Original Article

The Cleft Palate-Craniofacial Journal

1-7
Does the Timing of 1-Stage Palatoplasty ª 2021, American Cleft Palate-
Craniofacial Association

With Radical Muscle Dissection Effect Article reuse guidelines:

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DOI: 10.1177/10556656211013174
Long-Term Midface Growth? journals.sagepub.com/home/cpc

A Single-Center Retrospective Analysis

Vikram Shetty, MDS, DNB, MBBS1, Nanda Kishore Patteta, BDS, MDS2,
Anirudh Yadav, BDS, MDS3 , Devyani Bahl, BDS3, and Hermann F. Sailer4

Abstract
Objective: To evaluate the long-term effect of timing of 1-stage palatoplasty on midfacial growth in patients with cleft lip and palate (CLP).
Design: Retrospective observational cohort study.
Study Setting: Institutional hospital.
Patients: One hundred twelve patients with CLP who underwent palatoplasty and were divided into 3 groups: group I: operated
between 9 and 11 months; group II: operated between 18 and 20 months; and group III: operated between 21 and 24 months.
Interventions: All patients underwent von Langenbeck palatoplasty technique, which was converted to a Bardach 2-flap technique in
case of any technical difficulties. The patients were followed up between 8 and 9 years when they reported for secondary alveolar
bone grafting. Postsurgical cephalometric and dental casts measurements were taken for midfacial growth analysis.
Main Outcome Measures: The cephalometric measures were analyzed for midfacial growth and compared within the groups.
Results: Statistically significant difference (P < .01) was found on comparing the cephalometric parameters such as sella–nasion–A
point angle (SNA), A point–nasion–B point angle (ANB), n toperpendicular to point A (N-perpA), condylon to point A (Co-A),
anterior nasal spine to posterior nasal spine (ANS-PNS), nasion to Anterior nasal spine (N-ANS), nasion to menton (N Me), and
witts appraisal (Witt (AO-BO)) in group I when compared to both group II and group III patients, implying deficient midfacial
growth in group I. No statistical difference was found in the cephalometric values between group II and group III. Group II had
better cephalometric measurements than group III, showing better growth in group II than group III. Overall, there was less
incidence of midfacial hypoplasia in patients treated between 18 and 20 months (group II).
Conclusion: We conclude that palatal closure carried out at 18 to 20 months and 21 to 24 months is associated with better
midfacial growth when compared to closure at 9 to 11 months. The best time to operate would be between 18 and 20 months to
avoid speech disturbances. Midfacial growth can be greatly influenced by the timing of 1-stage palatoplasty.

Keywords
von Langenbeck palatoplasty, Bardach 2-flap palatoplasty, midfacial hypoplasia

