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Introduction: Speech development is of utmost importance and requires early closure of a palatal cleft. On the other hand, it is well known that all types and timings of surgical repair of facial clefts are detrimental to maxillary growth. Nevertheless, these days one is more and more confronted with a world-wide tendency in favour of the one-in-all operation to close clefts of the lip, alveolus, and palate. Therefore, a three-centre study was performed for testing - once more - the value of two-stage palatoplasty as a means to reduce the detrimental effects of surgery on palatal growth and at the same time to also enable early speech development., Material and Methods: Plaster casts from 85 patients have been re-evaluated. All of them had a complete unilateral cleft of lip, alveolus, and palate. They had been treated according to the old therapy protocols followed in either one of the three different cleft centres many years ago, namely in Hamburg, (Western) Germany, Iowa City, IO, USA, and Rostock, (in those days still Eastern) Germany. The impressions had been taken already in 1987 from patients being either 8 years (36 pts.) or 16 years of age (49 pts.). Three different treatment protocols had been followed for these patients in those centres in those days: The main difference was that in centres A and B the palates were closed in two stages whilst in centre C palatoplasty was performed in just one operation., Results: The most interesting results regarding the palatal growth were that: 1. In centre C (one-stage palatoplasty) the patients had more constricted palates. 2. In centre A (two-stage palatoplasty) the patients had least often an anterior cross-bite., Discussion and Conclusion: It appears that it was possible to show once more that closing the palate in one stage at age 1 year or less is interfering most with maxillary growth. This study leads us to conclude that two-stage palatoplasty is still a valuable treatment protocol for patients with a complete unilateral cleft of lip, alveolus, and palate, especially as apparently good guidance of speech development can lead to satisfactory speech for cleft patients in whom the hard palate was closed at a later age., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The present study was designed to evaluate the relationship between varying sequences of lip and palate repair and maxillary growth. To investigate this problem, an experimental study using beagles was conducted to assess the influence of three different sequences of lip and palate repair. The first sequence constitutes the commonly accepted approach of lip repair first, palate repair second. The second sequence was reversed: palate repair first, lip repair second. The third sequence consisted of simultaneous lip and palate repair. Using 70 eight-week-old beagles, we tested the following hypothesis: The sequence of lip repair first and palate repair second is less detrimental to maxillary growth than the other two sequences. The animals were assigned to two control groups (unoperated and unrepaired animals) and three experimental groups, in which three different sequences of repair were executed. Upon sacrifice, 11 maxillary variables were measured directly from cleaned skulls and analyzed by univariate and multivariate techniques. The most important finding from this analysis is that the commonly accepted sequence of cleft lip and palate repair (lip first, palate second) is less detrimental to maxillary growth than repairing the palate first and the lip second or simultaneous closure of both defects.

This study was designed to assess the effects of the commonly accepted sequence of cleft lip and palate repair on subsequent maxillofacial growth and to compare these effects with those resulting from simultaneous lip and palate repair. Using 62 eight-week-old normal beagles, we tested the hypothesis that sequential repair (lip first, palate second) of surgically induced lip and palate defects is less detrimental to maxillofacial growth than simultaneous repair of both surgically created defects. Animals were assigned to one of four groups: two control groups (unoperated and unrepaired) and two experimental groups. Defects simulating cleft of the lip, alveolus, and palate were surgically created in the unrepaired controls and in the experimental animals. In one experimental group, the lip and palate defects were repaired immediately and simultaneously. In the other experimental group--simulating current clinical practice--the lip defect was repaired first at the time that it was created, while closure of the palatal defect was delayed 4 weeks. After the animals were killed at 36 weeks of age, 11 maxillary variables were measured directly from cleaned skulls and analyzed by using univariate and multivariate techniques. Animals that had lip and palate defects closed in sequence had less severe maxillofacial aberrations than animals with simultaneously closed defects. Sequential closure of the defects also had identifiable effects on maxillofacial form. The growth aberrations observed among animals with sequential closure, however, are primarily attributable to surgical creation of the defects and not to the surgical repair. Delaying palate repair is less traumatic to the subsequent growth of the maxillary complex than simultaneous repair of lip and palate defects.

Bilateral cleft of the lip and palate is by many standards the most complex and severe form of the defect. The complexity and severity of the defect require an unusual degree of cooperation among all specialists and especially between the surgeon and the orthodontist. There are no published findings that we know about in which comprehensive data from a number of disciplines are reported for the same group of bilateral cleft patients. Fifty randomly selected patients with bilateral complete clefts were examined by the Iowa team and two orthodontists from other institutions. The evaluations revealed that a large number of patients over the age of 10 have multiple residual problems requiring further treatment. Only 23 percent of the older patients studied were judged to have had treatment completed by the surgeon, speech pathologist, and orthodontist. It is very difficult to state whether the results obtained by our team can be considered satisfactory because there are no comparable studies that have attempted to evaluate the same parameters in multidisciplinary management.

