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Original Investigation |

Effect of Lip Closure on Early Maxillary Growth in Patients With Cleft Lip and Palate FREE

Pascal Rousseau, MD, PhD1,2; Marc Metzger, MD, DDS, PhD1; Sibylle Frucht, DDS1,3; Wipke Schupp, MD, DDS1; Mareike Hempel, DDS1; Jörg-Elard Otten, MD, DDS, PhD1
[+] Author Affiliations
1Department of Oral, Maxillofacial, and Facial Plastic Surgery, University of Freiburg, Freiburg, Germany
2Department of Plastic, Aesthetic, and Reconstructive Surgery, Centre Hospitalier Universitaire, Angers, France
3Department of Orthodontics, University of Freiburg, Freiburg, Germany
JAMA Facial Plast Surg. 2013;15(5):369-373. doi:10.1001/jamafacial.2013.335.
Text Size: A A A
Published online

Importance  Debate continues about the cause of midfacial growth disturbance in patients with facial clefts.

Objective  To evaluate the functional effect of surgical closure of the lip before palatal closure according to the technique by Delaire on early maxillary growth in patients with complete unilateral cleft lip and palate.

Design, Setting, and Participants  Twenty-two patients with unilateral cleft lip and palate were studied using plaster casts obtained at the time of cheilorhinoplasty and 6 months later before palatal closure. The interrupted lateral muscles were anatomically repositioned using the surgical technique by Delaire. No patients had received preoperative orthodontic treatment or a passive palatal plate. Cast analyses were performed using a digital caliper.

Main Outcomes and Measures  Landmark positioning was performed 3 times by 2 different examiners to define intraobserver and interobserver differences. The final maxilla dimensions were recorded as the distances between the mean landmark positions. Using the t test, dimensions obtained before palatal closure were compared with dimensions obtained before lip closure.

Results  The method allowed good reproducibility. Functional closure of the lip significantly narrowed the transverse anterior cleft areas by −2.36 mm (P < .05). Sagittal variables were increased by 1.68 mm on the nonaffected side and by 1.48 mm on the affected side (P < .05 for both).

Conclusions and Relevance  Functional closure according to the technique by Delaire narrows the transverse dimensions of the maxilla, while simultaneously preserving initial sagittal growth.

Level of Evidence  4.

Figures in this Article

Debate continues about the cause of midfacial growth disturbance in patients with facial clefts. Initially, intrinsic factors were addressed as a reason for developmental deficiency.1 Subsequently, negative effects of surgical repair were considered an unfavorable variable for maxillary growth.1,2 The exact effects of these 2 midface retrusion variables remain unclear. No visible deficiencies in sagittal growth of the cleft and noncleft sides have been observed in nontreated adult patients with facial clefts, suggesting a predominant surgical reason underlying growth inhibition.35

The literature on iatrogenic surgical maxilla inhibition suggests that lip pressure caused by surgical repair has a particularly large effect during the period following surgical treatment.6,7 Palatal surgical repair has also been considered a major factor in maxilla bone disturbance due to pterygopalatine scar tissue and reduced blood supply to the maxilla after raising palatal mucoperiosteal flaps.1,8,9 Whether lip closure, palatal closure, or both are responsible for midface retrusion is still debated.

Many authors have elucidated the unclear aspects of iatrogenic factors and agreed on the necessity of early orthodontic treatment. Different presurgical appliances are integrated into the treatment concept at most unilateral cleft lip and palate (UCLP) centers. Unfortunately, orthodontic management represents another variable complicating the analysis of maxilla retrusion in many investigations, with debate on later growth of the maxilla.1,10

The aim of this study was to evaluate the functional effect of surgical closure of the lip on early maxillary growth in patients with complete UCLP who had not received orthodontic treatment or a passive palatal plate before any palatal correction. Included in the study were all patients with UCLP in the Department of Oral, Maxillofacial, and Facial Plastic Surgery of Freiburg, Germany, who had undergone cheilorhinoplasty according to the technique by Delaire, a functional approach based on repositioning of the muscular fibers of the interrupted lateral muscles in front of the septum and anterior nasal spine.

