Complete Bilateral Cleft Lip and Palate

  • Samuel Berkowitz
  • Samuel Berkowitz
  • Samuel Berkowitz


Management of the prominent premaxilla in bilateral cleft lip and palate remains challenging, and consequently, many different approaches have been tried. Surgical setback at time of lip repair is one approach that provides immediate resolution of the excessive midfacial prominence. However, follow-up studies have demonstrated severe deleterious effects on midface growth resulting from this treatment (see Chap. 7).

This chapter shows that surgical premaxillary manipulation has not succeeded in reducing the premaxillary prominence. Any approach that results in retraction of the entire premaxilla, including the anterior nasal spine area, has the potential to contribute to maxillary growth inhibition. The currently advocated nasoalveolar molding therapy (NAM) may also succeed in bringing the entire premaxilla back to a position between the lateral segments. This will facilitate a tension-free lip repair and may also allow periosteoplasty to replace missing bone. These procedures contribute to maxillary growth inhibition and interfere with later expansion to correct anterior crossbites.

This chapter shows that lip repair without presurgical orthopedics causes, in most cases, tipping of the premaxilla which reduces the prominence with growth enough to allow a good surgical outcome. The repaired lip will further mold the alveolar process of the premaxilla. Bodily premaxillary retraction will cause an eruption into an anterior crossbite.


