, 840 Murodocho Izumi, Osaka 5941101, Japan; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6710-0020$36.00/0 doi:10.1016/j.joms.2009.04.038
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applied by subsequent clinicians with substantial modifications. The principal concept of 2-stage palatoplasty is to postpone hard palate closure until maxillary development has proceeded sufficiently to become resistant to surgical interference to the hard palate. As first argued by Slaughter and Brodie,5 hard palate closure performed at 12 to 14 years of age provides patients with cleft palate with favorable maxillary development (delayed hard palate closure).6,7 However, because previous studies have also consistently shown that speech development is disturbed after delaying hard palate closure past the age of integrated speech development,8-10 investigators have started to consider early 2-stage palatoplasty (ETS) in which hard palate closure is performed at a relatively young age, such as 1.5 to 2.5 years. Recently, Rohrich et al11,12 advocated ETS with hard palate closure at 15 to 18 months of age, based on their longitudinal studies in which hard palate closure at a young age (11 months) resulted in a significant improvement in speech development, yet no significant difference in maxillary growth was observed compared with delayed hard palate closure performed at 4 years of age.13 Subsequent studies have supported the observations of Rohrich et al,14,15 indicating that early 2-stage treatment protocols may be a preferable alternative to delayed hard palate closure for rendering favorable facial growth and speech development. However, because the timing of hard palate closure is at a younger age and the expected benefit of the 2-stage treatment on palatal growth is thus less, a question remains; that is, does an early 2-stage protocol induce better palatal development than conventional 1-stage palatoplasty, and if so, how much better is it? Although this is an important question, it has not yet been well documented. Wardill-Kilner push-back palatoplasty (PB), developed in 1937,16 is one of the most widespread surgical techniques for cleft palate repair. We performed WardillKilner PB for patients with complete unilateral cleft lip and palate (CUCLP) at 12 months of age until 1997. Although it consistently provided patients with satisfactory speech, many patients (about 30%) operated on by 1-stage PB exhibited maxillary ankylosis with the collapse of the dental arch. This figure is consistent with previous findings.17,18 Furlow19 designed a unique procedure for cleft palate repair, which attempts to obdurate the defect and lengthen the soft palate by double opposing Z-plasty. One of the most significant features of this technique is that the soft palate is lengthened and retropositioned by the tissue of the soft palate itself. This means that this procedure does not produce major bone denudation on the hard palate, which causes palatal ankylosis. Furthermore, it is possible for us to adopt this technique in a 2-stage protocol. Together with these findings, Nishio et al20 designed a procedure for ETS, which consists of soft
palate closure at 12 months of age by a modified Furlow palatoplasty and hard palate closure at 18 months of age. We have practiced this protocol for patients with CUCLP since 1997. The aim of this article is to discuss the maxillary arch morphology of children with CUCLP after ETS and compare it with the morphology of patients with CUCLP treated by conventional Wardill-Kilner PB and children with noncleft palate.
Patients and Methods SUBJECTS
Of the patients with CUCLP who have been treated in Osaka Medical Center and Research Institute for Maternal and Child Health (Osaka, Japan), 72 cases without any associated malformations were enrolled in this study. The patients were divided into 2 groups by their treatment protocol: 30 patients born from 1996 to 1999 had been treated by ETS (ETS group), and 42 patients born from 1990 to 1996 had undergone PB (PB group). Cross-sectional control records were obtained from 66 healthy children with noncleft palate (control group). TREATMENT PROCEDURE
Treatment protocols for the CUCLP subjects were as follows (Fig 1). All subjects with CUCLP underwent early presurgical orthopedic treatment advocated by Hotz and Goninski.21 Lip repair was carried out by a modified Millard technique at 3 months of age. In ETS, soft palate closure was performed by a modified Furlow palatoplasty at 12 months of age (Fig 2) and hard palate closure at 18 months of age. For several cases we used the Veau (for narrow clefts) or the bridge flap technique (for wide clefts) to close the hard palate. Subjects in the PB group underwent Wardill-
FIGURE 1. Treatment protocols of subjects with CUCLP. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
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Detailed measurements of the subjects (Tables 1, 2) showed significant differences in gestation period and timing of soft palate closure between the ETS and PB groups, but body weight showed no significant differences. DENTAL CAST ANALYSIS
Maxillary dental casts were taken at ages 3 months (before primary lip repair), 12 months (before soft palate closure), 18 months (before hard palate closure), and 2, 3, and 4 years for the ETS and control groups. For the PB group, these were taken at 3 months, 12 months, and 4 years of age. All measurements of these maxillary casts were carried out by 1 examiner using a contact measurement device (QM Measure, Mitsutoyo Co, Osaka, Japan) at the reference points shown in Figure 3. Each cast was measured 3 times and the mean value was used. Means and SDs were calculated for the measurements. Multiple statistical tests among the 3 groups were performed with the Bonferroni test, in which each pair of measurements was compared by unpaired t test, and P less than .017 (.05 for 3 comparisons) was considered statistically significant. Comparisons between the ETS and PB groups were analyzed by paired or unpaired t test with P less than .05 as the critical region. Statistical tests were not available between the control and the ETS or PB groups in developmental analyses because the control group comprised cross-sectional data (Figs 4-8).
