A REVIEW OF THE RESULTS OF OPERATIONS ON CLEFT PALATES WITH REFERENCE TO MAXILLARY GROWTH AND SPEECH FUNCTION

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1 A REVIEW OF THE RESULTS OF OPERATIONS ON CLEFT PALATES WITH REFERENCE TO MAXILLARY GROWTH AND SPEECH FUNCTION By AMBROSE JOLLEYS, M.D., F.R.C.S. Surgeon, Royal Manchester Children's and Booth Hall Hospitals MOST workers are still dissatisfied with the results of treatment of patients with cleft palates. Apart from the deficiencies of speech, the distorted growth of the palate gives rise to deformities of the alveoli, malocclusion of the teeth, and a poor profile. It has long been realised that certain types of operation restricted the growth of the maxilla to a grave extent, and more recently work by Graber (I949) has shown that any operation in early life will result in some limitation of growth. It is clear that the growth and development of the normal and of the cleft palate, with and without operation, must be studied and the findings considered before the best line of treatment can be decided upon. Different opinions are expressed as to whether the defect is purely a lack of fusion or whether there is an under-development of the maxillary processes. The " simple lack of fusion" theory was probably first mentioned in I844 by Hullihen. Smith (I867) made measurements of the maxilla in normal individuals and in cleft palate patients and concluded that there was a separation of the two sides without loss of tissue. Furthermore, the width between the bicuspid teeth in unoperated cleft palate patients was greater than that in patients with repaired cleft palates. He felt that this finding was an argument for delaying the operation. In I931 Peyton described a careful study of the essential defect at birth and the subsequent development of the palate. He was among the first to point out the desirability of studying living growing skulls rather than dried skulls, the resuks of many years of growth. He found that the cleft palate patients began life with a greater transverse diameter to the upper jaw than normal infants. But the width of the actual palate tissue was normal and furthermore its growth during the first year was quite normal. During the closing years of the last century Brophy began to write on his cleft palate work. He stated that there was no deficiency of the tissue at birth and that the maxilla~ tended to separate as growth continued. He believed that the tongue forced the two segments apart and also that the lower jaw, bearing on the inclined plane of the upper jaw, aggravated this process. Brophy therefore practised early operations, performed as soon as possible after birth. He used wires to pull the two halves of the upper jaw together and suggested that a normal palate resuked. He believed that the deformky which developed shortly afterwards was only a temporary phenomenon and that later the maxilla and teeth grew normally. However, voices were soon raised against Brophy's advocacy of early operation. Federspiel (i923) considered that after early interference the upper jaw failed to grow properly and remained stunted. In I93I Kirkham reported a series of measurements, made over a period of years, which showed that the worst aberrations of growth occurred after early traumatic surgery. In England, in x925, 229

2 23o BRITISH JOURNAL OF PLASTIC SURGERY Rayner had come to the same conclusion, and Kelsey Fry thought that the irregularity of the molars and premolars could always be ascribed to surgery. Since the introduction of the Broadbent cephalometer (I93I, I937), which enables the accurate measurements of the bony face and skull to be made in the living, interest in the subject has been stimulated. By the repeated examinations of numbers of normal children an accurate idea of normal development has been achieved, and comparison of cleft palate patients is possible. Using these techniques Slaughter and Brodie (1949) concluded that surgery can and does inhibit normal growth. They considered that the interference is directly proportional to the amount of injury and to the diminution of blood supply to the parts concerned. They found that the interference was greater when the number of operations was increased. They also found evidence that these congenitally deformed parts, unless damaged, grow at normal rates. Therefore they advised that the initial operations on the lip should be done in stages so as to avoid trauma as far as possible and that the operation on the palate should be delayed for some years. Graber in the same year reported a cephalometric study of 175 cleft palate patients and compared them with normal individuals. He found that the cleft palate series as a whole had a deficient pattern of maxillary growth and that the patients treated surgically had the worst deformities. On the other hand, in the cleft palate patients who had not been subjected to operation, growth had occurred almost normally. He pointed out that a large proportion of the maxillary growth occurs in the first five years of life and that therefore repair of the palate should be delayed until after the fourth year, and that the cleft could be satisfactorily closed by prostheses until then. This teaching has attracted considerable support in recent years. MATERIAL A series of children who had had cleft palates repaired by various techniques at different ages was available for study. From them it was hoped to find some indications as to the best time for operative interference. It was decided to examine not only the maxillary growth and to correlate it with the time and the nature of the operation, but also the development of the soft palate and the speech function. It has always been supposed that poor speech was accounted for by anatomical defects in the pharyngeal mechanism, but it has never been clear why the age at the time of the operation should modify the functioning of the soft palate. The growth of the maxilla and the soft palate were measured by cephalometry. The growth pattern of normal children's skulls has been studied by Ortiz and Brodie (1949). As regards the face, they showed that until the age of 5 years there is a generalised growth on almost all surfaces of all bones. After this age the surface accretion is very slight and growth continues at certain special sites. These centres are active from birth and they continue so almost until the cessation of bodily growth. Brodie (I94I) has shown by serial radiographic studies of individuals that the proportions of the face remain constant through childhood. Various bony landmarks bear a constant relationship to one another. The floor of the nose, the lower mandibular border, and various frontal planes have always the same angular relationships during growth. That is, their growth is such that any disturbance

