Craniofacial development after three different palatoplasties in children born with isolated cleft palate

Introduction: Different palatoplasties are applied for the surgical correction of children born with an isolated cleft in the palate (ICP). During the last decades the Veau-Wardill-Kilner (VWK), Minimal Incision (MI) and Minimal Incision with radical muscle reconstruction (MMI) palatoplasties were performed by the Stockholm Craniofacial Team.

Aims: To compare the VWK, MI and MMI techniques for repair of isolated clefts of the soft and/or hard palate regarding surgical complications, dentoalveolar outcome at 5 years, facial growth at 5 and 10 years, and to compare patients with ICP with children born without a cleft at 10 and 16 years of age.

Materials: A consecutive series of 247 Caucasian non-syndromic children born with isolated cleft palate between 1980 and 2007 and treated surgically at 13 months were studied. Children with Pierre Robin Sequence (PRS) were included in the study. The patients were divided into six groups: three groups regarding the three surgical techniques and two groups regarding cleft length (extending in the soft, or hard and soft palate). A control group of 55 children (25 boys and 30 girls) without a cleft registered at 10 years and another 55 (25 boys and 30 girls) at 16 years of age was used.

Methods: Retrospective study of A. medical records of patients treated with MI or MMI concerning time for surgery, blood loss, complications in the immediate postoperative period, frequency of fistulas and additional pharyngeal flap surgery; B. study models of patients treated with MI or MMI at 5 years concerning dental relations, structure of the palatal mucosa, and height of the palatal vault; C1. lateral cephalograms of patients treated with VWK, MMI or MMI at 5, 10 and 16 years of age calculating fourteen skeletal and one soft tissue measurement; C2. lateral cephalograms of patients born without a cleft at 10 and 16 years calculating fourteen skeletal and one soft tissue measurement.

Results: A. surgical complications. The MMI, compared to the MI, technique resulted in statistically significant increased operation time, less need for pharyngeal flaps, and to shallower palatal vault. Big clefts result in statistically significant increased operation time and need for pharyngeal flaps. B. dentoalveolar outcome. Dental relations and the structure of the palatal mucosa were the same in all groups. The palatal height was reduced in the MMI group distal of the first primary molars. C1. facial growth. Only minor differences in cephalometric morphology were found between the techniques at 5 years and 10 years. Comparing VWK to MI, the only statistically significant difference was at 5 years, where a shorter mandible in the MI big cleft group (p<0.01) was found. Comparing MI to MMI, at 5 years, statistically significant increased inclination of the palatal plane in the big MMI cleft group (p<0.01), increased posterior upper face height (p<0.01) and longer mandibular length (p<0.001) in the small MI cleft group was observed. Comparing MI to MMI, at 10 years, statistically significant increased inclination of the palatal plane (p<0.001), decreased posterior upper face height (p<0.001) and longer palatal length (p<0.01) was seen in the big MMI group. Similar results were found independent of cleft length or the inclusion of children with PRS in the sample. C2. Facial growth after MI or MMI versus matched children without a cleft. Comparing children operated with MI to a group without cleft, at both 10 and 16 years of age, a retrognathic, smaller and with a posteriorly inclined maxilla and a retrognathic mandible was measured in treated patients born with a palatal cleft compared to the control group. Additionally, at 10 years of age a smaller mandible and reduced posterior face heights were recorded.

Conclusions: The muscle reconstruction has been shown to result in less need for pharyngeal flaps, but to shallower palatal vault and demand for almost double operation time. Dental relations were the same with or without performed the muscle reconstruction. The craniofacial cephalometric morphology at 5 and 10 years of age in patients with isolated cleft palate is similar between the three surgical groups. The craniofacial morphology at 10 and 16 years of age in treated patients born with an isolated cleft in the palate differs compared to the morphology of a normal control group born without an isolated cleft in the palate: both the maxilla and the mandible are retrognathic, and the maxilla is smaller and posteriorly inclined.

List of scientific papers

I. Facial growth at five and ten years after Veau-Wardill-Kilner versus Minimal-Incision Technique Repair of Isolated Cleft Palate. Parikakis K, Larson O, Larson M, Karsten A. The Cleft Palate-Craniofacial Journal. (2018); 55: 79-87.
https://doi.org/10.1177/1055665617718839

II. Minimal Incision Palatoplasty with or without muscle reconstruction in patients with isolated cleft palate – A cast and medical records analysis. Parikakis K, Larson O, Larson M, Karsten A. European journal of orthodontics. (2018); 40: 504-511.
https://doi.org/10.1093/ejo/cjx090

III. Minimal Incision Palatoplasty with or without muscle reconstruction in patients with isolated cleft palate – A cephalometric study at 5 and 10 years. Parikakis K, Larson O, Karsten A. European journal of orthodontics. (2018). [Accepted]
https://doi.org/10.1093/ejo/cjy077

IV. Facial growth in patients with treated isolated cleft palate compared to a normal population – A cephalometric study at 10 and 16 years of age. Parikakis K, Larson O, Karsten A. [Submitted]