Treatment VariablesAffecting Growth in Unilateral Cleft Lip

Treatment VariablesAffecting Growth in Unilateral Cleft Lip and Palate. Part 5: Timing of Palate : Cephalometric radiographs of a sample of 538 males with complete unilateral cleft lip and palate were analyzed to determine the effect on facial growth of the patient's age at the time of palate repair. The least interference with growth was noted in cases with no hard palate repair or repair in the late teens. There were few significant variations in facial growth following repair prior to this regardless of the age, although the early repair group (repair prior to 12 months of age) seemed to have slightly better facial growth than the others. The delayed hard palate repair group (repair at 4 to 9 years) was slightly worse. Other variables prevent a more definitive conclusion. Surgical repair of the hard and soft palates has enormous functional implications for the child with cleft lip and palate. The eventual quality of the child's speech, facial growth, mastication, and breathing are directly or indirectly dependent on the effectiveness of the surgery provided. Other factors are, of course, of great importance e.g., the genetic potential, the intrinsic dysplasia, the child's intelligence and motivation, and secondary procedures. There is no more effective way, however, of achieving the best possible result than by providing excellent initial palate surgery. Clinicians will affirm that it is extremely difficult to rectify the results of unsatisfactory initial surgery. There are only three requirements of palate surgery: 1. To provide a soft palate that will achieve velopharyngeal closure on demand (satisfying the demands for responsiveness, mobility, size, position) and will not interfere with normal respiration To separate the oral and nasal cavities._ To inhibit growth as little as possible. This may seem to be a negative way to state the requirement, but it follows from earlier discussion, which concluded that all surgery in this area inhibits growth to some extent. G hbj The literature is confusing on the "'best'" way to accomplish these goals. The two major areas of contention are how to manipulate the tissues and when. Graber's classic study (1949), although considering the results of surgery that was rather crude by today's standards, first proved what many clinicians of the time realized, but most refused to admit. He concluded that surgery could severely inhibit midface growth, and that most of the midfacial growth problems in clefts 34 were related to the surgery. Subsequent studies have refined the concepts somewhat, although we are still dealing in hypotheses based on limited experimental work and clinical observation (Ross, 1970; Kremenak, 1984). Interference with the growth of the facial skeleton following cleft palate surgery would be the result of scar tissue formation on critical areas, rather than damage to the growing bone itself. Anteroposterior and vertical growth of the midface depend on a number of different growth mechanisms. The maxilla moves forward bodily, (although at present the stimulus or growth force is not completely understood). As it does so, bone is laid down by apposition in convenient places (i.e., in the sutures and on the maxillary tuberosity). During growth, there is actually resorption of bone in the anterior basal area to permit remodeling of the surface (Bjork, 1966; Enlow, 1968). The post-tuberosity structures (pterygoid plates, pyramidal process of palatine bone) do not contribute to anteroposterior development of the face, so that the pterygomaxillary fissure (PTM in cephalometrics) appears to descend vertically from the cranial base in longitudinal growth recordings. The freedom of movement of the maxilla can be restricted by various means (Wieslander, 1963; Jakobsson, 1967; Droschl, 1973), and the amount of forward protrusion of the maxilla can be reduced. One theory of abnormal growth in cleft lip and palate (Ross, 1970) is that excessive postoperative scar tissue adjacent to the pterygopalatinetuberosity sutures can inhibit the forward movement of the maxilla and thus reduce maxillary length. Vertical growth of the maxilla is mainly dependent on apposition of bone on the superior