3 OPERATIONS ON CLEFT PALATES: FIG. 2 Diagram of the face showing the bony points and the measurements used for estimating the degree of maxillary growth. MAXILLARY GROWTH AND SPEECH FUNCTION 23I of the normal proportionate growth will be at once apparent even if patients of slightly different age groups are compared. Because of the individual variations in facial proportions in normal people the average of the measurements of a series of cases must be taken (Figs. I and 2). Two lateral films were exposed in each case. One was taken with the mandible at physiological rest and the other with the patient phonating "Ah-h." At the same time the posterior edge of the hard palate was marked with a lead marker. The following measurements are used in the succeeding discussion :- The Nasion-Sella Turcica (N-S) Distance.--The point at the centre of the bony outline of the sella was taken. The Length of the Hard Palate.-- FIG. I The anterior limit of the maxilla was Diagram showing the sites of maxillary growth. taken as Point A, which is the most Generalised surface accretion occurs until recessive point on the curved anterior the age of 5 years, whereas in the dotted areas bony development occurs throughout the surface of the maxilla between the period of growth. anterior nasal spine and the alveolus. The Length of the Soft Palate.--These two palate lengths were expressed as percentages of the nasion-sella distance. The Facial Angle.--The internal angle between the x "Frankfurt plane" and the line from the nasion to the pogonion (the most anterior point of the symphysis of the mandible). The line used was not strictly the Frankfurt plane but a line through the inferior rim of the... orbit and through the centre of, ~... N~,~I~R~ the bony meatus seen on the I "POINT A diagram. The Angle of Convexity.-- The complement of the ~ I O N angle between the three points Nasion-Point A-Pogonion. A positive angle indicates a convex profile. The S-N-A Angle.--The angle between the sella, the nasion, and Point A. These three angular measurements provide an indication of the postero-anterior