Study Design

The principles outlined in the Declaration of Helsinki were followed throughout the study. Patients with complete UCLP treated at the Department of Oral, Maxillofacial, and Facial Plastic Surgery, University of Freiburg, Freiburg, Germany, were recruited for the study between January 1, 2006, and January 31, 2009. Inclusion criteria were complete UCLP and repair according to the technique by Delaire,11 with primary surgical lip closure between ages 5 and 6 months (mean [SD] age, 5.18 [0.85] months) and a second palatal closure 5 to 6 months later (mean [SD] age, 10.45 [2.04] months). Exclusion criteria were association of the cleft with a syndrome, a sequence, or karyotype abnormalities. No patient included in the study had received preoperative orthodontic management or preoperative use of a passive palatal molding plate, representing potential confounding factors.

Twenty-two patients (16 male and 6 female) met the selection criteria and were included in the study. Thirteen had left complete UCLP, and 9 had right complete UCLP.

At the time of surgical lip closure, a preoperative impression was obtained for each patient with alginates (Vivadent Dental GmbH), and orthodontic plaster casts were prepared from these alginate models (Bethmann Dental Discount). Before palatal repair, a second plaster cast was similarly obtained for each of the 22 patients.

Eleven landmarks usually described in the literature1214 were defined on the plaster casts to measure bilateral frontal, sagittal, and vertical maxillary dimensions (Figure 1A). Using these landmarks, 13 maxillary measurements were defined (Figure 1B).

Place holder to copy figure label and caption
Figure 1.
Eleven Landmarks Defined on the Plaster Casts to Measure Bilateral Frontal, Sagittal, and Vertical Maxillary Dimensions

A, Landmarks used for maxillary measurements. B, Distances used for maxillary measurements. I indicates incisory point; C1-C1′, anterior canine point; C2-C2′, posterior canine point; G-G′, point where the lateral sulcus intersects the gingival groove; S-S′, anterior points of the cleft segment of the alveolar rind; and B-B′, base point of the foveolae palatinae.

Graphic Jump Location

For the assessment of maxillary arch dimensions, measurements on the plaster casts were obtained manually with a digital caliper (Schlieblehre M823-160; Mannesmann). This allowed for precision measurement to 0.01 mm.

Each landmark positioning was performed for each model 3 times by 2 examiners (M.M. and M.H.) to define intraobserver and interobserver differences. A washout period of 2 months was observed between positioning performed by the same physician. A comparison was then made between models (before lip closure and before palatal closure) and allowed for analysis of maxillary growth during this 5- to 6-month period.

Statistical Analysis

An initial comparison was performed for the assessment of intraobserver and interobserver differences in methods of measurement. For each distance, the between-observer results were quantified in millimeters, and the mean (SD) difference for 13 distances was calculated per patient. Intraobserver and interobserver reproducibility was calculated using weighted the κ test15 (MedCalc 11.5.0.; MedCalc Software). Statistical significance was set at P = .05.

The mean values for 3 landmark positions were recorded for the final measurements, and a statistical analysis using the t test was then performed for each of 13 dimensions for each of 22 patients with the same software. Results are expressed in mean (SD) millimeters.

The weighted κ test results obtained on 13 dimensions of 22 patients by the 2 examiners are given by observer in Table 1. The results range from 0.64 to 0.90, with mean values of 0.82, 0.76, and 0.75 for intraobserver, first interobserver, and second interobserver differences, respectively. According to the usual κ scale interpretations (with 0.61 considered good and 0.81 considered excellent15), the results revealed no significant difference between observers.

Table Graphic Jump LocationTable 1.  Intraobserver and Interobserver Differences in Landmark Positioninga

The mean maxillary measurements are summarized in Table 2. Between the time of cheilorhinoplasty and palatal closure, the following 3 distances significantly increased: C1-B, C1′-B′, and I-C1. The following 7 distances significantly decreased: C1-C1′, C2-C2′, G-G′, I-C1′, I-C2′, I-S′, and S-S′. (A indicates landmarks used for maxillary measurements; B, distances used for maxillary measurements; I, incisory point; C1-C1′, anterior canine point; C2-C2′, posterior canine point; G-G′, point where the lateral sulcus intersects the gingival groove; S-S′, anterior points of the cleft segment of the alveolar rind; and B-B′, base point of the foveolae palatinae.) The following 3 distances were not significantly changed: B-B′, I-C2, and I-S. A summary of the results is shown in Figure 2.

Place holder to copy figure label and caption
Figure 2.
Summary of Results

A, Maxillary measurements after lip closure. B, Maxillary growth (synthetic results) in millimeters. Black indicates decreased values; red, increased values. Three values (B-B′, I-S, and I-C2′) demonstrated no significant change during the period between lip closure and palatal treatment and are not shown. Functional closure of the lip according to the technique by Delaire leads to narrowing of the lateral dimensions of the maxilla, while preserving early maxillary sagittal growth on the noncleft side (I-C1, I-C2, and C2-B) and on the cleft side (C2′-B′).

