One of the most widely debated areas in the ­treatment of cleft lip and palate involves the use of presurgical orthopedics and periosteoplasty with lip adhesion (POPLA) designed by Ralph Latham (orthodontist) and D. Ralph Millard, Jr. (plastic surgeon) (Millard 1980, 1986). They contend the POPLA procedure is superior to a conservative nonpresurgical orthopedic treatment (non-POPLA) for producing more aesthetically appealing lip/nose surgery, while still allowing for good midfacial growth and dental occlusion in complete unilateral cleft lip and palate (CUCLP) and complete bilateral cleft lip and palate (CBCLP) patients. This study ­compares the dental occlusion of POPLA with conservative, nonpresurgical orthopedic treatment (non-POPLA), which Millard had been using between 1960 and 1980 (Berkowitz 1996a, b). POPLA proponents and others, who may not resort to a lip adhesion but who still use the same presurgical orthopedic procedure designed by Latham in CBCLP patients for forcefully retracting the protruding premaxilla, favor the attainment of improved facial aesthetics and palatal arch alignment soon after birth with or without periosteoplasty. They speculate that the early aesthetic benefits will remain as the face grows and develops (Millard and Latham 1990; Dufresne and So 1992; Millard et al. 1998; Mulliken 2001).

In CUCLP and CBCLP, presurgical orthopedics is usually followed by periosteoplasty in the expectation that the resulting bone bridging created will avert the need for secondary alveolar bone grafts at a later date.

It is not a simple or a lightly assumed task to offer a brief challenging the rationale for presurgical orthopedics and periosteoplasty for infants with complete unilateral or complete bilateral cleft lip and palate. Advocates of the POPLA concept, or a variant of it, are few but well respected. Their proposed goal of making things right and whole as early as possible seems sensible and has great emotional appeal.

This first of a two-part serial retrospective dental occlusal and facial study covers more than 40 years of recording with serial dental casts and lateral cephaloradiographs, the sequential influences of both the POPLA and conservative non-POPLA procedures on palatal development, and the anterior and buccal dental occlusion. Part one of this study uses serial dental casts to ­determine the extent of anterior and buccal crossbites. Detailed dental occlusal analyses of these records test the efficacy of the POPLA procedure compared to the non-POPLA treatment employed by Millard and Berkowitz from 1960 to 1980 prior to the POPLA treatment years.

Part two of this study will analyze facial changes using serial lateral cephaloradiographs.

Millard and Berkowitz have been associated since 1961 with the South Florida Cleft Palate Clinic, where presurgical orthopedic treatment (PSOT) was not being used. Millard has always been a strong supporter of the importance of serially documenting treatment outcomes with lateral cephalometric radiographs, dental casts, panorexes, and facial/intraoral photographs. To that end, they have worked diligently.

After 20 years of performing nonpresurgical orthopedics (non-PSO) prior to the utilization of the POPLA treatment procedure, Millard published an operational plan to investigate and record facial–palatal changes when utilizing the Latham procedure (Millard et al. 1988). Today, Berkowitz has assembled an extensive collection of serial records that have always been available for review by any interested party. Kai Henkel (1997), a visiting professor of plastic surgery from Rostock, Germany, after reviewing the POPLA treatment serial case records, published a review stating that the procedure resulted in unsatisfactory facial aesthetics and dental function.

After 40 years of recording facial, palatal, and dental growth changes in POPLA and non-POPLA cases, the authors of this brief believe that criticism is in order for a clinical procedure whose outcome results have now been adequately reviewed using serial objective records.

It is unfortunate that a controversy still exists as to the utility of POPLA or similar treatment with or without lip adhesion 20+ years after its introduction and after the critiques to which it has been subjected (Berkowitz 1996a, b). First, Georgiade and Latham (1975) and Latham (Latham 1970, 1973, 1980) have failed to publish any outcome studies. More recently, Millard and Latham have published a limited outcome report using Berkowitz’s palatal cast records (Berkowitz 1996a, b). Millard and Latham’s coauthors Huifen, Spiro, and Morovic performed linear measurements of the changing palatal size rather than analyze the relative growth of the opposing jaws by reviewing the dental occlusion.

Dufresne and So, in their chapter supporting the presurgical orthopedic procedure for CBCLP and CUCLP patients, referred only to Millard’s original introductory statements of the POPLA procedure in Cleft Craft (Vol. III) (Millard 1980) and listed no other supporting references, yet advocate its use (Dufresne and So 1992). Cutting and Grayson (Cutting et al. 1998; Cutting and Grayson 2000) limited their PSOT report to the effect of periosteoplasty in successfully ­producing bone bridging of the alveolar cleft, yet no ­mention was made of its effect on the dental occlusion.