4 232 BRITISH JOURNAL OF PLASTIC SURGERY growth of the maxilla. The facial angle and the convexity must be considered together. The Width of the alveolus was measured with callipers at the level of the first molar. This instance was also expressed as a percentage of the nasion-sella distance. Other measurements were taken to study the vertical growth of the maxilla but they are not recorded in this article. Speech Function.--For the purposes of comparison it was necessary to classify the cases according to the quality of the speech. This was done in general terms only. An attempt was made to determine the cause of the imperfection when it was present. If the speech was so poor that most of the words were unintelligible then it was defined as " bad " speech. If it was intelligible only with great concentration owing to the mispronunciation of most of the consonants and some of the vowels it was regarded as "fair" speech. In "good" speech there was trouble with only one or two consonants such as "s" and "sh," whereas "perfect" speech was indistinguishable from normal. Two main groups of patients were available for study. In the larger group the palates had been repaired by the simpler Langenbeck (I86I) procedure, at various ages, mostly after the age of 2½ years. Patients with complete clefts had lip repairs at 6 months of age, on the average, and in bilateral cases both lip clefts were dealt with at the same operation. No attempt had been made to close the anterior part of the palate at the first operation, nor were vomer flaps elevated to repair the floor of the nose. These cases and also the post-alveolar clefts were repaired by a Langenbeck type of operation, again without elevation of mucosal flaps on the nasal side of the palate. The other group of cases had been managed by the techniques described by Veau (I93 I) and Ward_ill 0928, x94o). The lips of the complete cleft cases had been repaired, on the average, at 5 months of age, and at the same time the anterior part of the palate had been repaired. The posterior part of the palate was then repaired at about I8 months of age by the method of Veau, with two long mucoperiosteal flaps, or by the method of Wardill with four short flaps. Flaps of nasal mucosa were elevated and sutured in a separate layer. RESULTS The clinical records of 254 cases were studied and x65 patients were examined in detail. Of the 254 cleft palates I22 were of the post-alveolar type, seventy being in female patients and fifty-two in male. Of the I32 with complete clefts fifty were female and eighty-two male. Forty-four of these complete clefts were bilateral and of the eighty-eight unilateral cases the cleft was more commonly found on the left than on the right side. Speeeh.--A definite difference was found in the quality of the speech between those whose palates had been repaired before the age of 2 years and those cases where satisfactory repair had not been achieved until after 3 years. Of the former group of cases twenty-five had perfect, twenty-three had good, and five had fair speech, and none spoke badly, whereas of those repaired after 3 years of age fifteen had perfect, thirteen had good, thirty-three had fair, and fourteen had bad speech. These results are shown graphically, along with more detailed analyses, in Figs. 3 and 4. It will be seen that, as expected, the post-alveolar cases have

5 OPERATIONS ON CLEFT PALATES: MAXILLARY GROWTH AND SPEECH FUNCTION 233 better function than the children with complete clefts. The results are very much the same for patients operated upon under 2 years of age whether the operation was done by Wardill's or Langenbeck's technique. It was hoped to draw some conclusions about the speech func- POST-ALVEOLAR CLEFTS tion after a breakdown and a double operation on the soft palate. As the EXCELLEN~ GOOD FAIR BAD EXCELLENT GOOD FAiR BAD OPERATION BEFORE 2½ YEARS OPERATION AFTER 2½ YEARS COMPLETE E CEtLENT GOOO FAI~ BAD EXCELLENT GOOO PAIR ~AO OPERATIONS BEFORE SECOND OPERATIONS AFTER THIRD EXCELLEm GOOO FAIR BAO EXCE~LEN~ GOOD fair B~O BIRTHDAY BIRTHDAY OPERATION BEFORE 2 YEARS OPERATION AFTER 2 YEARS FIG. 3 FIG. 4 Fig. 3.--Diagram showing the effect of timing on the speech results. This diagram illustrates results in I28 cases and includes complete and incomplete clefts, but in each group the ratio of the two types is very nearly equal. Fig. 4.--Diagram showing the effect of timing of the operation on the speech results in complete and incomplete cleft palate patients shown separately. Besides illustrating that the younger age groups have better speech in each case, it shows the superiority of the result in post-alveolar clefts. number of unsuccessful operations in any particular group of patients is small it is impossible to give a definite answer. However, no marked deterioration in the expected quality of the speech occurred as the result of breakdowns. Cephalometry.--For the purposes of comparison the patients were divided into five groups :-- I. Complete clefts repaired before the age of 2 years by Wardill's method-- twenty-three cases. 2. Complete clefts repaired before the age of 2 years by Langenbeck's method --thirteen cases. 3. Complete clefts repaired after the age of 3 years by Langenbeck's method --twenty-nine cases. 4. Post-alveolar clefts repaired before the age of 21 years by Wardill's method --nine cases. 5- Post-alveolar clefts repaired after the age of 21 years by Langenbeck's method--twenty cases. Normal children with ages corresponding to the cleft palate cases were X-rayed and the means of the measurements for these and for the cleft palate cases are shown in the table. It will be seen that for the cases with complete