The authors present their reflections on several of the major topics related to research. The subjects discussed include the quantity and quality of research; the motivation for research; the research process; research paradigm; restraints of research; and freedom to research. They point out that the haste to achieve success and to publish in most cases has precluded the learning process about the substance and methodology of research. An attempt is made to relate general problems of research and its methodology to research in the area of congenital facial deformities.

Forty-five randomly selected patients with unilateral cleft lip, alveolus, and palate, all operated upon by Dr. Wolfram Schweckendiek were evaluated by three American specialists to assess the validity of primary veloplasty. Examination revealed an unusually high incidence of short palate and poor mobility of the soft palate. Facial growth was found to be highly acceptable in the majority of the patients. Unusually high incidence of velopharyngeal incompetence was found in these patients.

This study was designed to test the hypothesis that simultaneous lip and palate repair results in more severe craniofacial growth aberrations than lip repair or palate repair performed separately. Seventy-six purebred beagles were divided into five groups. Two of these groups were controls (unoperated and unrepaired animals); the three remaining groups were experimental (in one group only the lip was repaired, in another only the palate was repaired, and in the last the lip and palate were repaired simultaneously). Cephalometric measurements were analyzed using univariate and multivariate statistical techniques. In multivariate analysis, stepwise multiple regression and discrimination were applied to precisely assess the effects of the various surgical procedures. The results of this study indicate that simultaneous lip and palate repair results in more severe craniofacial growth aberrations than lip repair or palate repair performed separately.

The secondary nasal skin envelope asymmetries were studied after unilateral cleft lip repair using the original (obsolete) rotation-advancement (Millard I) and the triangular flap techniques (Bardach's modification). Secondary correction of the nasal deformity was not performed in either group. Our findings indicated that in both groups, vertical asymmetries of the nasal skin envelope were similar. The alar dome on the cleft side was depressed, the columella was shorter on the cleft side, and there was hooding at the nostril apex. The principal difference between the two lip repairs was observed in the horizontal dimension of the nasal skin envelope. The position of the alar base was more normal following the Millard I repair, while the triangular flap repair left the alar base laterally displaced. When considered together with flattening of the cleft alar dome, a horizontal skin-envelope deficiency from middome to lateral alar crease was produced in the Millard I group. More lateral positioning of the alar base after the triangular flap technique minimized this horizontal skin deficiency. The triangular flap technique produced a secondary nasal deformity that looked worse but was easier to correct. The clinical implications of these findings are discussed.

The present study was performed in rabbits to test the hypothesis that incisions in the sulcus and soft-tissue undermining at the time of cleft lip repair contribute more to midfacial growth inhibition and aberrations than lip repair only. The design of this study, using three control groups, permitted assessment of the effects of soft-tissue undermining independently of the other surgical procedures. This study revealed that lip repair combined without soft-tissue undermining. Direct cephalometry on the skulls indicated that anteroposterior facial growth was most severely affected mean quantitative assessment revealed that anteroposterior facial growth inhibition was significantly greater when lip repair was combined with soft-tissue undermining than without. Maxillary width was found to be the greatest in groups 3 and 4 compared with the other two groups. Mean quantitative assessment revealed that lip repair with or without soft-tissue undermining was shown to overcorrect normal transversal growth. Significant growth aberrations also were found in maxillary height, posterior facial height, and nasal deflection. Constant high lip pressure can be explained as a result of an interaction of lip repair and scar contraction from soft tissue undermining. Results of this study cannot be readily transferred to the clinical setting, but they present the first documented evidence elucidating the influence of soft-tissue undermining on facial growth. Further experimental and clinical research is needed to determine the extent of growth inhibition that may be related to the use of this procedure.

Complex segregation analysis of pedigrees having nonsyndromic cleft lip with or without cleft palate (CL/P) (Chung et al. 1986; Marazita et al. 1986) has shown that a major-locus model best explains the observed recurrence of CL/P in Caucasian families. To identify this major gene, we compared the frequencies of 12 RFLPs at five loci-epidermal growth factor, transforming growth factor-alpha, epidermal growth factor receptor, glucocorticoid receptor, and estrogen receptor-in both a group of 80 subjects with nonsyndromic CL/P and 102 controls. These candidate genes were selected because studies in rodents had suggested their possible involvement in palatogenesis. A significant association was observed between two RFLPs at the transforming-growth-factor-alpha (TGFA) locus and the occurrence of clefting (P = .0047 and P = .0052). This suggests that either the TGFA gene itself or DNA sequences in an adjacent region contribute to the development of a portion of cases of CL/P in humans and provides an opportunity to begin to examine the molecular events underlying lip and palate formation.