Ross, Timing or PaALATE Repa 55 surfaces, enormous increase in alveolar bone associated with the teeth, and an inferior apposition-superior resorption process which ''lowers'' the palate. Excess scar tissue in the palate may inhibit the vertical eruption of the teeth by anchoring the periodontal fibers that are attached to the teeth. Another important element in the establishment ofjaw function is the dentoalveolar adjustment mechanism. Pressure on the teeth cause them to move to establish an equilibrium of forces. They do this by resorption of alveolar bone relative to the compressed periodontal structures and a build-up of alveolar bone in response to a stretching of the periodontal fibers. Here again, the presence of scar tissue in the palate will interfere with this adjustment mechanism (Ross, 1970). Teeth are guided palatally by the anchored periodontal fibers as they continuously erupt, accounting for most of the posterior crossbites that develop over the entire growth span of the individual with a repaired cleft palate. The traditional timing of hard and soft palate surgery has until quite recently been between 15 and 24 months. This appears to have been an empiric decision that evolved and was passed on from one generation of surgeons to the next. There was no satisfactory evidence that a change in this timing would affect either speech or facial growth, although there was theoretical and anecdotal evidence that would persuade most clinicians to maintain this timing as a good compromise between speech and growth requirements. The philosophy of repairing the soft palate for speech requirements but delaying the hard palate repair to reduce growth inhibition was introduced by Gillies and Fry in 1921 and was introduced to clinical practice by Schweckendiek in the 1940s when he delayed hard palate repair into the adolescent years (Schweckendiek, 1978). Robertson and Jolleys (1974) reported on the results of a compromise delayed hard palate repair, and Hotz and her associates (1978) have made the delaying of hard palate repair until the early mixed dentition an acceptable, widely used practice. It is interesting that the very similar delayed hard palate techniques adopted by Jolleys and Robertson in Manchester and by Hotz and Perko in Zurich have apparently achieved very different results. The technique had long been abandoned in Manchester as being unsatisfactory, but was being enthusiastically promoted by the Zurich group. Evidence for the value of these procedures has been scanty, although Olin (Bardach et al, 1984) provided good evidence that facial growth using the Schweckendiek procedure was excellent. Blijdorp and Egyedi (1984) found no difference between the results when the hard palate was repaired at 3 years or 6 years of age. Late repair in theory should be less damaging than early repair, on the assumption that the more growth that has occurred, the less there remains to interfere with. There has, however, been no adequate evidence to support the theory that growth will be improved by delaying surgery for several years (Witzel et al, 1984). Meanwhile, many speech scientists have been less than enthusiastic, particularly in North America, about the results of delaying surgery past the age of early speech development (Dorf and Curtin, 1983; Witzel et al, 1984). This paper investigates the effect on facial morphology of variation in the timing of hard and soft palate repair. SAMPLE The sample of 538 males with complete unilateral cleft lip and palate and the method of investigation have been described in detail in the initial paper of this series. There were five obvious divisions of the sample based on the timing of palate surgery (Table 1). They were: 1. Early. There were 44 cases with hard and soft palate repair completed at 11 months of age or earlier. The alveolus had been repaired in 77 percent of these cases. 