FIGURE 2. Surgical design of modified Furlow palatoplasty. Top, Schematic drawings represent incision and suture lines for soft palate closure. Middle, Drawings correspond to hard palate closure. Bottom, Drawings show coronal sectional view at the black horizontal lines on the hard palate. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
Kilner PB at 12 months of age. All cleft surgeries were performed by a single surgeon (J.N.). No patient developed postoperative complications or wound infections.
Results Table 3 presents a summary of the measured parameters.
Table 1. DETAILED RECORDINGS OF SUBJECT WITH CUCLP
At birth Body weight (g) Gestation period (wk) Hotz plate set (d after birth) Primary lip repair Age (mo) Body weight (kg) Soft palate closure (ETS), palatoplasty (PB) Age (mo) Body weight (kg) Hard palate closure (ETS) Age (mo) Body weight (kg) Age 4 yrs Body weight (kg)
ETS
PB
P
3.2 ⫾ 0.5 39.7 ⫾ 1.1 16.0 ⫾ 18.3
3.1 ⫾ 0.4 38.8 ⫾ 1.6 12.0 ⫾ 13.9
⬍.05
2.7 ⫾ 0.8 6.0 ⫾ 0.7
2.9 ⫾ 0.6 5.9 ⫾0.6
11.0 ⫾ 0.7 8.9 ⫾ 1.1
12.1 ⫾ 1.7 9.1 ⫾ 0.9
17.4 ⫾ 1.0 10.3 ⫾ 1.0
— —
16.8 ⫾ 0.8
16.5 ⫾ 0.5
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
⬍.05
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Table 2. DETAILED RECORDINGS OF CONTROL SUBJECTS
Stage
Primary Lip Repair
Soft Palate Closure
Hard Palate Closure
2 yrs
3 yrs
4 yrs
Cases Age (mo) Body weight (kg)
3 5.3 ⫾ 0.6 7.6 ⫾ 0.4
16 11.3 ⫾ 1.9 9.5 ⫾ 0.8
12 18.4 ⫾1.2 10.1 ⫾ 0.8
15 25.0 ⫾ 1.5 13.5 ⫾ 0.2
10 35.9 ⫾ 1.6 15.1 ⫾ 0.3
10 48.6 ⫾ 1.1 17.2 ⫾ 0.7
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
COMPARISON OF MAXILLARY ARCH MORPHOLOGY AT 3 AND 12 MONTHS OF AGE
There was no significant difference in each measured value between the ETS and PB groups at 3 and 12 months of age. CHANGE IN CLEFT WIDTH
Cleft widths at ages 3 and 12 months showed no significant difference between ETS and PB. A decrease in the size of the cleft width was observed in the ETS group after soft palate closure. The average reduction in cleft width was 3.9 mm at MM= and 1.8 mm at CC= from 12 to 18 months of age. The ratio of cleft width to arch width (cleft width/arch width) significantly decreased during this period (paired t test, P ⬍ .05; Fig 4), implying that a considerable reduction occurred in cleft width. MAXILLARY ARCH MORPHOLOGY AT AGE 4 YRS
A-TT= at 4 years of age was 37.2 ⫾ 0.9 mm in the control groups, 33.6 ⫾ 1.7 mm in the ETS group, and 30.6 ⫾ 2.4 mm in the PB group, indicating significant differences among the 3 groups (Bonferroni, P ⬍ .017). Similarly, C=-TT= of the control group was the largest among groups, whereas the PB group had the smallest C=-TT= (Bonferroni, P ⬍ .017).