Mixed Dentition Deciduous Dentition Facial Convexity Bilateral Cleft Buccal Tooth 
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  1. Aduss H, Friede H, Pruzansky S (1974) Management of the protruding premaxilla. In: Georgiade NG, Hagerty RF (eds) Symposium on management of cleft lip and palate and associated deformities. April 12–14, Duke University, Durham, NC, 1973. CV Mosby, St Louis, pp 111–117Google Scholar
  2. Atherton JD (1967) Morphology of facial bones in skulls with unoperated unilateral cleft palate. Cleft Palate J 4:18–30PubMedGoogle Scholar
  3. Atherton JD (1974) The natural history of bilateral cleft. Angle Orthod 44:269–274PubMedGoogle Scholar
  4. Bergland O, Borchgrevink H (1974) The role of the nasal septum in mid-facial growth in man elucidated by maxillary development in certain types of facial clefts. Scand J Plast Reconstr Surg 8:42–48PubMedCrossRefGoogle Scholar
  5. Bergland O, Semb G, Abyholm F, Borchgrevink H, Eskeland G (1986) Secondary bone grafting and orthodontic treatment on patients with bilateral complete clefts of the lip and palate. Am J Plast Surg 17:460–471CrossRefGoogle Scholar
  6. Berkowitz S (1959) Growth of the face with bilateral cleft lip from 1 month to 8 years of age. University of Illinois School of Dentistry, ChicagoGoogle Scholar
  7. Berkowitz S (1982) Some questions, a few answers in maxilla-mandibular surgery. Clin Plast Surg 9:603–633PubMedGoogle Scholar
  8. Bishara SE, Olin WH (1972) Surgical repositioning of the premaxilla in complete bilateral cleft lip and palate. Angle Orthod 42:139–147PubMedGoogle Scholar
  9. Blocksma R, Leuz CA, Mellerstig KE (1975) A conservative program for managing cleft palates without the use of mucoperiosteal flaps. Plast Reconstr Surg 55:160–169PubMedCrossRefGoogle Scholar
  10. Boyne PJ (1974) The use of marrow cancellous bone grafts in maxillary alveolar and palatal clefts. J Dent Res 14:821–824Google Scholar
  11. Browne D (1969) Hare-lip. Am R Coll Surg 5:1949Google Scholar
  12. Burston WR (1960) The pre-surgical orthopaedic correction of the maxillary deformity in clefts of both primary and secondary palate. In: Wallace AB (ed) Trans-actions of the international society of plastic surgeons, second congress, London, 1959. E&S Livingston Ltd, Edinburgh, London, pp 28–36Google Scholar
  13. Burston WR (1967) Treatment of the cleft palate. Ann R Coll Surg Engl 25:225Google Scholar
  14. Coup TB, Subtelny JD (1960) Cleft palate deficiency or displacement of tissue. Plast Reconstr Surg 26:600CrossRefGoogle Scholar
  15. Dahl E (1970) Craniofacial morphology in congenital clefts of the lip and palate – an x-ray cephalometric study of young adult males. Acta Odontol Scand 28(Suppl):57Google Scholar
  16. Delaire J, Precious D (1985) Avoidance of the use of vomerine mucosa in primary surgical management of velopalatine clefts. Oral Surg Oral Med Oral Pathol 60:589–597PubMedCrossRefGoogle Scholar
  17. Delaire J, Precious D (1986) Influence of the nasal septum on maxillonasal growth in patients with congenital labiomaxillary cleft. Cleft Palate J 23:270–277PubMedGoogle Scholar
  18. Enlow DH (1982) Handbook of facial growth. WB Saunders, PhiladelphiaGoogle Scholar
  19. Enmark H, Bolund S, Jorgensen I (1990) Evaluation of unilateral cleft lip and palate treatment: long term results. Cleft Palate J 27:354–361CrossRefGoogle Scholar
  20. Friede H (1973) Histology of the premaxillary-vomerine suture in bilateral cleft case. Cleft Palate J 10:14–22PubMedGoogle Scholar
  21. Friede H (1977) Studies on facial morphology and growth in bilateral cleft lip and palate. University of Goteborg. Thesis, GoteborgGoogle Scholar
  22. Friede H (1978) The vomero-premaxillary suture – a neglected growth site in mid-facial development of unilateral cleft lip and palate patients. Cleft Palate J 15(4):398PubMedGoogle Scholar
  23. Friede H, Johanson B (1977) A follow-up study of cleft children treated with vomer flap as part of a three-stage soft tissue surgical procedure: facial morphology and dental occlusion. Scand J Plast Reconstr Surg 11:45–57PubMedCrossRefGoogle Scholar
  24. Friede H, Morgan P (1976) Growth of the vomero-premaxillary suture in children with bilateral cleft lip and palate: a histological and roentgenocephalometric study. Scand J Plast Reconstr Surg 10:45–55PubMedGoogle Scholar
  25. Friede H, Pruzansky S (1972) Longitudinal study of growth in bilateral cleft lip and palate from infancy to adolescence. Plast Reconstr Surg 49:392–403PubMedCrossRefGoogle Scholar
  26. Friede H, Moller M, Lilia J, Lauritzen C, Johanson B (1987) Facial morphology and occlusion at the stage of early mixed dentition in cleft lip and palate patients treated with delayed closure of the hard palate. Scand J Plast Reconstr Surg 21:65–71CrossRefGoogle Scholar
