Cleft lip and palate is considered to be the most common facial birth defect worldwide. Attempts to repair these deformities date back to the sixteenth century. In 1552, Jacques Houllier proposed that the cleft edges be sutured together, but his operation was unsuccessful. Nearly 200 years later, LeMonnier, a French dentist, successfully completed the repair of a cleft velum. It was not until 1816, however, that the first successful closure of a cleft palate was performed by Carl Ferdinand von Graefe in Germany. An interesting approach was attempted in 1826 by Johan Fredrick Dieffenbach, closing the hard palate and the soft palate. The technique consisted of passing wire through the medial aspect of the cleft, followed by lateral incisions to osteotomize the junction of the palatal bones and the alveolar process; finally, the wires were twisted to close the defect. Unfortunately, this technique had frequent wound breakdowns with subsequent fistula formation.
In the eighteenth century a German surgeon, Bernard Rudolph Conrad von Langenbeck, recognized the potential of periosteum to produce bone. von Langenbeck suggested that inclusion of the periosteum of the palatal bones might produce a stable cleft palate repair. It was not until 1861 that the first cleft palate closures with predictable outcomes were described with a technique that included the use of mucoperiosteal flaps. As a reaction to this, J.B. Hulke, a surgeon at King’s College of London, claimed that the repair described by von Langenbeck was already used in England. Nevertheless, von Langenbeck published a detailed description of his surgical technique in Die Uranoplastikmittelst Ablösung des mucös-periostalen Gaumenuberzuges .
The German triumvirate of von Grafe, Dieffenbach, and von Langenbeck gave birth to the palatoplasty techniques used in modern medicine. Modifications to this technique have been completed, such as that of Billroth in 1868, who thought that fracturing the hamulus would enable better outcomes in surgery. This modification was used for many years and is no longer used because of poor evidence of improvement of the clinical outcome. Victor Veau (1871–1949) made a notable contribution, introducing the pushback technique for the repair of cleft palates. Further modifications of the von Langenbeck technique came from Gillies, Fry, Kilner, Wardill, Dorrance, and Bardach.
Timing and goal
The ultimate goal of the primary repair of a cleft palate is to achieve closure of the hard and soft palates, including any oronasal communication, recreating the natural insertion of the soft palate musculature at the same time. The palatoplasty should create a dynamic soft palate that crosses the lateral and posterior pharyngeal walls to improve velopharyngeal closure. The surgical technique and timing of the repair should be determined on an individual basis. The most important factors are the child’s language and speech ages. The surgery should be performed before speech development of the individual. If the defect is left unrepaired, the child’s intelligibility could develop compensatory articulations that might be difficult to correct.
Comparison of the palatoplasty techniques
Three major surgical techniques used throughout the world for cleft palate repair are the bipedicle flap technique (Von Langenbeck, 1861); opposing Z-plasties technique (Furlow Z-plasty, 1986); and the two-flap technique (Veau-Wardill-Kilner, 1931 and 1937), commonly referred to as the Bardach technique (1987). Each surgical technique has its own technical limitations and theoretic benefits. Studies comparing the techniques showed a wide discrepancy in determining which technique is better. The selection should be performed on an individual basis, considering the age of the patient and the size of the cleft.
The precise cause of maxillary hypoplasia is not clear. Surgical scarring from the cleft palate repair has been reported to cause considerable growth restriction, however. Palmer and colleagues examined the bipedicle flap and two-flap techniques. They concluded that the simpler the surgical technique, the less is the growth restriction.
Jolleys’ observation was that maxillary growth after a von Langenbeck palatoplasty was “slightly better” when compared with a two-flap procedure. These results were not statistically significant in a similar study by Farzaneh and coworkers , however. Bishara and Tharp compared a cephalometric analysis of 55 individuals with isolated cleft palate who had a bipedicle flap palatoplasty and recognized that the growth restriction was not statistically significant.