The control group had the largest CC= and MM=, whereas the smallest values were observed in the PB group. Significant differences among the 3 groups were demonstrated in CC= (Bonferroni, P ⬍ .017). In MM=, there were significant differences between the ETS and PB groups and between the PB and control groups (Bonferroni, P ⬍ .017), yet there was no significant difference between the ETS and control groups. TT= was the largest for the ETS group, whereas the smallest TT= was in the PB group, but there was no significant difference between the ETS and control groups. CHANGE IN MAXILLARY ARCH MORPHOLOGY FROM 12 MONTHS TO 4 YRS OF AGE
In this period, increases in A-TT= and C=-TT= in the ETS group were 28.3% and 31.2%, respectively, whereas they were 12.3% and 22.0% in the PB group (Fig 5; unpaired t test, P ⬍ .05 for A-TT= and C=-TT=). During the same period, the control group showed an 18.1% increase in A-TT=; thus, A-TT= in the ETS group showed a greater increase than that in the control group. The periods during which the ETS group showed a more rapid increase in A-TT= than the control group were 12 months to 2 years and 3 to 4 years of age (Fig 6).
FIGURE 3. Mucosal reference points on maxillary cast models and measurements. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
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FIGURE 6. Change in arch length during each period.
FIGURE 4. Changes in the ratio between cleft width and alveolar width (cleft width/alveolar width) from 12 to 18 months of age. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
The increase in arch width from 12 months to 4 years of age was largest in the control group and smallest in the PB group at every point measured (Fig 7; unpaired t test, P ⬍ .05 between ETS and PB groups). MM= and CC= of the PB group at 4 years of age were 5.0% and 2.7% smaller, respectively, than those at age 12 months (paired t test, P ⬍ .05). In contrast, MM= and CC= in the ETS group increased by 3.8% and 5.4%, respectively, and increased in the control group by 9.5% and 10.3%, respectively (unpaired t test, P ⬍ .05 between ETS and PB groups for each parameter). Precise analysis of arch width development in the ETS and control groups (Fig 8) showed that a rapid increase in CC= occurred from 18 months to 2 years of age in the control group, whereas the ETS group showed decreases in arch width during the same period.
Discussion
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
the result with that of patients with CUCLP treated by conventional PB and children with noncleft palate. The main results are as follows. 1) The anteroposterior palatal length of the ETS group was significantly greater than that of the PB group by 9.8% at 4 years of age. 2) At 4 years of age, transversal palatal width of the ETS group was markedly greater than that of the PB group at every point measured. 3) The ETS group showed potential catch-up growth in palatal length from 12 months to 4 years of age. Those results clearly demonstrate that ETS by modified Furlow technique results in better palatal development than PB. To show the negative influence of a treatment regimen for cleft on maxillary development, we must consider several factors such as cleft type, surgeon, individual intrinsic growth potential, and timing and technique of cleft surgery. The subjects enrolled in this study possessed the same cleft type (CUCLP) and ethnic background (Asian Japanese) and were adjusted for age, surgeon, and consecutive treatment protocol. Maxillary arch morphology at ages 3 and 12
In this study, we measured the palatal morphology of patients with CUCLP treated with ETS and compared
FIGURE 5. Changes in arch length from 12 months to 4 years of age.