Berkowitz (1996a, b), in a preliminary report, compares Millard’s POPLA with Millard–Berkowitz’s conservatively (non-POPLA) treated CBCLP outcomes. That comparative outcome study confirmed the negative effects of POPLA on facial aesthetics and dental occlusion. The study presented herein expands on that report.

In 1996, Berkowitz and Latham were asked by the American Cleft Palate Craniofacial Association program committee to debate the utility of this procedure at their annual meeting in San Diego, California. At that meeting, Berkowitz and LaRossa (plastic surgeon) ­presented ­long-term case reports that were ­critical of the procedure, but no supporting case studies were forthcoming from Latham and Morales (plastic surgeon).

Many clinicians who advocate the use of Latham’s or any other presurgical orthopedics (PSO) state that one of the appliance’s benefits is to prevent “collapse” of the lateral palatal segments. The frequent use of the word “collapse” to describe palatal arch relationships after neonatal lip surgery is unfortunate and needs to be better understood. The term is misleading for it conjures up an unwarranted sense of foreboding.

The word “collapse” was introduced into the cleft-treatment lexicon in the 1960s by some surgeons and orthodontists to describe the palate’s physical state after uniting of the lip and causing medial palatal movement of overexpanded palatal segments. They evidently did not realize that in complete lip and palatal clefts, the resulting medial palatal movement (molding) is beneficial because it reduces palatal cleft size and corrects the overexpanded palatal segments relationship. Serial studies have shown that overlapping ­palatal segments in the deciduous and mixed dentition are of no clinical importance.

The word “collapse” implies that this condition is bad and should be prevented. However, after years of analyzing serial dental casts, many orthodontists have concluded that establishing lip muscle continuity leads to good geometric ­palatal changes no matter their temporary ­neonatal ­geometric relationship. Overlapped segments do not impede normal palatal growth, and in most cases, such overlapped segments can easily be properly realigned using relatively simple orthodontics. Cleft segments in posterior crossbite at an early age are not indicative of future palatal maldevelopment. Since the width of the cleft space influences the type and timing of surgical palatal closure, one would prefer to have a small cleft space prior to palatal surgery to reduce the possibility of creating growth-inhibiting scarring while producing a normal palatal vault space.

In contrast to conservative non-POPLA cases, POPLA-treated patients require extensive and costly orthodontic treatment to correct the anterior crossbites, regain lateral incisor spaces, and achieve upper to lower anterior arch congruency. Often the degree of facial and palatal distortion is so extensive in POPLA cases that additional surgical intervention is necessary at a later age. Some parents have reported their children’s experiencing psychosocial problems due to the lack of peer acceptance of the concave facial profile.

POPLA in CBCLP (Table 21.1): The bodily retracted protruding premaxilla is retracted and placed in excellent alignment within the alveolar segments (Fig. 21.1a, b). Since no lateral flexion of the nasal septum is seen in cat scans, it was concluded that the premaxilla is “telescoped” posteriorly at the premaxillary vomerine suture (PVS) (Fig. 21.4). The bending at the PVS is also seen in POPLA-treated CUCLP (Fig. 21.5). The PVS is not observed in follow-up palatal POPLA radiographs (Fig. 21.5).

The diagram (Fig. 21.7) is designed to show the error of palatal segmental movements in POPLA CUCLP cases. Our 3D analysis of the CUCLP palatal arch changes demonstrates that the premaxillary portion of the noncleft segment is brought mediopalatally while the smaller cleft segment is advanced, resulting in the loss of the lateral incisor space. This explains why an anterior dental crossbite is most likely to result.

Millard (1980) has written that premaxillary retraction and periosteoplasty might have a negative effect on palatal growth, but he nevertheless believes this trade-off is acceptable to obtain early aesthetics, to close the floor of the nose, and to avoid the need for secondary alveolar bone grafting.

The desire of some surgeons to establish a child’s well-balanced, aesthetically pleasing lips and nose soon after birth is understandable. However, extensive facial growth studies make clear that this should not be the top priority – that is, at the cost of good midfacial growth, dental occlusion, and speech at adolescence (Berkowitz 1996a, b; Pruzansky 1953; Pruzansky et al. 1973; Handelman and Pruzansky 1968; Friede and Pruzansky 1972; Friede 1973, 1977, 1978; Friede and Morgan 1976; Aduss et al. 1973