The lip pressure exerted by the repaired cleft lip was studied in 35 rabbits during a 20-week period. Animals were divided into four groups. Two of them were controls, and in the other two, two different surgical procedures were used for the lip repair. The results of this study indicate that there was reduction in lip pressure resulting from the surgically induced cleft lip, alveolus, and palate. Substantial increases in lip pressure were shown in both groups in which lip repair was completed. The influence of primary unilateral cleft lip repair on the facial growth of rabbits in this study will be presented in Part II of this report.

The present study was designed to examine the role of the animal model on investigations of craniofacial growth. Identical experimental protocols were followed using 6-week-old rabbits and 8-week-old beagles. Three groups were used for each species, two control groups and one experimental group. The groups within each experimental model were compared for lip pressure, occlusion, and cephalometrics. Statistical analyses including analyses of correlations were used to evaluate dimensional craniofacial relations. The results of this study revealed that dimensional relations were significantly different in rabbits and beagles despite the similarities observed in overall craniofacial growth aberrations. Analysis of the results does not allow strong conclusions about which animal model (rabbits or beagles) is more appropriate for studying craniofacial growth.

The present study was designed to quantitatively assess lip pressure changes following cleft lip repair in infants with unilateral cleft lip, alveolus, and palate. Lip pressure measurements were taken using an electronic transducer system developed especially for this study. Lip pressure was monitored from 3 months (preoperatively) through 2 years of age in cleft and normal control children. Findings from the present study confirm the hypothesis that lip repair in infants with unilateral cleft lip and palate significantly increases lip pressure and that increased lip pressure remains significantly higher than in normal control children for the 2-year duration of the study. Thus increased lip pressure when the palate is unrepaired has to be considered as a factor modulating subsequent craniofacial growth.

On October 14 to 17, 1987, a meeting entitled "State of the Art Conference: Multidisciplinary Management of Cleft Lip and Palate" was held in Iowa City. The major purpose of the conference was to review the available knowledge concerning management of unilateral cleft lip and palate from the perspectives of surgery, speech-language pathology, and orthodontics. The closing feature of the conference was the identification of issues for future research. Participants identified issues of high priority that were then discussed by the entire conference faculty. This paper reports the summary of that discussion and the recommendations of the Conference.

This study was designed to test the influence of simultaneous cleft lip and palate repair on facial growth in rabbits. Three groups of rabbits were used. Group I consisted of control rabbits who had no surgery; Group II had surgically created, but unrepaired, clefts of the lip, alveolus, and palate; and Group III had surgically created clefts of the lip, alveolus, and palate followed by immediate simultaneous lip and palate repair. In Group III, the lip was repaired using the Millare technique and the palate using two-flap palatoplasty, leaving no bare bone exposed. All animals were sacrificed after twenty weeks. Results of the direct cephalometry of the skulls confirmed that simultaneous lip and palate repair results in inhibition of anterior-posterior and transverse maxillary growth. Some significant changes were also found in mandibular length and nasal deflection. All 15 rabbits with simultaneous cleft lip and palate repair developed anterior crossbites and functional shifts to the left or cleft side. Further analysis comparing the results of facial growth inhibition in this study with inhibition following lip repair only or palate repair only will be necessary to assess the severity of secondary maxillo-facial deformities resulting from lip and palate repair.

The present study was designed to test the hypothesis that undermining of the soft tissues on the surface of the maxilla at the time of lip repair in unilateral cleft lip, alveolus, and palate results in more severe craniofacial growth aberrations than lip repair alone. Sixty-seven purebred beagles were used in this experiment. The animals were divided into four groups: two control groups (unoperated and unrepaired) and two experimental groups (lip repair without undermining and lip repair with undermining). Lip pressures were monitored in all groups. Significantly higher lip pressures were observed in animals with soft-tissue undermining. Cephalometric measurements were analyzed using univariate and multivariate techniques. The results of this study indicate that lip repair performed with soft-tissue undermining results in more severe craniofacial growth aberrations than lip repair performed alone.

Two different methods of lip repair were used on rabbits with surgically created unilateral clefts of the lip, alveolus, and palate. Control groups involved both unoperated animals and those with unrepaired surgically created clefts. The resulting lip pressure in the rabbits with repaired cleft lips was found to be significantly higher than in the control groups. Direct skull measurements showed that the rabbits whose lips had been surgically repaired also had significantly shorter maxillae that did the control groups. The correlation found between the amount of lip pressure and the degree of growth inhibition indicated a causal relationship.

A model was designed for evaluating protocol and management strategies in the multidisciplinary approach to cleft lip and palate treatment. The treatment history and present status of 45 patients 14 to 22 years of age were evaluated by a plastic surgeon, orthodontist, and speech pathologist. Results indicated that only about half of these patients had completed treatment by one of the specialties by the time they were 14 years or older. Even more surprisingly, only 7 patients (16%) had completed treatment by all three specialties by this age. Factors that may contribute to this low percentage of completed treatments are discussed.