FIGURE 7. Changes in arch width from 12 months to 4 years of age.
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
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FIGURE 8. Change in arch width during each period. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
months demonstrated no significant difference between the ETS and PB groups at any points measured, indicating that the influences of initial treatment and the intrinsic growth potential up to soft palate closure are almost identical between groups. Hence, the subjects enrolled in this study were suitable for this comparative study. During 6 months after soft palate closure, the remaining cleft width in the hard palate narrowed markedly for the ETS group. The ratio of cleft width to arch width significantly decreased during this period, suggesting that this reduction is predominantly caused by
a reduction in cleft width. This is consistent with a previous finding,22 which demonstrated a similar reduction in residual cleft width, which reached a plateau 6 to 12 months after soft palate closure. Because a smaller residual cleft requires less surgical intervention to the hard palate, it is important to know how long it takes for the natural reduction of the residual cleft to reach its plateau. In our subjects, we could not identify the period in each case, but we observed contact between both sides of the anterior tips of the alveolar segments in most subjects in the ETS group at 18 months of age. From the observation that the remaining cleft width in the hard palate is hardly reduced after both sides of the segments come in contact with each other, we believe that the reduction in residual cleft width mostly finishes 6 months after soft palate closure. Berkowitz23 defined “catch-up growth” in patients with cleft palate as a state in which the palatal development in these patients becomes superior to that of a normal person during a given period, and achieving catch-up growth has been one of the most important objectives in cleft treatment. The comparison between the ETS and control groups in the present study showed that the increase in A-TT= of the ETS group from 12 months to 4 years of age exceeded that in the control group (a statistical analysis could not be
Table 3. MEASUREMENT RESULTS
Group Cleft width cc= mm= tt= Anteroposterior length A-TT= C=-TT= Alveolar width CC= MM= TT=
3 mo
12 mo
18 mo
2 yrs
3 yrs
4 yrs
ETS PB ETS PB ETS PB
9.8 ⫾ 31 8.8 ⫾ 3.1 12.8 ⫾ 2.1 12.2 ⫾ 2.4 12.4 ⫾ 1.8 11.8 ⫾ 2.2
4.3 ⫾ 2.8 3.2 ⫾ 2.6 8.4 ⫾ 2.5 7.3 ⫾ 2.7 10.2 ⫾ 1.9 9.2 ⫾ 2.2
2.5 ⫾ 2.1
ETS PB Control ETS PB Control
24.9 ⫾ 1.7 25.0 ⫾ 2.1 27.8 ⫾ 0.6 16.4 ⫾ 1.5 16.2 ⫾ 1.9 19.7 ⫾ 1.4
26.4 ⫾ 1.6 27.3 ⫾ 1.9 31.4 ⫾ 0.8 18.4 ⫾ 1.1 18.6 ⫾ 1.6 20.8 ⫾ 0.3
28.3 ⫾ 1.9 — 32.7 ⫾ 0.9 19.4 ⫾ 1.2 — 21.8 ⫾ 0.9
30.2 ⫾ 2.0 — 33.4 ⫾ 0.9 20.4 ⫾ 1.6 — 22.9 ⫾ 0.3
32.0 ⫾ 16 — 35.8 ⫾ 1.1 22.3 ⫾ 1.4 — 24.8 ⫾ 0.9
33.6 ⫾ 1.7*‡ 30.6 ⫾ 2.4† 37.2 ⫾ 0.9 23.9 ⫾ 1.1*‡ 22.6 ⫾ 1.8† 27.0 ⫾ 1.8
ETS PB Control ETS PB Control ETS PB Control
32.8 ⫾ 2.4 32.2 ⫾ 2.9 31.3 ⫾ 2.2 38.3 ⫾ 2.0 38.9 ⫾ 2.7 37.2 ⫾ 2.9 34.2 ⫾ 1.8 34.2 ⫾ 2.2 32.9 ⫾ 2.6
31.3 ⫾ 2.2 31.3 ⫾ 2.7 31.4 ⫾ 1.4 39.2 ⫾ 2.0 39.8 ⫾ 2.5 38.8 ⫾ 1.7 35.8 ⫾ 1.9 36.6 ⫾ 2.3 33.4 ⫾ 1.1
31.2 ⫾ 2.2 — 32.2 ⫾ 1.4 38.2 ⫾ 2.0 — 39.6 ⫾ 1.3 34.7 ⫾ 1.6 — 34.7 ⫾ 0.8
31.6 ⫾ 2.2 — 33.6 ⫾ 0.8 38.9 ⫾ 2.1 — 39.9 ⫾ 1.3 36.0 ⫾ 1.5 — 35.3 ⫾ 2.3
32.1 ⫾ 2.3 — 33.8 ⫾ 1.2 40.7 ⫾ 2.4 — 41.8 ⫾ 0.3 38.6 ⫾ 2.3 — 37.6 ⫾ 1.7
32.2 ⫾ 2.4*‡ 30.3 ⫾ 2.7† 34.3 ⫾ 1.2 41.2 ⫾ 2.4* 37.8 ⫾ 3.1† 42.8 ⫾ 2.6 40.2 ⫾ 2.1* 38.3 ⫾ 3.1 39.6 ⫾ 1.9
4.5 ⫾ 1.4
P ⬍ .017, Bonferroni test, for *ETS versus PB group, †PB versus control group, ‡ETS versus control group. Abbreviations as in Figure 3. Yamanishi et al. Early 2-Stage Palatoplasty. J Oral Maxillofac Surg 2009.