Graphic Jump Location

The aim of this study was to evaluate the functional effect of surgical lip closure alone on early maxillary growth using dental casts in patients with UCLP. Measurements obtained on dental casts represent a well-established quantitative method.13,16 Although 3-dimensional (3-D) methods, such as computed tomography, have been proposed for these measurements and show promising results, their use is rare in the management of cleft lip and palate and requires irradiation and patient compliance.17 Little information in the literature addresses the precision and reproducibility of 2-dimensional (2-D) and 3-D landmark positioning that can be used for the edentulous cleft lip and palate maxilla of the infant or the amount of variation that can be considered acceptable. The different methods that have been published lead to errors of up to 1.5 mm on usual measurements18 or up to 1.01 mm in 3-D digitalized models.19 Although a learning effect seems to exist in landmark positioning, it remains indubitable that 2-D analysis and 3-D analysis are plagued with intrinsic confusion about sources and limits.20 Determination of which method should ultimately be used is based on the complexity of the analysis.17 In this study, an initial analysis of the accuracy of the digital caliper measurements was performed, showing acceptable results and reproducibility in accord with the literature13,18 and confirming their use in patients with cleft lip and palate and on plaster casts.2022

Few data exist on physiological growth of the maxillary in the first year of life, and it is difficult to compare the results of patients with UCLP in this study with usual growth of the maxilla in childhood. Nevertheless, our results are consistent with previously published investigations on cast measurements of the width of the alveolar arch before and after lip closure.23 The total growth capacity of the maxillary in millimeters is globally identical in both sagittal and anteroposterior dimensions, corresponding to 3 mm in the first year of life.23 Our main results concerning the preservation of maxillary sagittal growth demonstrated increased values of 1.48 and 1.68 mm on the cleft and noncleft sides, respectively, which is in accord with previously reported results during a 5-month period.23

Although recent work seems to minimize the importance of surgical chronology,24 the pressure caused by lip closure on the anterior cleft of the maxillary has been largely explored.25,26 The lip pressure caused by surgical treatment of the lip and the perioral muscles when the palate is unrepaired seems to have a negative effect on maxillary growth.2729 Opposing viewpoints exist, with some authors considering early palatoplasty the main reason for this retroposition.1,30 Nevertheless, investigations are few on the effect of surgical management alone of unilateral clefts without palatal plates or orthodontic treatment.25 This has led to divergent opinions about lip closure, and the effect of surgery on further growth and stability after treatment is still under discussion.26 The immediate postoperative period has been identified as most critical for maxillary retrusion.6,7 Whether lip pressure or scar tissue is responsible is difficult to judge. Many surgical and medical methods have been tried to decrease pressure on the alveolar and maxillary bone, leading to proposals such as the injection of botulinum toxin into the orbicularis oris muscle.31

Decisions are difficult because preoperative orthodontic management interferes with facial growth32 and leads to anterior arch contraction. Moreover, passive palatal plates have been shown to interfere with facial growth and with the interpretation of surgical results.33

The basis of the technique developed by Delaire was that careful anatomical repositioning of the interrupted lateral muscles leads to normalized growth of the underlying bony structures.11 Delaire’s technique involves wide subperiosteal undermining (maxilla, nasal bone, and zygoma) to the infraorbital rim with dissection of the infraorbital nerve, wide subperichondrial dissection of the cleft side of the nasal septum to allow proper midline placement of the septum, and large dissection, identification, and mobilization of the musculature, leading to reorientation of the muscular fibers. This naturally includes subcutaneous separation of the fibers of the orbicularis oris and the zygomaticus major and zygomaticus minor at the region of the modiolus, as well as identification and separation of the levator labii superioris alaeque nasi and nasalis pars transversa. The identified musculature is anchored to that of the noncleft side on the spina nasalis anterior and on the septum.34,35 The goal of this functional approach is to restore complete function by repair of the lip, nose, maxilla, and palate.

The combination of both pressure and movement of repositioned muscles aims to reestablish a lost balance, leading to restored nasal breathing, physiological osteoperiosteal stimulation, and secondarily, to a proportional growth-inducing effect.36,37 This concept of interaction between primary and secondary growth centers was established by Joos and Friedburg,38 and both magnetic resonance imaging and the histologic findings have demonstrated an intimate connection between the perinasal and perioral muscles and the growth centers of the midface. The anatomical restoration herein (which for others has been achieved with supraperiosteal surgical undermining) was performed using the subperiosteal approach according to Delaire et al.34 To the best of our knowledge, the present study represents the first documentation in the literature that surgery has no measurable negative effect on sagittal growth for 6 months after lip repair.