6 234 BRITISH JOURNAL OF PLASTIC SURGERY alveolar clefts certain measurements are given for unilateral and bilateral cases separately. When the cleft is bilateral the premaxilla is displaced and its complete reposition is rarely achieved, so that measurements of the facial angles will give a wrong impression of the forward growth of the maxilla. All the measurements have been subjected to statistical analysis and various significant differences were found between the various groups of patients. When all the patients with complete unilateral clefts (Groups I and 2), operated upon when less than 2 years of age, are compared with the normal, it will be seen that the mean length of the hard palate is only 56.1 per cent. of the nasion-sella distance compared with the normal of per cent. This represents an absolute difference of about 6 ram. The width between the alveoli is also considerably less, with an actual difference of about 3.6 ram. in the average case. That the shortness of the hard palate is due to the lack of postero-anterior growth is indicated by the examination of the S-N-A angle, the facial angle, and the convexity. The angle of convexity and the facial angle are 6" 7 and 4"1 degrees less than the respective normal measurements. The means of the S-N-A angles show a reduction of 3"5 degrees in the cleft palate patients. It is clear that an operation before the age of 2 years does not result in any reduction of the length of the soft palate. The soft palate length is 5o-4 per cent. of the nasion-sella distance in the normal group and 5I'I per cent. in this group with complete clefts. If in this age group of patients with complete clefts the results of Wardill's methods are compared with those of Langenbeck's operation it is found that the latter are slightly better as far as maxillary growth is concerned. The hard palate length, the S-N-A angle, facial angle, and convexity show less reduction than after Wardill's operation. On the other hand there is no significant difference in the lengths of the soft palates, indicating that the apparent lengthening at the time of the operation is subsequently lost, probably due to fibrosis. When the measurements of the patient with the incomplete clefts repaired before the age of 2½ years are considered it is seen that again there is a marked reduction in the postero-anterior growth and that the soft palate length is not affected. As perhaps would be expected, when the alveolar arch is intact the width shows no significant change from normal. The complete clefts operated upon after 3 years of age and the incomplete ones repaired after 2½ years of age were all subjected to Langenbeck's operation. It will be seen that there is reduction in the forward growth as indicated by the hard palate length and the angular measurements. The figures for the incomplete clefts show slightly better development. The widths of the alveoli in these cases are normal. However, in this group, operated upon when older, there is a significant reduction in the soft palate lengths. In the complete clefts the length was 39 per cent. and in the incomplete clefts 4 per cent. of the nasion-sella distance. This is equivalent to a reduction by one-fifth of the normal length. Groups 2 and 3 can be compared to determine if the age of the child at operation affected the degree of maxillary growth. Although the figures in Group 2 reveal a slightly greater reduction in development, these differences are not significant. It must be pointed out that the majority of cases in Group 3 had been repaired before 5 years of age, and it may be that if the operation were postponed even further a substantial improvement in maxillary growth might

7 OPERATIONS ON CLEFT PALATES: MAXILLARY GROWTH AND SPEECH FUNCTION 235 result. Five patients were found whose operations had been delayed until after their first decade. The means of the measurements of this small number FIG. 5 FIG. 6 Fig. 5.--End result of an operation at sixteen months of age on a patient with a complete cleft palate showing poor maxillary growth. Fig. 6.--Radiograph of patient shown in Fig. 5. Lack of postero-anterior growth of the maxilla and crowding of the teeth are seen. Fig. 7.--Another patient with maxillary recession due to operation on a complete cleft palate. FIG. 7 approximated to the rest of the group and certainly were significantly less than the normals. For this purpose Groups 4 and 5 can also be compared. Although Group 4 cases were operated upon by Wardill's method, in the case of post-alveolar clefts