2216 carried out). Although this may be partly because of the very short A-TT= in the ETS group at 12 months of age, probably associated with the primary lip plasty, this finding suggests that catch-up growth occurred during this period in the ETS group. We did not observe such rapid palatal development in the PB group. MM= of the PB group at 4 years of age was smaller than that at 12 months of age. This may be caused by scar contraction in the hard palate associated with PB. In contrast, the palatal width for the ETS group constantly increased from 18 months to 4 yrs of age. These findings indicate a disadvantage of intensive surgical intervention to the hard palate by the PB surgery at around 12 months of age. Comparison of CC= between the ETS and control groups demonstrated that the increase in CC= for the ETS group from 18 months to 4 years of age was significantly smaller than that for the control group. A detailed analysis showed that the largest difference in the increase in CC= between the ETS and control groups was from 18 months to 2 years of age. This is most likely because of the hard palate closure performed in the ETS groups at 18 months of age. However, considering that a developmental spurt in palatal width, probably associated with the eruption of the deciduous molars, occurred in control subjects during this period, an additional 3- to 6-month delay (after the subject reaches 18 months of age) in the timing of hard palate closure might result in efficient palatal growth. If we perform hard palate closure after 18 months of age, however, the lateral incisor in the minor segment might erupt at the cleft margin, making hard palate closure difficult. Therefore, we need to carefully observe the development of individual patients when delaying the timing of hard palate closure for another several months when they reach 18 months of age. In conclusion, in the present study, we demonstrated the advantage of ETS on palatal development compared with PB. The results also showed potential catch-up growth in arch length after performing ETS.
References 1. Kilner TP: The management of the patient with cleft lip and/or palate. Am J Surg 93:204, 1958
EARLY 2-STAGE PALATOPLASTY 2. Friede H: Growth sites and growth mechanisms at risk in cleft lip and palate. Acta Odontol Scand 56:346, 1998 3. Semb G, Shaw WC: Facial growth after different methods of surgical intervention in patients with cleft lip and palate. Acta Odontol Scand 56:352, 1998 4. Gillies HD: Plastic Surgery of the Face. London, England, Frowde, 1920 5. Slaughter WB, Brodie AG: Facial clefts and their surgical management. Plast Reconstr Surg 4:311, 1949 6. Liao YF, Mars M: Hard palate repair timing and facial morphology in unilateral cleft lip and palate: before versus after pubertal peak velocity age. Cleft Palate Craniofac J 43:547, 2006 7. Friede H, Enemark H: Long-term evidence for favorable midfacial growth after delayed hard palate repair in UCLP patients. Cleft Palate Craniofac J 38:323, 2001 8. Noordhoff MS, Kuo J, Wang F, et al: Development of articulation before delayed hard-palate closure in children with cleft palate: A cross-sectional study. Plast Reconstr Surg 80:518, 1987 9. Witzel MA, Salyer KE, Ross RB: Delayed hard palate closure: The philosophy revisited. Cleft Palate J 21:263, 1984 10. Cosman B, Falk AS: Delayed hard palate repair and speech deficiencies: A cautionary report. Cleft Palate J 17:27, 1980 11. Rohrich RJ, Byrd HS: Optimal timing of cleft palate closure. Speech, facial growth, and hearing considerations. Clin Plast Surg 17:27, 1990 12. Rohrich RJ, Love EJ, Byrd HS, et al: Optimal timing of cleft palate closure. Plast Reconstr Surg 106:423, 2000 13. Rohrich RJ, Rowsell AR, Johns DF, et al: Timing of hard palatal closure: A critical long-term analysis. Plast Reconstr Surg 98: 236, 1996 14. Noverraz AE, Kuijpers-Jagtman AM, Mars M, et al: Timing of hard palate closure and dental arch relationships in unilateral cleft lip and palate patients: A mixed-longitudinal study. Cleft Palate Craniofac J 30:391, 1993 15. Swennen G, Berten JL, Schliephake H, et al: Midfacial morphology in children with unilateral cleft lip and palate treated by different surgical protocols. Int J Oral Maxillofac Surg 31:13, 2002 16. Wardill WEM: The technique of operation for cleft palate. Br J Surg 25:117, 1937 17. Friede H, Persson EC, Lilja J, et al: Maxillary dental arch and occlusion in patients with repaired clefts of the secondary palate. Influence of push back palatal surgery. Scand J Plast Reconstr Surg Hand Surg 27:297, 1993 18. Ross RB: Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J 24:5, 1987 19. Furlow LT Jr: Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 78:724, 1986 20. Nishio J, Adachi T, Hirano Y, Sako M: A new designed twostage palatoplasty using Furlow’s veloplasty. Transactions of the 9th International Conference of Cleft Palate and Related Craniofacial Anomalies. Göteborg, Sweden, 2001, p 173 21. Hotz MM, Gnoinski WM: Effects of early maxillary orthopaedics in coordination with delayed surgery for cleft lip and palate. J Maxillofac Surg 7:201, 1979 22. Lohmander-Agerskov A, Friede H, Söderpalm E, et al: Residual clefts in the hard palate: Correlation between cleft size and speech. Cleft Palate Craniofac J 34:122, 1997 23. Berkowitz S: Lip and palatal surgery, in Cleft Lip and Palate: Perspectives in Management. London, Singular, 1996, pp 65-82