Journal of Cranio-Maxillofacial Surgery (2003) 31, 137–141

r 2003 European Association for Cranio-Maxillofacial Surgery.

doi:10.1016/S1010-5182(03)00016-7, available online at http://www.sciencedirect.com

Dento-alveolar development in unilateral cleft lip, alveolus and palate

Makoto Noguchi, Yoshiyuki Suda, Shizuyo Ito, Gen-iku Kohama

Department of Oral Surgery (Chairman: Gen-iku Kohama), Sapporo Medical University School of
Medicine, Japan

SUMMARY. Background and objective: Palatal surgery for cleft lip, alveolus and palate is considered to have the
most powerful negative impact on maxillary growth. The aim of this study was to compare dento-alveolar
development of the permanent dentition and morphology of the palate after surgery in unilateral cleft lip, alveolus
and palate patients following two types of palatoplasty: supraperiosteal flap vs mucoperiosteal flap
technique. Patients: Thirty-eight patients born between 1976 and 1983 with a complete unilateral cleft of lip,
alveolus and palate were studied. Fifteen patients were treated with supraperiosteal flaps (SP group), and the other
23 patients with mucoperiosteal flaps (MP group). In this cross-sectional study, dental casts of stage IV A of
Hellman’s dental age in each patient were used. Methods: The following distances were measured: (1) transverse
distance C–C0 , (2) transverse distance M–M0 , (3) palatal length, (4) palatal height. Results: No statistically
differences were seen between the SP and MP groups regarding C–C0 and M–M0 . However, palatal length and
palatal height were significantly greater in the SP than in the MP group. Conclusion: The technique that leaves no
denuded palatal bone is considered to be advantageous for the development of the alveolar process. r 2003
European Association for Cranio-Maxillofacial Surgery.

Keywords: Cleft lip and palate; Palatal surgery; Maxillary development; Supraperiosteal flap technique;
Mucoperiosteal flap technique

INTRODUCTION final outcome closely resembled that of the control

Palatal and dento-alveolar development must
always be considered in the management of
patients with clefts of the lip, alveolus and palate.
Palatoplasty has probably one of the most powerful
negative impacts on maxillary growth (Ross et al.
1972a,b). Herfert et al. (1958) revealed in an
experimental study that raising mucoperiosteal flaps
and leaving denuded bone exposed to the oral
environment resulted in maxillary growth impair-
ment. Wijdeveld et al. (1989, 1991) found that
narrowing of the posterior dental arch was caused
by palatal surgery, using von Langenbeck’s technique
(1861) in Beagle dogs of different ages in a non-bony
cleft model. They thought the scar tissue adjacent to
the bone caused narrowing of the dental arch in
growing animals, and suggested prevention of scar
tissue might lead to more favourable dento-alveolar
development.
Leenstra et al. (1995) developed a partially split
flap technique, which simulated a combination of
the mucosal palatal flap technique used by Perko
(1974, 1979) and the von Langenbeck technique, to
prevent denuded bony areas postoperatively. In an
experimental study of Beagle dogs it was found
that the partially split flap technique largely pre-
vented the development of Sharpey’s fibres. It was
concluded that palatoplasty applying the partially
split flap technique resulted in significantly wider
transverse dimensions of the maxillary dental arch
than following the von Langenbeck procedure. The
group.
Perko (1974, 1979) had suggested that palatal
surgery without denuding bone has a positive effect
on dento-alveolar development in man. Leenstra et al.
(1996) compared the perioperative and postoperative
courses and the dento-alveolar development of the
deciduous dentition in patients with unilateral clefts
of the lip, alveolus and palate, and isolated cleft
palates, up to 5 years of age. Two different types of
palatoplasty were tested, the supraperiosteal flap
technique described by Kohama (1991) without
denudation of bone, and the push-back technique
described by Wardill (1937) resulting in denuded
bone.
It was found in this clinical study that re-
epithelialization of the wound areas after supraperi-
osteal repair takes about 1 week, which is one third of
the time associated with healing following the push-
back technique. In addition, palatal length in the
deciduous dentition following the supraperiosteal
technique was improved when compared with the
push-back technique. However, the question of
whether or not the supraperiosteal technique pro-
duces more favourable dento-alveolar development
than the Wardill type push-back technique in the
permanent dentition in man remained unanswered.
The aim of this retrospective study was therefore to
compare the dento-alveolar development of the
permanent dentition and morphology of the palate
following two types of palatoplasty in unilateral clefts
of the lip, alveolus and palate.