In conclusion, functional closure cheilorhinoplasty according to the technique by Delaire without preoperative orthodontic management or a passive palatal plate leads to narrowing of the transverse dimensions of the maxilla, while preserving maxillary sagittal growth. This sagittal growth was preserved on the noncleft side and on the cleft side of the maxillary.

Corresponding Author: Pascal Rousseau, MD, PhD, Department of Plastic, Aesthetic, and Reconstructive Surgery, Centre Hospitalier Universitaire, 4 Rue Larrey, 49933 Angers, France (dr.pascal.rousseau@gmail.com).

Published Online: July 18, 2013. doi:10.1001/jamafacial.2013.335.

Author Contributions:Study concept and design: Rousseau, Metzger, Frucht, Otten.

Acquisition of data: Rousseau, Metzger, Frucht, Schupp, Hempel.

Analysis and interpretation of data: Rousseau, Metzger, Hempel, Otten.

Drafting of the manuscript: Rousseau, Metzger, Hempel.

Critical revision of the manuscript for important intellectual content: Rousseau, Metzger, Frucht, Schupp, Otten.

Statistical analysis: Rousseau, Metzger, Hempel.

Obtained funding: Rousseau.

Administrative, technical, and material support: Rousseau, Metzger, Frucht, Otten.

Study supervision: Rousseau, Metzger, Frucht, Otten.

Conflict of Interest Disclosures: None reported.