2. Medium. There were 211 cases with hard and soft palate repair completed between the ages of 12 and 20 months. The alveolus had been repaired in 27 percent of these cases. 3. Late. There were 129 cases with hard and soft palate repair completed between the ages of 21 and 33 months. The alveolus was repaired in 39 percent of these cases. 4. Delayed Hard Palate (Delayed HP). There were 35 cases with early soft palate repair and with hard palate repair completed between the ages of 4 and 9 years. The Zurich and Manchester samples comprised this group. The alveolus was repaired in 49 percent of these cases. 5. Unoperated Hard Palate (Unoperated HP). There was a group of 52 cases, many of whom had early soft palate repair, but none had hard palate repair more than 1 year prior to the availability of cephalometric records. All of the Unoperated sample and practically all of the Marburg sample were in this category. There were no cases of alveolus repair recorded. There were some problems with the ages of the samples, as the Delayed HP subjects were very young (oldest usable mean age 11.0 years) while the Unoperated HP subjects were older (youngest usable mean age 19.6 years). For-

56 Cleft Palate Journal, January 1987, Vol. 24 No. 1 TABLE 1 Palate Surgery and Alveolar * Alveolar Group N Centers** (%) Early (<11 mo) 44 Au:3lt, ML:9, Ch:3, TL:1. 77 Medium (12-20 mo) 211 TB:84, TL:51, Pe:20, St:16, 27 TO:14, Ch:12, MIl:5, Up:4, Au:3, Os:2 Late (21-33 mo) 129 TB:40, Co:34, Os:23, Up:19, 39 St:7, TL:4, Co:1, Pe:l Delayed HP (4-9 yr) 35 Mn:18, Zu:17 49 Unoperated HP 52 Mr:33, Un:19 0 Total 471 34 * The sample used in this study is broken down into the age palate surgery was completed, and whether alveolar repair was carried out ** Au=Auckland, Ch=Chicago, Co=Copenhagen, Go=Goteborg, MlI=Malmo, Mn=Manchester, Mr=Marburg, Os=Oslo, Pe=Perth, St=Stockholm, TB=Toronto Base, TL=Toronto Lindsay, TO=Toronto Orthopaedic, Up=Uppsala, Un=Unoperated { The samples from the Centers in italics had alveolar repair tunately, other controls and the Toronto Standards were available. The other three groups were more flexible, and comparable mean ages could be established. Some preliminary analysis of the sample was necessary to form the groups listed above. The samples from Manchester and Zurich were compared to assure that they were sufficiently similar to justify being pooled to form the Delayed HP group. The Marburg and Unoperated samples were compared as well to justify pooling to form the Unoperated HP group. Unfortunately, the anterior region of the maxilla was influenced by the surgical management of the alveolus, and it was previously noted in this series that anterior vertical height of the maxilla was particularly sensitive to alveolus repair. The critical measurable effects of palate surgery were on maxillary length and protrusion, pharyngeal depth, dentoalveolar horizontal development and posterior maxillary height. FINDINGS METHOD The morphological differences between groups of cases receiving growth-inhibiting surgery to the hard and soft palate compared to groups receiving less damaging repair would be expected to manifest as disturbances in the following areas: 1. Anteroposterior maxillary position: The measurement basion to posterior maxillary point (Ba-PMP) indicated this. 2. Anteroposterior maxillary length: indicated by PMP-ANS. 3. Maxillary protrusion: which was the combination of maxillary length and position as indicated by Ba-N-ANS. 4. Anteroposterior development of maxillary dentoalveolar process: indicated by the measurement PMP-A Pt and Ba-N-A Pt. 5. Vertical development of the maxillary dentoalveolar process: indicated by the measurement ANS-1. 