  27. Hanada K, Krogman W (1975) A longitudinal study of postoperative changes in the soft-tissue profile in bilateral cleft lip and palate from birth to 6 years. Am J Orthod 67:363–376PubMedCrossRefGoogle Scholar
  28. Handelman C, Pruzansky S (1968) Occlusion and dental profile with complete bilateral cleft lip and palate. Angle Orthod 38:185–198PubMedGoogle Scholar
  29. Harvold E (1954) Cleft lip and palate: morphologic studies of the facial skeleton. Am J Orthod 40:493CrossRefGoogle Scholar
  30. Hellquist R, Svardstrom K, Ponten B (1983) A longitudinal study of delayed periosteoplasty to the cleft alveolus. Cleft Palate J 20:277–288PubMedGoogle Scholar
  31. Latham RA (1969) The septopremaxillary ligament and maxillary development. J Anat 104:584PubMedGoogle Scholar
  32. Latham RA (1973) Development and structure of the premaxillary deformity in bilateral cleft lip and palate. Br J Plast Surg 26:1–11PubMedCrossRefGoogle Scholar
  33. Mazaheri M, Harding RL, Cooper JA, Meier JA, Jones TS (1971) Changes in arch form and dimensions of cleft patients. Am J Orthod 60:19–32PubMedCrossRefGoogle Scholar
  34. McNeil CK (1950) Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec 70:126–132Google Scholar
  35. Millard DR Jr (1978a) The forked flap. In: Millard Dr JR (ed) Cleft craft, 3rd edn. Little, Brown, BostonGoogle Scholar
  36. Millard DR Jr (1978b) The lip-switch flap. In: Millard DR Jr (ed) Cleft craft, 3rd edn. Little, Brown, BostonGoogle Scholar
  37. Millard DR Jr (1980) Cleft craft. Little, Brown, Boston, p 3Google Scholar
  38. Molsted K (1987) Kraniofacial morfologi hos born med komplet unilatral laebe-og ganespalte. University of Copenhagen, CopenhagenGoogle Scholar
  39. Narula JK, Ross RB (1970) Facial growth in children with complete bilateral cleft lip and palate. Cleft Palate J 7:239–248PubMedGoogle Scholar
  40. Posnick JC, Tompson B (1993) Modification of the maxillary Lefort I osteotomy in cleft-orthognathic surgery: the bilateral cleft lip and palate deformity. J Oral Maxillofac Surg 51:2–11PubMedCrossRefGoogle Scholar
  41. Pruzansky S (1953) Description, classification, and analysis of unoperated clefts of the lip and palate. Am J Orthod 39:590CrossRefGoogle Scholar
  42. Pruzansky S (1971) The growth of the premaxillary-vomerine complex in complete bilateral cleft lip and palate. Tandlaegebladet 75:1157–1169PubMedGoogle Scholar
  43. Pruzansky S, Aduss H (1967) Prevalence of arch collapse and malocclusion in complete unilateral cleft lip and palate. Trans Europ Orthod Soc 1–18Google Scholar
  44. Pruzansky S, Friede H (1975) Two sisters with unoperated bilateral cleft lip and palate: age 6 and 4 years. Br J Plast Surg 28:251–258PubMedCrossRefGoogle Scholar
  45. Prysdo V, Holm PC, Dahl E, Fogh-Andersen P (1974) Bone formation in palatal clefts subsequent to palato-vomer plasty: influence on transverse maxillary growth. Scand J Plast Reconstr Surg 8:73–78CrossRefGoogle Scholar
  46. Ross RB (1987) Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J 24:05–77Google Scholar
  47. Scott JH (1956a) The analysis of facial growth, part I: the anteroposterior and vertical dimensions. Am J Orthod 44:507CrossRefGoogle Scholar
  48. Scott JH (1956b) The analysis of facial growth, part II: the horizontal and vertical dimensions. Am J Orthod 44:585CrossRefGoogle Scholar
  49. Semb G (1991) A study of facial growth in patients with bilateral cleft lip and palate treated by the Oslo CLP team. Cleft Palate Craniofac J 28:22–39PubMedCrossRefGoogle Scholar
  50. Smahel Z (1984) Variation in craniofacial morphology with severity of isolated cleft palate. Cleft Palate J 21:140–158PubMedGoogle Scholar
  51. Vargervik K (1983) Growth characteristics of the premaxilla and orthodontic treatment principles in bilateral cleft lip and palate. Cleft Palate J 20:289PubMedGoogle Scholar
  52. Veau V (1934) Le sequalette du bec-de-lievre. Ann Anat Pathol 11:873Google Scholar
  53. Veau V, Borel S (1931) Division palatine. Masson & Cie, Paris, p 35Google Scholar
  54. Wolfe SA, Berkowitz S (1983) The use of cranial bone grafts in the closure of alveolar and anterior palatal clefts. Plast Reconstr Surg 72:659–666PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Samuel Berkowitz
    • 1
  • Samuel Berkowitz
    • 2
  • Samuel Berkowitz
    • 3
  1. 1.Department of OrthodonticsCollege of Dentistry, University of IllinoisChicagoUSA
  2. 2.South Florida Cleft Palate ClinicUniversity of Miami School of MedicineMiamiUSA
  3. 3.Craniofacial Anomalies ProgramMiami Children’s HospitalMiamiUSA

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