1
Nitte Meenakshi Institute of Craniofacial Surgery, NITTE Deemed to be
University, Mangalore, India
Introduction 2
Department of Cleft and Craniofacial Orthodontics, NITTE Meenakshi
Cleft lip and palate (CLP) are one of the most common con- Institute of Craniofacial Surgery, NITTE Deemed to be University,
Mangalore, India
genital anomalies affecting 1:700 live births, and isolated cleft 3
Department of Oral and Maxillofacial Surgery, A.B. Shetty Memorial Institute
palate has an incidence of 1:2500 live births with a higher of Dental Sciences, NITTE Deemed to be University, Mangalore, India
female gender predilection (Mahajan et al., 2018). Patients 4
Chairman, Klinik Professor Sailer, Zurich, Switzerland
with clefts are born with a challenging deformity that requires
multiple surgical interventions in order to achieve functional and Corresponding Author:
Anirudh Yadav, Department of Oral and Maxillofacial Surgery, A.B. Shetty
esthetic harmony. The goal of the surgical repair of the palate is to Memorial Institute of Dental Sciences, NITTE Deemed to be University,
provide an anatomic separation of the oral cavity from the nasal Mangalore 575018, India.
cavity and the creation of a functional velopharyngeal mechanism Email: anirudhyadav6469@gmail.com
2 The Cleft Palate-Craniofacial Journal XX(X)
without causing growth restriction of the maxilla. Ideally, surgical
repair of the palate should provide for normal hearing and speech,
uninhibited growth of maxilla, and an ideal occlusion relationship
and without hindering psychosocial development (Kuijpers-
Jagtman & Long, 2000; Pereira et al., 2011).
Primary surgical reconstructions in patients with CLP result
in scar tissue formation at the operated site. Ultimately, this
causes static and dynamic alterations that, in association with
the cleft itself, have negative consequences on maxillary
growth and development, thus affecting the whole maxillofa-
cial complex of the patient (Ross 1987; Rohrich et al., 2000;
Friede, 2007; Stein et al., 2007). According to previous studies,
the restriction of maxillary growth does not depend on the
genetic predisposition associated with the presence of the cleft
but is rather a consequence of the primary surgical repair (Mars
& Houston, 1990; Capelozza et al., 1996; Shetye & Evans, 2006).
Nevertheless, the timing of palate repair, the ability of the
surgeon, the width of the cleft, and the surgical technique have
an impact on the results and also interfere with the growth and
development of the facial structures involved.
Understandably, the surgery differs from center to center
and surgeon to surgeon. Cleft palate repair is usually performed
at approximately 9 to 18 months of age for speech development
(Ahmed & Sondos, 2012).
This study aimed to determine the ideal age for the surgical
repair of cleft palate and assess the impact of palatal repair on
the maxillary growth.
Materials and Methods
Source of Data
This retrospective study was conducted at the Nitte Meenakshi
Institute of Cleft and Craniofacial Surgery, Nitte Deemed to be
University in Mangalore, India.
Methods of Collection of Data
In all, 112 patients who underwent palatoplasty between the
ages of 9 and 24 months, from 2007 to 2010, were evaluated.
The sample was divided into 3 groups based on the timing of
palatoplasty, group I (9-11 months), group II (18-20 months), and
group III (21-24 months). We obtained written informed consent
from the patient’s parents/guardians for their participation in the
study. The ethical clearance was obtained from the institutional
review board for the conduction of the study. The study was
carried out in accordance with the Declaration of Helsinki.
Inclusion Criteria
1. Patients with unilateral CLP who have undergone lip and
palate surgeries at our centre—The palate surgery should
have been done as per the technique mentioned below.
2. Patients who presented to the center at 8 to 9 years of age.
3. Nonsyndromic patients.
4. Patients showing willingness to participate in the study.
Exclusion Criteria
1. Patients having undergone osteotomies, distraction
osteogenesis, fixed orthodontic therapy, or bone
grafting.
2. Patients with isolated cleft palate.
3. Patients with severe systemic conditions affecting
growth.
4. Patients with incomplete intraoperative records, irregu-
lar follow-up.
A minimum follow-up of 8 years was used to assess maxillary
growth. When the patients presented for follow-up at 8 to 9 years
of age, a lateral cephalogram was taken, study casts were made,
photographs taken, and a detailed history was documented.
Eight to 9 years is taken as the age for assessment of max-
illary growth in these patients prior to the secondary alveolar
bone grafting (SABG) procedure. The SABG involves further
dissection of the mucosa up to the piriform; hence, it can fur-
ther attribute to restricted maxillary growth. Therefore, as we
are concerned with establishing an ideal age for palatoplasty,
we have taken this age as the point of assessment.
When the patients reported at the said age, we assessed the
following clinical parameters with the help of clinical photo-
graphs and dental casts:
 Upper incisor visibility (repose and smile)
 Intercanine width
 Intermolar width
With the help of intercanine and intermolar width values on
the dental casts, we calculated the Modified Huddart and Bod-
enham (MHB) index (Mossey et al., 2003) to correlate and
assess the predictive maxillary growth in all the 3 groups.
We recorded the following cephalometric parameters with
the lateral cephalogram. The cephalometric parameters
included both angular and linear measurements.
 SNA
 ANB
 Nperp-A
 Co-A
 ANS-PNS
 Witt (AO-BO)
 N-ANS
 N-Me
All the observations were done twice by 2 independent
observers, and the mean of the observations was taken as the
final measurement. The cephalometric analysis was carried out
using the Nemoceph software 2017.
Surgical Technique
The patients were operated by a 1-stage palatoplasty using the
von Langenbeck technique with radical muscle dissection and
pushback as the first choice, which was converted to the
Shetty et al 3