8 236 BRITISH JOURNAL OF PLASTIC SURGERY the operation is very little more radical than Langenbeck's operation and the comparison is a useful one. Again there is no difference in the maxillary growths although the difference in the lengths of the soft palate is very marked. Operative Mortality.--It was found that of eighty-nine cases repaired by a flap method before the age of 2 years, five had died from causes which appeared to be related to the operation. Out of 164 cases operated upon by the simpler techniques only one had died. This difference in mortality would appear to be mainly due to the early operative interference and partly to the increased severity of the operation. Table showing the Mean Measurements of the Facial Skeleton and Palate in Normal Children and in Five Groups of Children with Cleft Palates 1 Normals Complete Clefts-- Group I : Repaired before 2 years of age Wardill's method. Group 2 : Repaired before 2 years of age Langenbeck's method All complete clefts repaired before 2 years of age Group 3 : Repaired after 3 years of age Langenbeck's method Incomplete Clefts-- Group 4 : Repaired before 2~ years of age, Wardill's method Group 5 : Repaired after 21 years of age, Langenbeck's method Hard Soft Palate Palate I Width. Length Lergth. r cent. I Per cent. I Per cent. 67 "7 5 '4 i "9 55"I 50"9 -/ [- 58"I 5[' 5 59"I 51"2 j~79'7 ~ 56"1 51"1 77"7 60 "2 39 -o i i; o 8I.6 J 55" " o 85 "7. Convexity. Degrees. + IO ateral) + I4'4 teral) +11'2 ateral) +IS"I teral) +4"o +6"6 ateral) + 12"8 teral) [0" The lengths and widths are expressed as a percentage of the nasion-sella distance. S-N-A Angle.,yees 76 ' "9 76 "4 76 "7 78 "4 77;9 77 "4 DISCUSSION Speeeh.--When the palate was successfully repaired before the age of 2 years the speech was undoubtedly superior to that in cases completed after the age of 3 years. This superiority is due to greater length, better muscular development, and increased mobility of the palate. These features are in all probability due to the early establishment of natural function. The soft palate does not act purely as a flap. It is the middle third of the velum, at about the level of the attachment

9 OPERATIONS ON CLEFT PALATES : MAXILLARY GROWTH AND SPEECH FUNCTION 237 of the levatores palati, which approximates to the postero-superior wall of the nasopharynx (Fig. 8). Nevertheless if the soft palate is short it is impossible to produce satisfactory closure (Fig. 9). Brophy suggested that the soft palate was diminished in power and reduced in length because of stretching due to increased width between the maxillary tuberosities and pterygoid hamuli. Wardill and others measured a series of old skulls with cleft palates and compared them with normals, and showed that there was a significant widening of the posterior part of the alveolus. It seems likely that these clefts had never been repaired, however, and the unopposed pull of the external and to some extent of the internal pterygoid muscles would produce a widening of the arch. In this series the widths of repaired palates were either normal or reduced. FIG. 8 FIG. 9 Fig. 8.--A cephalogram of a normal subject showing the approximation of the middle third of the soft palate to the postero-superior pharyngeal wall during phonation. Fig. 9.--Cephalogram of a repaired palate showing a soft palate deficient in length with a well-developed Passavant's ridge opposite the atlas vertebra. This overdevelopment was seen only in patients with deficient palates. It does not seem likely that increased width between the maxillary tuberosities plays any part in the lack of development of the soft palate if the palate is repaired in the first half of childhood. Wardill considered that it was essential to produce an intact palate before the child began to speak, otherwise bad speech habits developed and were difficult if not impossible to eradicate. Although abnormal methods of articulation are certainly fostered by delaying operation it is doubtful if they are ever the cause of permanently poor speech. Causes could always be found on clinical and X-ray examination in cases with inadequate speech. It appears that there is an actual failure in development of the cleft velum. The muscle slings which lift the intact