6. Vertical maxillary position: The measurement registration point to posterior maxillary point (R-PMP) would express the posterior development, and nasion to anterior nasal spine (N-ANS) would define the anterior development. Delayed HP: Manchester and Zurich Samples These two samples are compared in Table 2 and Figure 1. The length and protrusion of the maxilla was essentially the same, the slight difference of 0.6 mm and 0.4 degrees favoring the Zurich sample. The mandible was 5.6 mm larger in the Manchester sample (significant at the 0.005 level), with a 4.8 degree more open mandibular plane, (significant at the 0.003 level), which gave slightly more protrusion and much greater lower face height (by 2.1 mm). The jaw relations were more favorable in the Zurich sample (0.9-degree ANS-N-Pog difference, 1.4-degree ANB angle difference). Anterior maxillary vertical development was much greater in the Manchester sample (by 2.5 mm, 0.003 level of significance) as was posterior maxillary height. The vertical facial proportions were better in the Zurich sample, with the midface contributing an excellent 43.2 percent to total face height against the Manchester sample's 42.5 percent. The plots indicate that there was excellent congruence of the cranial base and other landmarks such as nasal bone, articulare, ramus, and condyle. In the anteroposterior plane, PTM, PMP, and ANS coincided. The major difference in morphology was related to the vertical dimen-

Ross, Timing or PaALATE REPAIR 57 TABLE 2 Comparison of the Two Delayed Hard Palate Samples (Manchester and Zurich) and the Two Unoperated Hard Palate Samples (Marburg and Unoperated) Mn-Zu Mr-TB Un-TB Mr-Un Data Mn* Zu Difference Difference Difference Difference Sample size 18 17 33-125 19-57 Mean age (yr) 10.8 10.7 15.2-15.3 27.2-19.1 Cranial Base Angle (N-S-Ba)(degrees) 47.4 48.0-0.6-0.4 -O0.8 0.4 Proportion (N-S/N-S-Ba) 61.4 61.8-0.4-0.7-0.4-0.3 Length (N-Ba)(mm) 105.5 107.1-1.6 4.3-7.] 12.0 Area (cm2)** 10.9 11.2-0.3 0.5-0.9 1.4 Adjusted Linear Measurements Pharynx (Ba-PMP)** 39.9 39.9 0.0 1.5 0.4 1.1 Maxilla (PMP-ANS)** 50.2 50.3 -O.1 0.6 1.0-0.4 Maxilla (PMP-A Pt)** 44.6 45.2-0.6 2.4 1.0 1.4 Ba-ANS** 90.1 90.2 -O.1 2.1 1.4 0.7 Ba-A Pt** 84.1 84.9-0.8 3.9 1.8 2.1 Ba-UI** 86.7 87.4 -O0.7 3.7 2.8 0.9 Ba-LI** 87.2 85.1 2.1 1.6 1.9-0.3 N-ANS** 47.9 45.2 2.7-0.6 1.2-1.8 N-ANS/N-Men 42.5 43.2-0.7 0.5-1.1-1.6 ANS-UI/N-Men 25.1 24.8 0.3 0.3 1.9-1.6 Men-LI/N-Men 34.9 35.5-0.6 0.7 0.3 0.4 Mandible (Co-Gn)** 106.2 100.4 5.8-1.5 5.7-7.2 Angles (degrees) Ba-N-ANS 64.0 64.4-0.4 2.6 1.5 1.1 Ba-N-A Pt 57.2 58.1-0.9 4.2 1.8 2.4 Ba-N-UI 57.2 58.6-1.4 3.2 1.2 2.0 Ba-N-LI 57.7 57.1 0.6 1.6 0.8 0.8 Ba-N-B Pt 55.9 55.4 0.5 0.9 0.9 0.0 Ba-N-Pog 57.0 56.5 0.5 0.4 0.8-0.4 N-UI-UI apex 13.5 14.3-0.8 ~-4.8-3.8 1.0 SNA 75.1 76.1-1.0 4.3 1.6 2.7 SNB 73.9 73.4 0.5 1.1 0.8 0.3 ANB 1.2 2.7] -1.5 3.2 0.9 2.3 Mandibular plane 57.8 53.0 4.8-0.7 0.7-1.4 Nasal bone angle 102.7 102.9-0.2 0.7 2.3-1.6 + Toronto Standards Maxilla (Ba-N-ANS) -0.3 0.1-0.4 2.5 1.5 1.0 Mandible (Ba-N-Pog) 0.5 0.0 0.5 0.6 0.8-0.2 AP Jaw (ANS-N-Pog) -0.8 0.1-0.9 2.0 0.7 1.3 AP Jaw (ANB) -1.4 0.0-1.4 3.2 0.9 2.3 Maxilla height** 0.8-1.7 2.5-0.6 1.2-1.8 Lower face height 0.7-1.4 2.1-1.6 1.8-3.4 * Mn=Manchester, Zu=Zurich, Mr=Marburg, TB=Toronto Base, Un=Unoperated ** Raw measurements adjusted by dividing by cranial base length (N-Ba) and multiplying by 100. sions of the face. The maxilla showed greater vertical height both at PMP and ANS; the mandible was much longer and more open. The occlusal plane was in an intermediate position relative