Ross  RB.  Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J. 1987;24(1):5-77.
PubMed
Williams  AC, Sandy  JR.  Risk factors for poor dental arch relationships in young children born with unilateral cleft lip and palate. Plast Reconstr Surg. 2003;111(2):586-593.
PubMed   |  Link to Article
Mars  M, Houston  WJ.  A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J. 1990;27(1):7-10.
PubMed   |  Link to Article
Bishara  SE, Krause  CJ, Olin  WH, Weston  D, Ness  JV, Felling  C.  Facial and dental relationships of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J. 1976;13:238-252.
PubMed
Normando  AD, da Silva Filho  OG, Capelozza Filho  L.  Influence of surgery on maxillary growth in cleft lip and/or palate patients. J Craniomaxillofac Surg. 1992;20(3):111-118.
PubMed   |  Link to Article
Kramer  GJ, Hoeksma  JB, Prahl-Andersen  B.  Palatal changes after lip surgery in different types of cleft lip and palate. Cleft Palate Craniofac J. 1994;31(5):376-384.
PubMed   |  Link to Article
Kramer  GJ, Hoeksma  JB, Prahl-Andersen  B.  Early palatal changes in complete and incomplete cleft lip and/or palate. Acta Anat (Basel). 1992;144(3):202-212.
PubMed   |  Link to Article
Schweckendiek  W, Doz  P.  Primary veloplasty: long-term results without maxillary deformity. Cleft Palate J. 1978;15(3):268-274.
PubMed
Liao  YF, Cole  TJ, Mars  M.  Hard palate repair timing and facial growth in unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006;43(5):547-556.
PubMed   |  Link to Article
Bongaarts  CA, van ’t Hof  MA, Prahl-Andersen  B, Dirks  IV, Kuijpers-Jagtman  AM.  Infant orthopedics has no effect on maxillary arch dimensions in the deciduous dentition of children with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J. 2006;43(6):665-672.
PubMed   |  Link to Article
Delaire  J.  Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg. 1978;6(2):109-116.
PubMed   |  Link to Article
Leighton  BC.  Morphologische Variation der Alveolarbogen beim Neugeborenen [in German]. Fortschr Kieferorthop. 1976;37:8-14.
Link to Article
Brief  J, Behle  JH, Stellzig-Eisenhauer  A, Hassfeld  S.  Precision of landmark positioning on digitized models from patients with cleft lip and palate. Cleft Palate Craniofac J. 2006;43(2):168-173.
PubMed   |  Link to Article
Mazaheri  M, Harding  RL, Cooper  JA, Meier  JA, Jones  TS.  Changes in arch form and dimensions of cleft patients. Am J Orthod. 1971;60(1):19-32.
PubMed   |  Link to Article
Landis  JR, Koch  GG.  The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.
PubMed   |  Link to Article
Henkel  KO, Gundlach  KK.  Analysis of primary gingivoperiosteoplasty in alveolar cleft repair, part I. J Craniomaxillofac Surg. 1997;25(5):266-269.
PubMed   |  Link to Article
Kane  AA, DeLeon  VB, Valeri  C, Becker  DB, Richtsmeier  JT, Lo  LJ.  Preoperative osseous dysmorphology in unilateral complete cleft lip and palate. Plast Reconstr Surg. 2007;119(4):1295-1301.
PubMed   |  Link to Article
Seckel  NG, van der Tweel  I, Elema  GA, Specken  TF.  Landmark positioning on maxilla of cleft lip and palate infant: a reality? Cleft Palate Craniofac J. 1995;32(5):434-441.
PubMed   |  Link to Article
Boldt  F, Weinzierl  C, Hertrich  K, Hirschfelder  U.  Comparison of the spatial landmark scatter of various 3D digitalization methods. J Orofac Orthop. 2009;70(3):247-263.
PubMed   |  Link to Article
Oosterkamp  BC, van der Meer  WJ, Rutenfrans  M, Dijkstra  PU.  Reliability of linear measurements on a virtual bilateral cleft lip and palate model. Cleft Palate Craniofac J. 2006;43(5):519-523.
PubMed   |  Link to Article
Hansen  L, Skovgaard  LT, Nolting  D, Hansen  BF, Kjaer  I.  Human prenatal nasal bone lengths: normal standards and length values in fetuses with cleft lip and cleft palate. Cleft Palate Craniofac J. 2005;42(2):165-170.
PubMed   |  Link to Article
Nielsen  BW, Mølsted  K, Skovgaard  LT, Kjaer  I.  Cross-sectional study of the length of the nasal bone in cleft lip and palate subjects. Cleft Palate Craniofac J. 2005;42(4):417-422.
PubMed   |  Link to Article
Opitz  C, Kratzsch  H.  Maxilla dimension in patients with unilateral and bilateral cleft lip and palate. J Orofac Orthop. 1997;58(2):110-123.
PubMed
Richard  B, Russell  J, McMahon  S, Pigott  R.  Results of randomized controlled trial of soft palate first versus hard palate first repair in unilateral complete cleft lip and palate. Cleft Palate Craniofac J. 2006;43(3):329-338.
PubMed
Rullo  R, Laino  G, Cataneo  M, Mazzarella  N, Festa  VM, Gombos  F.  The effect of Delaire cheilorhinoplasty on midfacial growth in patients with unilateral cleft lip and palate. Eur J Orthod. 2009;31(1):64-67.
PubMed   |  Link to Article
Eichhorn  W, Blessmann  M, Vorwig  O, Gehrke  G, Schmelzle  R, Heiland  M.  Influence of lip closure on alveolar cleft width in patients with cleft lip and palate. Head Face Med. 2011;7(1):e3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038944/. Accessed June 2, 2013.
PubMed   |  Link to Article
Bardach  J, Bakowska  J, McDermott-Murray  J, Mooney  MP, Dusdieker  LB.  Lip pressure changes following lip repair in infants with unilateral clefts of the lip and palate. Plast Reconstr Surg. 1984;74(4):476-481.
PubMed   |  Link to Article
Bardach  J, Klausner  EC, Eisbach  KJ.  The relationship between lip pressure and facial growth after cleft lip repair: an experimental study. Cleft Palate J. 1979;16(2):137-146.
PubMed
Bardach  J, Eisbach  KJ.  The influence of primary unilateral cleft lip repair on facial growth. Cleft Palate J. 1977;14(1):88-97.
PubMed
Sommerlad  BC, Henley  M, Birch  M, Harland  K, Moiemen  N, Boorman  JG.  Cleft palate re-repair. Br J Plast Surg. 1994;47(6):406-410.
PubMed   |  Link to Article
Tollefson  TT, Senders  CM, Sykes  JM, Byorth  PJ.  Botulinum toxin to improve results in cleft lip repair. Arch Facial Plast Surg. 2006;8(3):221-222.
PubMed   |  Link to Article
Yamada  T, Mori  Y, Mishima  K, Sugahara  T.  Nasolabial and alveolar morphology following presurgical orthopaedic treatment in complete unilateral clefts of lip, alveolus and palate. J Craniomaxillofac Surg. 2003;31(6):343-347.
PubMed   |  Link to Article
Kozelj  V.  Changes produced by presurgical orthopedic treatment before cheiloplasty in cleft lip and palate patients. Cleft Palate Craniofac J. 1999;36(6):515-521.
PubMed   |  Link to Article
Delaire  J, Precious  DS, Gordeef  A.  The advantage of wide subperiosteal exposure in primary surgical correction of labial maxillary clefts. Scand J Plast Reconstr Surg Hand Surg. 1988;22(2):147-151.
PubMed   |  Link to Article
Precious  DS.  Primary unilateral cleft lip/nose repair using the “Delaire” technique. Atlas Oral Maxillofac Surg Clin North Am. 2009;17(2):125-135.
PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed

Figures

Place holder to copy figure label and caption
Figure 1.
Eleven Landmarks Defined on the Plaster Casts to Measure Bilateral Frontal, Sagittal, and Vertical Maxillary Dimensions

A, Landmarks used for maxillary measurements. B, Distances used for maxillary measurements. I indicates incisory point; C1-C1′, anterior canine point; C2-C2′, posterior canine point; G-G′, point where the lateral sulcus intersects the gingival groove; S-S′, anterior points of the cleft segment of the alveolar rind; and B-B′, base point of the foveolae palatinae.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Summary of Results

A, Maxillary measurements after lip closure. B, Maxillary growth (synthetic results) in millimeters. Black indicates decreased values; red, increased values. Three values (B-B′, I-S, and I-C2′) demonstrated no significant change during the period between lip closure and palatal treatment and are not shown. Functional closure of the lip according to the technique by Delaire leads to narrowing of the lateral dimensions of the maxilla, while preserving early maxillary sagittal growth on the noncleft side (I-C1, I-C2, and C2-B) and on the cleft side (C2′-B′).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Intraobserver and Interobserver Differences in Landmark Positioninga

References

Ross  RB.  Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J. 1987;24(1):5-77.
PubMed
Williams  AC, Sandy  JR.  Risk factors for poor dental arch relationships in young children born with unilateral cleft lip and palate. Plast Reconstr Surg. 2003;111(2):586-593.
PubMed   |  Link to Article
Mars  M, Houston  WJ.  A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J. 1990;27(1):7-10.
PubMed   |  Link to Article
Bishara  SE, Krause  CJ, Olin  WH, Weston  D, Ness  JV, Felling  C.  Facial and dental relationships of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J. 1976;13:238-252.
PubMed
Normando  AD, da Silva Filho  OG, Capelozza Filho  L.  Influence of surgery on maxillary growth in cleft lip and/or palate patients. J Craniomaxillofac Surg. 1992;20(3):111-118.
PubMed   |  Link to Article
Kramer  GJ, Hoeksma  JB, Prahl-Andersen  B.  Palatal changes after lip surgery in different types of cleft lip and palate. Cleft Palate Craniofac J. 1994;31(5):376-384.
PubMed   |  Link to Article
Kramer  GJ, Hoeksma  JB, Prahl-Andersen  B.  Early palatal changes in complete and incomplete cleft lip and/or palate. Acta Anat (Basel). 1992;144(3):202-212.
PubMed   |  Link to Article
Schweckendiek  W, Doz  P.  Primary veloplasty: long-term results without maxillary deformity. Cleft Palate J. 1978;15(3):268-274.
PubMed
Liao  YF, Cole  TJ, Mars  M.  Hard palate repair timing and facial growth in unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006;43(5):547-556.
PubMed   |  Link to Article
Bongaarts  CA, van ’t Hof  MA, Prahl-Andersen  B, Dirks  IV, Kuijpers-Jagtman  AM.  Infant orthopedics has no effect on maxillary arch dimensions in the deciduous dentition of children with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J. 2006;43(6):665-672.
PubMed   |  Link to Article
Delaire  J.  Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg. 1978;6(2):109-116.
PubMed   |  Link to Article
Leighton  BC.  Morphologische Variation der Alveolarbogen beim Neugeborenen [in German]. Fortschr Kieferorthop. 1976;37:8-14.
Link to Article
Brief  J, Behle  JH, Stellzig-Eisenhauer  A, Hassfeld  S.  Precision of landmark positioning on digitized models from patients with cleft lip and palate. Cleft Palate Craniofac J. 2006;43(2):168-173.
PubMed   |  Link to Article
Mazaheri  M, Harding  RL, Cooper  JA, Meier  JA, Jones  TS.  Changes in arch form and dimensions of cleft patients. Am J Orthod. 1971;60(1):19-32.
PubMed   |  Link to Article
Landis  JR, Koch  GG.  The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.
PubMed   |  Link to Article
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