137
138 Journal of Cranio-Maxillofacial Surgery

MATERIAL AND METHODS

Subjects

An earlier evaluation of the results following the

push-back palatoplasty using mucoperiosteal flaps
led us to adopt the supraperiosteal technique in about
1980. This decision was based on the impression that
scar formation on the palatal side of the alveolar
region inhibited the development of the alveolar
process. The subjects of this study were patients with
unilateral clefts (UCLAP) who underwent palato-
plasty before and after the change in the surgical
procedure.
Thirty-eight patients born between 1976 and 1983
with a complete unilateral cleft (UCLAP) were
evaluated. They were treated at the Department of
Oral Surgery, Sapporo Medical University School of
Medicine. Lip closure, using the Tennison–Randall
technique (Randall, 1959) was performed at a mean
age of 3 months. The alveolar process was not
surgically repaired. Fifteen patients (11, male; 4, Fig. 1 – Schematic drawing of techniques for raising mucoperiosteal
female) were treated using the Kohama (1991) and supraperiosteal flaps.
supraperiosteal flap technique (SP). Twenty-three
patients (14, male; 9, female) were treated using the
push-back technique (MP) described by Wardill
(1937). In both groups, palatal repair was performed
at the mean age of 17 months. All patients were
operated upon by one surgeon (GK). Orthodontic
management began at the mixed dentition stage.
In this cross-sectional study, dental casts of Hell-
man’s (1932) dental age stage IV A were used in each
patient. Lateral expansion was completed at this
stage in all our patients. The expanded dental arches
were maintained with a lingual arch appliance.
Mesio-distal movement of premolars and molars Fig. 2 – Schematic drawing of maxillary permanent dentition with
was not attempted. Patient’s ages at the time the measuring points.
impressions were taken for cast models ranged from
14 to 17 years for the SP group, and from 15 to 18
years for the MP group. The control group consisted
of 35 healthy adolescents (10 males and 25 females;
aged 15 to 19 years). All dental casts evaluated had been obtained after
completion of lateral expansion of the maxilla.
Palatal surgery Measuring points on the cast were determined as
follows with reference to the report of Ferrario et al.
(1998; Fig. 2).
The surgical procedure in both groups was a push-back
palatoplasty, but the method of elevating the palatal * Incision point (I): mid-point between the incisal
flaps differed. The MP group was performed according edges of the central incisors.
to Wardill’s method with mucoperiosteal flaps. In the * Canine point (C and C0 ): canine cusp.
SP group, the palatal flaps were raised so that the
periosteum remained on the palatal side of the alveolar
* Molar point (M and M0 ): mesiobuccal cusp of the
region: A no. 11 blade was advanced nearly parallel the first molar.
alveolar crest, and soft tissue was left in the alveolar * Gingival point (G): centre points at the palatal
region. On the palatine process, a mucoperiosteal flap gingival margin of the first molar.
was raised in such a manner that the neurovascular * Mid point (m): mid point of the line connecting the
bundle was enclosed within the flap (Fig. 1). most distal points of the first molar.
These landmarks were used to measure the
Measuring method following distances:
* The transverse distances between C and C0 and M
All patients were seen by an orthodontist, who and M0 .
commenced treatment in the mixed dentition phase. * Palatal length: the distance between I and m.
 Dento-alveolar development 139

* Palatal height: the distance from the line connect-
ing G and G0 to the most superior point on the
hard palate.
All these measurements were made by one person.
For determination of the measurement error, all casts
were digitized by two independent operators.
poor, and the palate was generally narrow and
shallow. In the SP group, by contrast, scar formation
on the palatal side of the alveolar crest was mild, the
alveolar region was developed adequately, and a deep
and wide palate was formed. The dental arches
tended to be slightly narrower in both groups when
compared with the control group (although they had
been treated orthodontically).