to maxilla and mandible. The only significant differences between the two samples were: (1) the mandibular size, which was probably also responsible for much of the vertical changes and influenced anteroposterior relations; and (2) the anterior maxillary vertical height caused by alveolus repair. Earlier portions of this study established that: (a) the Manchester cases had had infant orthopaedic treatment with extraoral strapping, a technique that probably influenced the position of point A and, thus, the ANB angle and the position of the maxillary incisors; (b) the Zurich cases had remarkably small mandibles; and (c) mandibular size is probably not influenced by treatment. It was decided that the two samples could be legitimately pooled to form the Delayed HP group. Unoperated Hard Palate: Marburg and Unoperated Samples These two samples, with the least amount of surgery and with essentially no hard palate or alveolus repair, were very valuable for comparison with other methods of repair. There are variables that must be taken into consideration in comparing these two samples: 1. The Unoperated group were obviously neglected surgically, and the lip repair may not have been as expertly performed as in the Marburg group. > 2. Many of the Unoperated group wore obturators and partial dentures, probably from an

58 Cleft Palate Journal, January 1987, Vol. 24 No. 1 Delayed Hard Palate Zurich Sample 17 males 10.7 yr Manchester Sample ---- -- 18 males 10.8 yr / relatedto this, which in turn led to less favorable vertical proportions. The alveolar development (A point) in the Marburg sample was excellent, but the Unoperated subjects had lost many teeth and this landmark was less dependable. Since the greatest differences were associated with the mandible and the maxillary A point, it was considered justified to pool the two samples UCLP Palate Marburg Sample 33 males 15.5 yr Toronto Base -- -- -- ~~~-. ~-\~_ A *--s. 125 males 15.3 yr FIGURE 1 Comparison of the mean facial plots of the Zurich and Manchester samples, the two samples of Delayed hard palate repair. The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba. early age. It is difficult to ascertain what influence that might have on maxillary and facial growth. 3. The Marburg group had soft palate repair at an early age, which might influence the maxilla in anteroposterior growth and posterior vertical height and position. UCLP Palate Unoperated Palate Sample 19 males 27.2 yr 4. Many of the Unoperated sample had lost incisor teeth, which made the plots of the incisors inaccurate and the A point a less reliable Toronto Base Sample ------ landmark. 57 males 19.1 yr To permit comparison between these two samples, both were compared to the Toronto Standards and to Toronto Base at the appropriate ages (Figure 2, Table 2) i.e., Unoperated to Toronto Base adults and Marburg to Toronto Base at age 15.3 years. Both samples, especially Marburg, had better f/ basal jaw relations than the Toronto Base and excellent alveolus development. Vertical height of the maxilla was greater in the Unoperated, especially in the posterior region, but slightly less in Marburg. The fact that no posterior surgery was performed on the Unoperated may be the cause of the greater posterior maxillary vertical growth, w. aon'} ny FIGURE 2 A. Mean facial plots of Marburg unoperated but the soft palate repair may have somewhat restricted posterior maxillary vertical growth in the Marburg sample. The Unoperated sample had very large mandibles, 7.2 mm longer than the Marburg sample, and the excessive lower face height is probably hard palate sample compared to a Toronto Base sample at the same age. B. Mean facial plots of the adult Unoperated sample compared to a Toronto Base sample of adults. The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba.