Bardach 2-flap technique in situations in which technical dif- Table 1. Distribution of the Patients Based on Surgical Technique.
ficulties (tension across the cleft) were encountered.
Surgical technique
Lignocaine (1:120 000) was used for the greater palatine and
incisive nerve blocks and for hydrodissection infiltration. The Von Langenbeck Bardach Total
incision for the von Langenbeck technique was carried out
Count 16 23 39
along the cleft margin with the mucoperiosteal flap remaining Group I % within group 41.0 59.0 100.0
pedicled anteriorly and posteriorly. The lateral releasing inci- % within surgical 42.1 31.1 34.8
sion was placed, leaving a cuff of marginal mucosa lateral to technique
the alveolus. The releasing incision was extended till the pos- Count 13 24 37
terior margin of the maxillary tuberosity without curving lat- Group II % within group 35.1 64.9 100.0
erally behind the tuberosity. The mucoperiosteal flap was % within surgical 34.2 32.4 33.0
elevated and mobilized around the greater palatine neurovas- technique
Count 9 27 36
cular bundle, after which the posterior margin of the hard palate Group III % within group 25.0 75.0 100.0
was identified and freed off the abnormal muscle attachments. % within surgical 23.7 36.5 32.1
Radical muscle dissection was carried out, exposing the levator technique
muscles, and the tensor muscles were elevated off the hamulus Count 38 74 112
without fracturing it. The nasal layer was elevated off the sep- Total % within group 33.9 66.1 100.0
tum. Z-plasty of the nasal layer was carried out in the soft % within surgical 100.0 100.0 100.0
palate area, allowing for a pushback of the soft palate muscles. technique
After the nasal mucosa and the soft palate muscles were closed
in layers, the oral mucoperiosteal flaps are brought together.
In cases where there was significant tension across the cleft Note that we did not include patients between 12 and
defect, which was often observed at the junction of the hard and 17 months as we did not have any patients in this interim age
soft palate regions, the procedure was modified to a Bardach group. According to the first protocol at our institute, patients
2-flap technique by incising behind the anterior alveolus, thus were operated between 9 and 11 months of age. The revised
mobilizing the flaps from the anterior end. It was observed that protocol at our institute follows the Zurich protocol timing and
the conversion was more commonly needed where the cleft hence we operated patients between 18 and 20 months.
defect was around 11 mm or more. Further mobilization was
achieved by undermining the palate mucosa at the posterior
Results
edge of the lateral releasing incision by incising the periosteum
and cauterizing the fine lesser palatine vessel allowing us to A total of 112 patients with CLP were evaluated, consisting of
stretch the greater palatine vessel out of the foramen without 8 to 9 years of age. The mean age of the patients getting oper-
damaging it. It may be necessary to carefully dissect the peri- ated for palatoplasty of groups I to III were 9.77 + 1.724,
osteal fibers around the neurovascular bundle to facilitate its 18.00 + 0.001, and 19.86 + 0.798 months, respectively.
unimpeded stretch out of the foramen. The periosteum poster- Table 1 presents the distribution of patients based on the sur-
olateral to the maxillary tuberosity was elevated by releasing the gical technique (von Langenbeck and Bardach 2-flap tech-
lateral fibrous attachments without tearing the overlying mucosa. nique). Table 2 provides comparisons of descriptive
statistics for all the cephalometric measurements among the
groups. All the cephalometric values had a statistically sig-
Assessment nificant difference (P < .05) when group I was compared with
group II and group III. However, no statistically significant
The cephalometric results obtained on follow-up were com- difference was found on comparing the parameters between
pared within the 3 groups to assess the maxillary growth. Also, group II and group III.
measurements were recorded on dental casts and the values On assessing the MHB scoring index on dental casts, those
compared to the MHB index to assess the craniofacial growth. patients in group I had a mean score of 4.25 + 0.23, group II
The scoring was done as 3 to þ1 from palatal to labial over- had a mean score of 1.42 + 0.06, and group III had a mean
lap for the incisors and from 0 to 2 from palatal to labial score of 1.82 + 0.14.
overlap for canines, premolars, and molars. The representative images of the patients in the 3 groups are
shown in Figures 1 to 3).

Statistical Analysis
The reliability of the single measurement was calculated using
the Dalberg formula of error method. SPSS statistical program
was used for calculations of mean values.
The nonparametric test was done using the Kruskal-Wallis
test and post hoc Mann-Whitney U test.
Discussion
Growth is one of the most important areas of study in CLP care
among other associated outcome variables. Growth is usually
measured based on the degree of vertical maxillary growth,
horizontal protrusion, transverse arch restriction, and
4 The Cleft Palate-Craniofacial Journal XX(X)

Table 2. Comparison Among the Groups (Post Hoc Tests).