STATISTICAL ANALYSIS Measurements

Since the data were not normally distributed, the
Mann–Whitney test was used for statistical analysis.
The level of significance in comparing the three
groups (MP group, SP group, control group) was
chosen to be 0.05/3=0.017 according to Bonferroni’s
modification.
RESULTS
Reproducibility
No significant systematic differences were found
between the two independent operators for the
above-mentioned variables; standard errors (range)
were 0.14 (0.09–0.21) for C–C0 , 0.16 (0.10–0.22) for
M–M0 , 0.14 (0.08–0.28) for palatal length, and 0.23
(0.18–0.27) for palatal height. Hence, the accuracy of
the method was considered to be acceptable.
Table 1 lists the results taken from dental casts of 35
normal controls. Since no significant gender differ-
ence was observed in any of the measured items,
gender was ignored in the following comparative
evaluation.
Table 2 lists the results of each measurement and
statistical analysis according to the surgical proce-
dure. C–C0 was greater in the control group than in
the MP group (po0:017), and M–M0 was greater in
the control group than in both the MP and SP groups
(po0:017). The palatal length was significantly
greater in the control group than in the MP group
(po0:017), whilst in the SP group it was greater than
in the MP group (po0:017; Fig. 3). The palatal
height was significantly greater in the SP group than
in the control group (po0:017) and in the control
group greater than in the MP group (po0:017;
Fig. 4).

Morphology DISCUSSION

In the MP group, marked scar formation was The development of the maxilla depends largely on
observed on the palatal side of the alveolar crest, the development of the alveolar process (Ross et al.
the development of the alveolar region was often (1972a, b). In patients with cleft palate, surgical
intervention in the maxilla, particularly the alveolar
process, as well as intrinsic cleft palate factors play a
Table 1 – Measurements in 10 male and 25 female healthy major role in growth inhibition of the maxilla. For
adolescents these reasons, two-stage closure was devised, delaying
Variable Male Female the time of closure for the hard palate. Following this
protocol, excellent maxillary development has been
Mean SD Mean SD reported (Hotz and Gnoiski, 1976). However, the
C–C 0
35.8 1.8 36.0 2.3 speech results were reportedly inferior to those
M–M0 54.1 2.2 56.0 3.2 patients in whom one-stage closure were performed
Palatal length 32.2 2.4 32.7 2.4 using the push-back operation (Bardach et al., 1984;
Palatal height 14.6 2.1 14.9 1.6
Cosman and Falk, 1980).

Table 2 – Comparison between the control group, the SP group, and the MP group
Variable Control (n=35) SP technique (n=15) MP technique (n=23) Test results p-value
Mean SD Mean SD Mean SD
C–C0 36.0 2.1 33.8 4.8 33.6 4.7 Control>MP 0.011
M–M0 55.4 3.0 51.3 4.8 52.4 5.4 Control>SP 0.002
Control>MP 0.012
Palatal length 32.7 2.4 30.9 4.1 27.2 4.0 Control>MP o0.001
SP>MP 0.016
Palatal height 14.9 1.7 16.1 2.3 12.2 2.9 Control>MP o0.001
SP>Control 0.014
SP>MP o0.001
140 Journal of Cranio-Maxillofacial Surgery
Fig. 3 – Palatal length in the control, the MP and the SP groups.
Fig. 4 – Palatal height in the control, the MP and the SP groups.
In the SP technique performed in this study, push-
back was performed by raising a mucosal flap on the
palatal side of the alveolus and the flap also
contained the periosteum of the palatal process and
the neurovascular bundle close to the cleft to prevent
perforation. Thus no denuded bone remains on the
palatal side of the alveolar crest.
Leenstra et al. (1996) compared the results of the
SP and the MP techniques in young children and
observed early re-epithelialization of the palatal
wound following the SP technique. They also
compared dental casts until 5 years postoperatively
and reported that the arch length was greater
following the SP technique. In this study, dental
casts of the permanent dentition were compared. The
dental arch width between the canines and between
the molars tended to be slightly narrower in both the
SP and MP groups than in the control group but was
not different between the two groups. The palatal
length was significantly less in the MP group than in
both the control group and the SP group. These
results support the data found in the deciduous
dentition by Leenstra and coworkers and suggest
satisfactory postoperative maxillary development in
the SP group. However, other factors including the
dental alignment and missing teeth are also to be
considered. The palatal height was significantly
greater in the SP group. Since the palatal height is
considered to represent the vertical development of
the alveolar process, this finding may be evidence for
the superiority of the SP technique with regard to
maxillary development. However, whilst there have
been reports that scar formation on the palatal side of
the alveolar process inhibits the vertical growth, other
reports have denied the influence of scar formation
(Ishikawa et al., 1999).
CONCLUSIONS
Although it is still premature to draw a definitive
conclusion from this study, less invasive surgical
intervention in the area of the alveolar crest appears
to be advantageous for palatal development.
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