' Ross, Timing or PaLATE RrEpair 59 and have one Unoperated HP group. The mean age of the pooled group was 19.6 years. This is accurate mathematically, but does not reflect the facial growth condition, since few measurements change after the late teen years. Thus, the old Unoperated sample raised the mean age without contributing additional growth. A more relevant mean age would be approximately 17 years for this sample, and that was used for subsequent comparisons. Age at Palate The data are presented in Table 3 and Figures 3 through 7. The differences in age of the groups were managed by using the Medium group as the standard and adjusting its age to correspond to the mean age of the other groups (Table 3). The Toronto Standards were also useful in this regard. Pharyngeal depths (Ba-PMP) were remarkably similar in all groups, except that this dimension was significantly greater (p <0.001) in the Unoperated HP group. The length of the maxilla (PMP-ANS) was also consistent, with the only difference being that the Early repair sample had a longer maxilla than the Late repair sample. The alveolus was more prominent in the Unoperated HP sample (p < 0.001) and less prominent in the Delayed HP (p < 0.05) and Late repair (p < 0.005) samples. Therefore, maxillary protrusion (Ba-N-ANS angle and Ba- ANS length) was most favorable in the Unoperated HP sample (p < 0.002 for both measure- TABLE 3 Effect of Variation in the Timing of Palate on Selected Measurements for Groups with Early (<12 mo), Medium (12-20 mo), Late (21-33 mo), Delayed Hard Palate (4-7 yr), and Unoperated Hard Palate. Age Differences Made It Impossible to Directly Compare All 5 Groups Delayed Data Early Medium Late Early Medium HP Unop HP Medium _ Sample size Mean age (yr) 44 15.2 195 15.3 127 15.2 40 11.0 192 11.3 32 11.0 52 19.6 123 17.3 Cranial Base Angle (N-S-Ba)(degrees) 47.7 48.8 48.8 47.4 48.4 47.8 47.7 48.7 Proportion (degrees) 61.4 60.8 60.5 1.8 61.3 61.3 60.1 60.6 Length (N-Ba)(mm) 112.9 112.3 110.0 106.6 107.0 107.3 112.8 115.3 Area (cm)* 11.7 12.0 11.8 10.9 11.3 11.1 1.9 12.3 Adjusted Linear Measurements Maxilla (PMP-A Pt)* 45.2 44.3 43.7 45.6 45.6 44.6 45.9 44.2 Ba-ANS* 90.7 89.6 89.1 90.5 90.2 90.0 90.6 89.1 Ba-A Pt* 84.5 83.8 83.0 85.2 85.3 84.3 86.0 83.0 Ba-UI* 88.6 88.5 88.5 87.2 87.5 86.9 91.7 88.7 Ba-LI* 88.0 87.4 87.6 86.6 86.6 85.7 89.0 87.7 Post. Mx. Ht. (R-PMP)* 39.3 41.4 41.5 37.6 40.0 40.0 43.4 41.9 Ant. Mx. Ht. (N-ANS)* 47.5 48.1 47.4 45.9 46.4 46.6 48.8 48.8 Lower face height 64.5 66.6 67.5 64.2 66.7 65.5 65.8 66.8 N-ANS/N-Men 42.8 42.6 41.7 43.2 42.7 43.2 42.7 42.5 ANS-UI/N-Men 24.4 24.4 24.6 25.2 25.1 24.8 25.5 23.9 Men-LI/N-Men 36.1 35.9 36.1 36.1 35.8 35.3 36.2 36.0 Maxilla area (cm?)* 25.7 26.0 24.5 21.8 22.7 22.7 26.9 27.7 Mandible (Co-Gn)* 107.3 107.6 108.1 102.7 103.2 102.8 109.3 109.3 Pharynx (Ba-PMP)* Maxilla (PMP-ANS)* 39.8 50.9 39.5 50.1 39.6 49.5 40.2 50.3 40.0 50.2 40.0 50.0 40.3 50.3 39.2 49.9 Angles (degrees) Ba-N-UI 58.9 58.6 58.7 58.3 58.3 57.8 60.5 58.6 Ba-N-LI 58.9 58.1 58.3 58.2 57.9 57.4 59.2 58.1 Ba-N-B Pt 56.9 56.0 56.0 56.3 55.7 55.7 56.9 55.9 Ba-N-Pog 58.7 57.4 57.6 57.5 56.5 56.8 58.2 57.6 N-UI-UI apex 16.1 16.5 18.7 6.3 12.7 13.4 12.3 18.4 SNA 75.7 75.7 75.0 76.2 76.8 75.5 77.9 74.8 SNB 75.0 74.8 75.0 74.0 74.1 73.8 75.6 74.8 ANB 0.7 0.9 0.0 2.1 2.8 1.7 2.3 0.0 Mandibular plane 53.4 55.7 55.7 35.9 56.1 54.8 55.5 55.7 Nasal bone angle 84.5 84.4 84.9 83.6 83.0 83.7 84.8 84.7 Ba-N-ANS Ba-N-A Pt 64.8 57.7 63.5 56.9 62.9 56.1 64.7 58.5 64.3 58.5 64.0 57.4 64.7 59.2 62.8 56.0 + Toronto Standards Maxilla (Ba-N-ANS) 1.9 0.7 0.0-0.2 2.2 Mandible (Ba-N-Pog) 1.5 0.1 0.4 0.3 0.3 AP Jaw (ANS-N-Pog) 0.1 0.2 -O0.7-0.5 1.9 AP Jaw (ANB) 0.4 0.7-0.3-0.9 3.3 Maxilla height* -1.4 -O0.8-1.5-0.6-0.5 Lower face height -2.1 -O.1 0.9-1.0 0.3 * Raw measurements adjusted by dividing by cranial base length (N-Ba) and'multiplying by 100.