95% CI

Dependent variable (cephalometric parameter) (I) Group (J) Group Mean difference (I-J) P Lower bound Upper bound
a
SNA (degrees) Group I Group II 6.205 .001 7.94 4.47
Group III 5.055a .001 6.80 3.31
Group II Group I 6.205a .001 4.47 7.94
Group III 1.150 .349 0.62 2.92
ANB (degrees) Group I Group II 3.493a .001 4.37 2.62
Group III 2.940a .001 3.82 2.06
Group II Group I 3.493a .001 2.62 4.37
Group III 0.553 .405 0.34 1.44
N-perpA (mm) Group I Group II 3.694a .001 4.67 2.71
Group III 3.000a .001 3.99 2.01
Group II Group I 3.694a .001 2.71 4.67
Group III 0.694 .282 0.31 1.69
Co-A (mm) Group I Group II 16.272a .001 18.90 13.65
Group III 13.739a .001 16.38 11.09
Group II Group I 16.272a .001 13.65 18.90
Group III 2.533 .070 0.15 5.21
ANS-PNS (mm) Group I Group II 7.484a .001 9.36 5.60
Group III 5.968a .001 7.86 4.07
Group II Group I 7.484a .001 5.60 9.36
Group III 1.516a .172 0.40 3.43
Witt (AO-BO) Group I Group II 2.790a .001 3.53 2.05
Group III 2.412 .001 3.16 1.67
Group II Group I 2.790a .001 2.05 3.53
Group III 0.378a .677 0.38 1.13
N-ANS (mm) Group I Group II 4.207a .001 6.20 2.22
Group III 3.096 .001 5.10 1.09
Group II Group I 4.207a .001 2.22 6.20
Group III 1.110a .559 0.92 3.14
N-Me (mm) Group I Group II 5.698a .001 8.34 3.06
Group III 3.951 .001 6.61 1.29
Group II Group I 5.698a .001 3.06 8.34
Group III 1.747a .352 0.94 4.44
Abbreviations: ANB, A point–nasion–B point angle; ANS-PNS, anterior nasal spine to posterior nasal spine; AO-BO, witts appraisal; Co-A, condylon to point A;
N-ANS, nasion to Anterior nasal spine; N-Me, nasion to menton; N-perpA, A- n to perpendicular to point A; SNA, sella–nasion–A point angle.
a
p < 0.05.

Figure 1. Group I patient at the time of assessment.