Pigott and colleagues reported that maxillary growth and articulation pattern improved with a technique that minimized periosteal undermining and residual exposure of the palatal shelves. Furthermore, a histologic animal study suggests that scar tissue firmly attached to bone by Sharpey fibers can be one of the reasons for growth limitation. Using a surgical technique that minimizes the reflection of periosteum might prevent formation of these strong attachments to bone.
In 1931, Victor Veau was the first to identify that speech outcome could be improved by an earlier repair of the cleft palate. Marrinan and colleagues reported a comparison of the bipedicle flap versus two-flap surgical techniques and their effect on the velopharyngeal function. There was no significant difference for the surgical technique.
The frequency of pharyngoplasties after cleft lip palate repair was assessed by Bicknell and colleagues , with no difference in the surgical results. Their observation was that the earlier the repair, the less was the chance of developing velopharyngeal insufficiency. In addition, similar studies have shown comparable results when comparing the different palatoplasty techniques. In contrast, another study demonstrated a similar comparison that the Furlow technique had better speech outcomes.
In summary, any type of palatal surgery performed in a growing child affects maxillary growth. For this reason, the least invasive surgical technique is preferable to minimize scarring and subsequent growth restriction. In addition, the size of the cleft and the experience of the surgeon determine which technique is most appropriate to achieve successful repair of the cleft palate.
Comparison of the palatoplasty techniques
Three major surgical techniques used throughout the world for cleft palate repair are the bipedicle flap technique (Von Langenbeck, 1861); opposing Z-plasties technique (Furlow Z-plasty, 1986); and the two-flap technique (Veau-Wardill-Kilner, 1931 and 1937), commonly referred to as the Bardach technique (1987). Each surgical technique has its own technical limitations and theoretic benefits. Studies comparing the techniques showed a wide discrepancy in determining which technique is better. The selection should be performed on an individual basis, considering the age of the patient and the size of the cleft.
The precise cause of maxillary hypoplasia is not clear. Surgical scarring from the cleft palate repair has been reported to cause considerable growth restriction, however. Palmer and colleagues examined the bipedicle flap and two-flap techniques. They concluded that the simpler the surgical technique, the less is the growth restriction.
Jolleys’ observation was that maxillary growth after a von Langenbeck palatoplasty was “slightly better” when compared with a two-flap procedure. These results were not statistically significant in a similar study by Farzaneh and coworkers , however. Bishara and Tharp compared a cephalometric analysis of 55 individuals with isolated cleft palate who had a bipedicle flap palatoplasty and recognized that the growth restriction was not statistically significant.
Pigott and colleagues reported that maxillary growth and articulation pattern improved with a technique that minimized periosteal undermining and residual exposure of the palatal shelves. Furthermore, a histologic animal study suggests that scar tissue firmly attached to bone by Sharpey fibers can be one of the reasons for growth limitation. Using a surgical technique that minimizes the reflection of periosteum might prevent formation of these strong attachments to bone.
In 1931, Victor Veau was the first to identify that speech outcome could be improved by an earlier repair of the cleft palate. Marrinan and colleagues reported a comparison of the bipedicle flap versus two-flap surgical techniques and their effect on the velopharyngeal function. There was no significant difference for the surgical technique.
The frequency of pharyngoplasties after cleft lip palate repair was assessed by Bicknell and colleagues , with no difference in the surgical results. Their observation was that the earlier the repair, the less was the chance of developing velopharyngeal insufficiency. In addition, similar studies have shown comparable results when comparing the different palatoplasty techniques. In contrast, another study demonstrated a similar comparison that the Furlow technique had better speech outcomes.
In summary, any type of palatal surgery performed in a growing child affects maxillary growth. For this reason, the least invasive surgical technique is preferable to minimize scarring and subsequent growth restriction. In addition, the size of the cleft and the experience of the surgeon determine which technique is most appropriate to achieve successful repair of the cleft palate.
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