10 238 BRITISH JOURNAL OF PLASTIC SURGERY palate are then divided in the centre. Instead of a combined action which pulls the palate upwards and backwards, the muscular forces act separately and pull the halves of the soft palate upwards and outwards. The muscle fibres become shortened and, furthermore, lacking the counter-attraction of the muscle on the opposite side, fail to grow. A similar situation arises in an amputation stump when the muscles atrophy. It would therefore appear advisable to provide a normally functioning soft palate as soon as possible in order to obtain a welldeveloped muscular action and the best speech results. Maxillary Growth.--Graber claimed that after operations on the cleft palate the development of the maxilla in the anterior and vertical directions was less than in normal persons and ascribed it to interference with the blood supply. In this series restriction of growth in the horizontal plane was found, but in the vertical direction the growth was normal. At similar ages a more extensive operation reduced development more than a simple one. It is difficult to believe that the blood supply is ever seriously curtailed, and even if local bony surfaces should be rendered temporarily ischmmic the mucosal flaps very rapidly reapply themselves in a child and bring back the blood supply. No restriction of growth results from turning bone flaps, which are rendered completely bloodless, in the skulls of growing infants. A large proportion of the blood supply to the very cancellous bone in the upper jaw is never cut off, even in the most radical operations. The mucosa covering the alveoli, the lateral wall of the nose, and the lining of the maxillary sinuses is not interfered with. The posterior and lateral walls of the maxilla remain untouched, leaving intact the infraorbital and the sphenopalatine arteries, and the posterior superior dental arteries which supply the upper alveolus. It seems much more likely that the growth is restricted by the fibrous tissue which results from the operation. All the observed phenomena can be produced by such a mechanism, and it explains the full development in the vertical plane. Unilateral complete clefts often show a typical deformity of the alveolus in which the maxilla on the cleft side is rotated and the anterior end lies behind the premaxilla (Figs. IO and ii). In bilateral clefts the operation often causes approximation of both maxillary segments behind the premaxilla which effectively prevents backward movement of the latter into line with the alveolar arch. These movements are most easily explained by the concept of restriction of growth due to fibrosis. There is some evidence that whenever the operation is performed the width of the upper jaw is decreased. Even in adult patients a narrowing of the alveolus has been observed after a repair. This illustrates the tremendous results of the contraction of fibrous tissue. Graber divided his patients into groups according to the age at which they had their operations and showed that the earlier the operation the greater was the degree of deformity. He also pointed out that most of the maxillary growth occurs before 5 years of age and suggested that any operation should be postponed until after that age. It would appear that the evils of early and of traumatic operations were combined and particularly apparent in his series of cases because they contained a number treated at an early age by the drastic methods of Brophy. This review suggests that the restriction of growth, although serious, has been overemphasised, and that it can be minimised by performing the simpler types of operation. From a separate examination of the partial post-alveolar clefts

11 OPERATIONS ON CLEFT PALATES: MAXILLARY GROWTH AND SPEECH FUNCTION 239 it is clear that the lack of growth is small and that a simple operation performed at about I year of age can be expected to give very satisfactory speech and also a well-developed upper jaw. The cases in this series do not show any significant increase in the restriction of growth if operated upon when under 2 years of age compared with those operated upon between 3 and 5 years of age. Various recommendations have been made to prevent these deformities. The wiring operations have been abandoned. Slaughter and Brodie (1949) have suggested that there should be no unnecessary trauma to soft tissues nor fracturing of bone, and that stripping of periosteum should be limited as far as possible. Huffman and Lierle (1949) have advised against the elevation of mucosal flaps from the inferior aspect of the palate when repairing the anterior part of the palate. They make incisions along the free edges of the cleft and vomer, and after FIG. IO FIG. II Fig. io.--models of patient now aged I6 years. His palate was operated on when he was aged 18 months for a left-sided unilateral complete cleft. The left half has rotated inwards and its anterior end lies behind the premaxilla. 51 is displaced medially. Fig. I I.--Malocclusion seen in a boy aged 6 years. He had a bilateral complete cleft, and operations were performed on the lip at 5 months of age and on the palate at 16 months, 22 months, and 27 months of age. Both maxillary segments are rotated so that their anterior ends lie behind the premaxilla and have prevented its full replacement. flaps are elevated from the nasal side they are sutured. The oral aspect is left as a triangular granulating surface. It appears that a good deal of fibrosis will result even with this less extensive operation. No difference in the operative mortality after Langenbeck's operation was