60 Cleft Palate Journal, January 1987, Vol. 24 No. 1 Palate \ 12-20 Mo. 195 males 15.3 yr <12 mo ------ -- 44 males 15.2 yr Palate 12-20 Mo 195 males 15.3 yr 21-33 Mo ------ --- 127 males 15.2yr FIGURE 3 Comparison of the mean facial plots of the Early repair group (repair prior to 12 months of age) and the Medium repair group (repair between 12 and 20 months of age). The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba. FIGURE 4 Comparison of the mean facial plots of the Late repair group (repair between 21 and 33 months of age) and the Medium repair group (repair between 12 and 20 months of age). The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba. Palate 12-20 Mo 192 males 11.3 yr Delayed Hard Palate --- -- 32 males 11.0 yr Palate \\ 12-20 Mo N 123 males 17.3 yr \ Unrepaired HP ----- & 52 males 19.8 yr \ FIGURE 5 Comparison of the mean facial plots of the Delayed HP repair group (repair between 4 to 9 years of age) and the Medium repair group (repair between 12 and 20 months of age). The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba. FIGURE 6 Comparison of the mean facial plots of the Unrepaired HP group and the Medium repair group (repair between 12 and 20 months of age). The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba.

Ross, Timing or PaLATE REpAIR 61 Palate < 12 Mo 40 males 11.0 yr Delayed Hard Palate -- --- 32 males 11.0 yr \ N Posterior maxillary height (R-PMP) was least in the Early repair group (p < 0.001) and greatest in the Unoperated HP group (p < 0.005). These morphological differences are morereadily ap- _ preciated in Figures 3 through 6. Two procedures which at present are controversial are the repair of the hard palate in the first year of life and delaying hard palate repair until age 4 to 7 years. These were directly compared in Figure 7 and Table 3. The only statistically significant differences that emerged were the posterior maxillary height (p < 0.001) and anterior mandibular height related to total facial height (Men-LI/N-Men) with a probability of < 0.01. Virtually all of the other measurements, while nonsignificant, favored the Early repair group. DISCUSSION FIGURE 7 Comparison of the mean facial plots of the Early repair group (repair prior to 12 months of age) and the Delayed Hard Palate group (repair between 4 and 9 years of age). The plots have been scaled so that the cranial base length (N-Ba) is identical in both samples. Superimposition was on N-Ba. ments) and in the Early repair sample (p < 0.02 for both). Measurements indicating the forward protrusion of A point (Ba-A Pt length, or the angles Ba-N-Apt and SNA) showed that the Unoperated HP sample had significantly more forward protrusion than the Medium repair sample, and the latter group had significantly more forward protrusion than the Late repair or Delayed HP repair samples. The Early repair sample had more protrusion but not at a significant level. The mandibles were not appreciably different in size. Protrusion of the mandible was greatest in the Early repair sample, and identical in the others. Jaw relations (ANS-N-Pog) were significantly better in the Unoperated HP sample, (p < 0.03) and least favorable in the Delayed HP and the Late repair samples (p < 0.05). The ANB angle was best in the Unoperated HP group (p < 0.001) and worst in the Delayed HP (p < 0.04) and Late repair (p < 0.01) group. Anterior maxillary height (N-ANS) was least in the Early repair (not significant) and Late repair (p < 0.04) groups. Lower face height was greater than the Toronto Standards in the Late repair group and less in the Early repair and Delayed HP repair groups. Overall facial vertical proportions were best at 43.2 percent maxillary contribution to the total in the Early and Delayed HP groups, and significantly worse (41.7 percent) in the Late repair group. The others were between 42.5 and 42.8 percent. Any effects of hard and soft palate repair should be manifest in the posterior vertical development of the maxilla, the anteroposterior growth and position of the maxilla, the anteroposterior development of the alveolus, and the position of the incisors. The vertical development of the alveolus was earlier noted to be strongly affected by the surgical management of the alveolar cleft. It is possible that hard palate repair also affects vertical alveolar development. The effect of soft palate repair can be guessed at by noting that the Marburg sample (with soft palate repair but no hard palate repair) had an average posterior maxillary height (Figure 2B) while the Unoperated sample (no soft palate repair) had much greater posterior maxillary height (Figure 2A). The wearing of a prosthesis or obturator precludes a definite statement, but the hint is there. There was obviously no