Shetty et al
Figure 2. Group II patient at the time of assessment.
Figure 3. Group III patient at the time of assessment.
occlusion. It is generally accepted that the surgical scarring
caused by primary surgical correction of CLP and other interven-
tions contributes greatly to midface growth restriction, resulting
in class III patterns (Chait et al., 2002; Campbell et al., 2010).
Early palatal surgery before 1 year of age leads to retarda-
tion of the growth of the maxilla due to insufficiency of the soft
tissue to cover the defect. This lack of soft tissue causes scar-
ring, leading to a higher risk of developing velopharyngeal
insufficiency, ultimately leading to improper speech. To coun-
ter these speech development problems, the best time to do the
surgery is 10 to 20 months of age (Langford et al., 2003).
One-stage cleft palate repair remains the most common pro-
tocol in North America (Kim et al., 2002). Early soft palate
repair at around 1 year of age using the 2-stage palatal repair
has been reported to have more favorable anteroposterior
growth outcomes due to the hard palate mucosa being
untouched at this age (Liao et al., 2010). Additionally, the
abnormal palatal anatomy arising from late hard palatal repair
5
(3-8 years) has been known to cause severe articulation errors
(Owman et al., 1998).
Thus, a delayed 1-stage cleft palate repair should be planned
at an age not too late to cause articulation errors while not being
too early to cause growth impairment. In this study, patients
were divided into 3 groups based on the age of repair of the
cleft palate. The patients were operated with a 1-stage palato-
plasty using the von Langenbeck technique with radical muscle
dissection and pushback as the first choice to minimize the palatal
scarring (Pigott et al., 2002). However, in situations where tech-
nical difficulties (increased tension across a wide cleft palate)
were encountered, the procedure was converted to the Bardach
2-flap technique. Table 1 shows that a high number of patients
were converted to the Bardach 2-flap technique as most of the
patients with cleft palate encountered in our center showed the
cleft width to be more than 11 mm. Also, the increase in the
conversion rates in subsequent groups (groups I through III)
shows that as the age at which palatoplasty is carried out
6 The Cleft Palate-Craniofacial Journal XX(X)
Figure 4. Timeline for sequence of palatoplasty protocol followed at NITTE Meenakshi Institute of Craniofacial Surgery.
increases, the width across the cleft at the junction of the hard and
soft palate also increases. Shaw et al. (2001) stated that palate
repair is a nightmare as the age of the patient increases. Though
the patients’ maximum age in our study did not exceed 24 months,
we noticed a gradual increase in difficulty with progressive age,
like increased chances of bleeding and the amount of dissection
required to achieve tension-free closure.
Our study assessed long-term growth outcomes in 112 patients
with unilateral CLP, 8 years after palate surgery, by measuring 8
cephalometric parameters. The additional use of ANB and Witt
appraisal in this study helped compare the midface growth in
relation to the mandible. Table 2 compares the midface growth
between the 3 groups. Our findings indicate that the growth mea-
sured across all 8 cephalometric parameters showed no signifi-
cant difference between group II and group III. However, patients
in group I showed a significant restriction in growth measured
across all the parameters compared to group II and group III.
Needless to say, the normal midface growth observed in
groups II and III consolidated our hypothesis that cleft width
(which also increased with the age of surgery) does not play a
role in growth restriction, provided the technique can be mod-
ified with regard to the requirements of individual patients.
Hence according to our study, the main parameter that
affects long-term midface growth is the timing of surgery. As
a single operator conducted all surgeries, the effect of operator
variations in surgical technique on growth could not be
assessed. In our study, the ideal age for carrying out 1-stage
palatoplasty would be 18 to 24 months if growth would be the
only criterion. However, as the production of speech is a major
determinant of the success of palate surgery, late intervention
may lead to errors in articulation and may cause hypernasality
due to inadequacy in the velopharyngeal valve. Although this
study does not measure speech outcomes, it has been proven
that speech deteriorates when palate surgery is postponed
beyond 20 months of age (Langford et al., 2003). Hence,
patients operated in group II would possibly show the maxi-
mum combined benefit in terms of speech and growth
parameters.
Although the GOSLON yardstick has been accepted as the
gold standard to assess the craniofacial growth of patients with
cleft, it can be used in patients after the complete eruption of
permanent dentition (Mars et al., 1987). However, here we
have used the MHB index to assess the craniofacial growth
of our patients with cleft as it can be used effectively in the
mixed dentition stage (Mossey et al., 2003), with a high corre-
lation to GOSLON yardstick as validated in literature by var-
ious studies (Almuhizi et al., 2016; Yakob et al., 2018). The
mean scores achieved from the MHB index for groups I to III
were 4.25, 1.4, and 1.82, respectively. Group I, where patients
who were operated between 9 and 11 months, had poorer scores
(mean ¼ 4.25) when compared to group II (mean ¼ 1.4) and
group III (mean ¼1.82), where patients were operated between
18 to 20 months and 21 to 24 months, respectively. This jus-
tifies the need for a midface advancement surgery later in the
life for group I patients rather than the other 2 groups based on
the assessment by this index.
The assessment of growth in our study was carried out at 8 to
9 years of age before alveolar bone grafting was carried out.
While the ideal age to measure growth would be after the
pubertal growth spurt, the mucosal dissection over the septum
and alveolus during bone grafting procedures may in itself
cause restriction of growth, thus causing a bias. On the other
hand, it has been shown that the maximal restriction of growth
due to the primary cleft procedures would be apparent by
9 years of age. Therefore, growth assessment at 8 to 9 years,
as carried out in this article, would offer substantial insight into
the effect of timing of the palatoplasty procedure on midface
growth. However, postpubertal assessment at a later stage will
offer more value to the literature.
It would also be pertinent to mention that the constant
ongoing evaluation of surgical protocols and their effects on
midface growth formed the basis of the 3 groups of this study.
Groups I and II signified the changes in the cleft palate proto-
cols followed in our center, the timeline of which is shown in
Figure 4. Group III consisted of patients who presented late for
surgery.
Shetty et al
Conclusion
According to various authors, centers, and organizations, there
are still controversies regarding the ideal age for cleft palate
repair. But with these cephalometric parameters, we can con-
clude that 18 to 20 months of age can be the ideal age for
performing palatal repair with improving the overall appear-
ance without compromising the patients’ speech and dentition.
The growth of the maxilla may be influenced by the timing and
technique of the surgery. But according to the literature, no tech-
nique has been presented with superiorly positive results in all
dimensions of maxillary growth. Still, it is mainly the timing of
the surgical repair that plays a key role in the maxillary growth.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Anirudh Yadav https://orcid.org/0000-0003-1868-5151
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