12 240 BRITISH JOURNAL OF PLASTIC SURGERY found between the different age groups. However, after Wardill's operation, performed before the age of 2 years, there was an increased mortality. Until some new line of treatment for complete clefts can be tried a choice must be made between function and appearance. It would appear to be preferable to sacrifice the latter to some extent in favour of function. This means a programme designed to produce a repaired palate by the age of 18 months, using the simplest operation possible. As an alternative it would seem logical to repair only the muscular part of the palate soon after birth. Little operative trauma need be inflicted and the operation is facilitated by the cleft in the lips, which could be repaired a few weeks later. Such an operation allows natural development of the muscular tissues and perhaps normal positioning of the posterior edge of the hard palate which in cleft cases is displaced forwards. At about the age of 3 years a prosthesis could be used to close the anterior part of the cleft. It would also serve to prevent the rotation of the maxillary segments behind the premaxilla. Thus normal growth of the upper jaw would occur and finally, between the ages of 5 and Io years, the hard palate could be repaired with the minimum risk of restricted growth. SUMMARY A review of patients with cleft palates is presented. They were operated upon at different ages by different techniques. The quality of the speech, the development of the bone of the maxilla, and the length of the soft palate were assessed. The speech function, which was found to be related to the development of the soft palate, was better after operations performed before 2 years of age than following operations performed after 3 years of age. There was a significant reduction in the length of the soft palate in the patients whose operations had been performed later. The speech was better in subjects born with a post-alveolar cleft than in subjects born with a complete cleft, but it did not appear to be influenced by the type of operation. Some clefts had been repaired by the simple technique of Langenbeck and some by the more complicated techniques of Veau and Wardill. The reduction in maxillary development due to the operations was confirmed and it was found to be more important in the case of the complete clefts than in the incomplete ones. Some reduction occurred no matter when the operation was performed, and it appeared to be due to fibrosis rather than to bone ischmmia. The amount of reduction was not found to be influenced by the age at operation, but the range of ages in the cases suitable for comparison was small in this series. Operations on cleft palates should therefore be as simple as possible, and it seems unnecessary to lift and suture flaps of nasal mucosa. The soft palate should be repaired as soon as possible, and in the case of clefts involving little more than the soft palate the repair should be performed during the first year. The complete cleft presents a more difficult problem, but it would seem practicable to repair the soft palate alone at the age of a few months and the hard palate a few years later. Alternatively the whole cleft should be repaired at about I8 months of age in order to obtain the best speech results at the risk of some maxillary deformity.

13 OPERATIONS ON CLEFT PALATES: MAXILLARY GROWTH AND SPEECH FUNCTION 24I This investigation was undertaken during the tenure of a Cow ~ Gate Research Fellowship in the Department of Child Health, University of Manchester. I wish to thank the surgeons of the Royal Manchester Children's Hospital and the Duchess of York's Hospital for Babies, Burnage, for permission to examine their patients, and the staff of the X-ray Department at the Children's Hospital for their co-operation. I am also indebted to Mr T. Cradoc Henry, F.D.S.R.C.S., and the Photographic Department ~f the Hospital for Sick Children, Great Ormond Street, for two of the photographs. REFERENCES BROADBENT, B. H. (1931). Angle Orthodont., 1, (1937). Angle Orthodont, 7, 183. BRODIZ, A. G. (1941). Amer. ft. Anat., 68, 2o9. BROPH, T. W. (1898). lnt. Dent. ft., Philad., i9, (19Ol). Dent. Cosmos, 43, (1923). "Cleft Lip and Palate," p Philadelphia : P. Blakst0n, Son & Co. FEDERSPIEL, M. (1923). Proc. Amer. Soc. Ortho., p. 69. FRY, K. (1925). Dent. Rec., 45, 30. GRABER, T. M. (1949 a). Quart. Bull. Northw. Univ. reed. Sch., 23, 153. (1949 b). Surg. Gynec. Obstet., 88, 359. HUFFMAN, W. C., and LIERLIE, D. M. (1949). Plast. reconstr. Surg., 4, 489 HULLIHEN, S. P. (1844). Amer. ft. Dent. Sci., 5, 166. KIRKHAM, H. L. D. (1931). Int. ft. Orthod., 17, lo76. LAN~ENBECK (1861). Dtsch. Klin., 50, 231. ORTIZ, M. H., and BROI)IE, A. G. (1949). Anat. Rec., 1o3, 311. PEYTON, W. T. (1931). Arch. Surg., 22, 7o4. RAYNER, H. H. (1925). Brit. dent. ft., 46, 591. SLAUGHTER, W. B., and BROBIE, A. G. (1949). Plast. reconstr. Surg., 4, (195o). ft. Pedlar., 37, 4oo. SMITH, T. (1867). Brit. ft. Dent. Sci., 1o, (1868). Dent. Cosmos, 1o, 159. VEAU, V. (1931). "Division Palatine." Paris : Masson et Cie. WAm~ILL, W. E. (1928). Brit. ft. Surg., 16, (194o). Brit. dent. ft., 68, )