interference with maxillary position resulting from soft palate repair, since PTM and PMP were well forward. Both the Unoperated and Marburg samples showed greater maxillary protrusion and the Marburg sample, excellent alveolus development and relative dental protrusion. The effect of repair of the hard palate is probably approximated in Figure 6; it causes decreased posterior maxillary vertical height, restricted maxillary forward positioning (shallower pharynx), little or no restriction in maxillary basal bone length, but restriction in forward development of the teeth and alveolar process. The jaw and incisor relations were much less satisfactory with palate repair. Was there a difference in these characteristics related to the age of the subject at palate repair? Posterior maxillary height was adversely affected - only in the Early repair group. This may have been a reflection of age per se, or that the Auck-

62 Cleft Palate Journal, January 1987, Vol. 24 No. 1 land sample had a palate repair which affected - posterior vertical height. The forward development of the alveolus was worst in the Late repair and the Delayed HP repair groups. The latter consisted in part of the Manchester sample, however, with a previously noted dentoalveolar retrusion associated (probably) with extraoral strapping during orthopaedic treatment. Another factor was that 77 percent of the Early repaired group had alveolus repair and 37 percent had early bone grafting, procedures which should adversely influence growth. The Medium repaired group had less of each (27 percent and 16 percent), and the Delayed HP group with 49 percent alveolus repair had no cases of bone grafting and should have had more favorable growth. Maxillary basal bone length was virtually the same in all age groups, although the Early repair group had significantly longer bone length than the Late repair group. There is no apparent clinical significance to a reduced posterior maxillary height. The overall conclusion must be that there is not a great deal of difference in facial growth related to the age of hard and soft palate repair, but the data seemed to favor Early repair in the first year of life as having a slight advantage over the Medium and Delayed Hard Palate repair groups, and the Late repair group results were not as good. It should be noted that the age of hard and soft palate repair was considered to be the age when all repairs were completed, and this is not necessarily the most significant date. The Oslo sample received hard palate repair at a very young age (approximately 3 months of age) but soft palate repair at a much later age. If hard palate repair is more important to subsequent maxillary growth, as seems apparent from this study, the very early repair may explain the unsatisfactory facial morphology earlier noted in the Oslo sample. More evidence is required before the minimum age for hard palate repair can be established. The direct comparison of the Early repair and Delayed Hard Palate repair groups reveal no statistically significant differences except posterior maxillary height, and no notable plot differences. The arguments circulated on the age at which to operate seem to focus on whether to operate early for speech purposes at the expense of facial growth, or to delay hard palate surgery for optimum growth at the expense of speech. This study demonstrates rather clearly and conclusively that facial growth is not the issue, and if anything, early repair provides better facial growth than does the delayed hard palate repair. CONCLUSION The reconstructive surgeon who repairs the hard and soft palate in an infant with complete unilateral cleft lip and palate has available a variety of approaches to satisfy the functional and esthetic demands of the growing child. The timing of this surgery has traditionally been considered to be of importance, and has given rise to a great deal of controversy. Speech requirements are not considered here, and successful closure of the oral and nasal cavities is assumed. The conclusions, therefore, are concerned only with the effect on facial growth of the timing of surgery. of the soft palate or the wearing of a prosthesis did not seem to appreciably inhibit growth. With respect to the hard palate, the clearly preferred treatment was never to close it, or at least delay closure until the teenage years or later. The choices for treatment were less important after that, since the differences in result were slight and there were other factors related to the surgery which may have influenced the result. It would appear, however, that the cases in this study who had surgery completed by 11 months or earlier had the next best result. 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