MID-FACIAL CONTOUR IN PATIENTS WITHCLEFT LIP AND CLEFT PALATE

Robert F. Hagerty, M.D., and Milton J. Hill, M.S.Cleft Lip and Cleft Palate Center and the Division of Plastic Surgery, Medical College of South Carolina

T HE PEDIATRICIANwith the responsibilityfor directing the care of a child with

a cleft lip and cleft palate is confronted byconflicting points of view in the literature,especially in regard to the effects of palatalsurgery on facial growth and contour. Formany years the majority of plastic surgeonshave recommended repair of the cleft lipin the first few months of life for both functional and cosmetic reasons. The repair ofthe palate is usually carried out during thelatter part of the second year of life toobtain optimal speech and to prevent refluxof food into the nasal fossae and internalauditory meati.

In recent years a sharp attack has beenmade on the results of cleft palate surgeryin regard to the ensuing high incidence offacial disfigurement. These criticisms arise,for the most part, from a group in the Chicago area trained in cephalometric techniques.1-― Their work has been characterized by the presentation of studies of patients with cleft palate exhibiting postoperative deformities and whose facial and dental defects they attributed to “¿�earlyandtraumatic― surgery of the palate. This disfigurement is said to result either directlyfrom operative interference with the maxillary growth centers, or indirectly from postoperative cicatricial contracture.1' Examplesof this point of view are seen in the following quotations from Craber:

“¿�Whatmay be a beautiful surgical successat 2 years of age, may be a facial deformityat 20. A nice soft tissue closure of a palatethat has been relieved of tensional stressthrough fracture of the hamular processes andincisions of the posterior pillars, and has beenwell sutured in the middle, may end up at 20

as a flat, fibrous, functionless scarified diaphragm that has been successful only in itssteel-like grip on futilely struggling maxillarygrowth centers.―

“¿�Cleftpalate individuals as a group show deficient patterns of maxillary growth, laterally,anteroposteriorly, and vertically. Early andtraumatic surgery results in the greatest deformity.―

“¿�Refinementsin surgical procedures and advances in asepsis have only served to amplifythe shortcomings of cleft palate correction.―

“¿�Andmore specifically of interest to us, canorthodontics be expected to recover the mistakes of nature, upon which have been superimposed severe man-made limitations, wheresurgical interference with growth centers anda dense unyielding band of fibrous scar tissuemake any hope of normal development a dubious one?―@

Since the type of cleft palate surgeryunder study was not stated, many readershave interpreted these very serious criticisms as applying to conventional repair ofcleft palate. These criticisms reached sucha point that national periodicals in 1951,131953,'@ and 1954―stressed ideas of the detrimental effects of surgery, advising postponement until the fourth or fifth year oflife. Because of the “¿�disserviceof surgicalintervention,― prostheses were suggested asthe better means of rehabilitation for theindividual with cleft palate. Two unfortunate consequences have resulted: 1) Conventional cleft palate surgery is presentedas a “¿�mutilating―procedure, and 2) palatalsurgery has been postponed in many cases,resulting in less than optimal speech forthe patient.

Since almost all surgery for cleft palaterepair is early if one considers that facial

This investigation was supported by a research grant (D-197) from the National Institute for DentalResearch of the National Institutes of Health, Public Health Service.

ADDRESS:(R.F.H.) Medical College of South Carolina, 55 Doughty Street, Charleston, South Carolina.PEmAmxcs, September 1960

387

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388 CLEFT LIP

than an evaluation of the relative merits ofsurgical techniques. He recommended compression of the dental arch in the first fewmonths of life, and the wiring together ofthe two palatal halves over lead plates.'9Brophy was a most industrious worker in

the Chicago area during the first part of thiscentury and, for a time, had many able andsincere followers, such as Logan,'° Blair,21and Ulrich.22

It is not surprising that these cases operated upon by the Brophy technique havenow grown to maturity and represent a significant percentage of the postoperativecleft-palate and cleft-lip population in theChicago area. It cannot be classed as a major medical breakthrough, however, thatcephalometric studies of these cases revealan unusual degree of facial disfigurement.It must be borne in mind that over onequarter of a century ago this was pointedout with great clarity by Federspiel,23 Kirkham,'4 Rayner,― and a host of others, resulting in the abandonment of this procedurea generation ago.

Other groups studying the problem of facial growth, using the cephalometric technique in postoperative cases of cleft palate,have failed to find the exaggerated differences from the normal as reported in theChicago area. In reports of studies elsewhere26.@2Sand in our own study, the operative procedure is described, the age at oper-'ation stated, and the cases grouped in accordance with, the major classifications ofthe original defect.

Moore and Ponterio'6 presented 41 postoperative cases of cleft palate in a study ofsuch precision and thoroughness that it canwell serve as a model for all such futurework. A soft-tissue surgical technique ofthe Langenbeck type was used in all casesby the chief surgeon or members of his

staff. The initial palatal surgery was carriedout, for the most part, during the first 2years of life. Comparisons were made of themajor groups of cleft palatal defects withnormals in regard to facial growth, and thelinear, and angular measurements statistically analyzed. These authors concluded

growth progresses for the first 19 years oflife'6—and all surgery is traumatic if oneconsiders the damage done to the dividedcells—it would appear that ascribing poorresults of palatal surgery to “¿�earlyandtraumatic― surgery has so little specificitythat it is all but meaningless. The facegrows so rapidly in the firstfew years of

life that if surgery has any deleterious effecton growth, that effect would be mostmarked ifthe surgery were performed prior

to the age of 3. In any study of this sort,one must at least state the type of surgery

that was carried out, the age at operation,and their relation to facial growth. In addition, postoperative and unoperated groupsof the major classes of palatal clefts shouldbe studied individually.

In a recent report from Graber,'7 a mem

ber of the Chicago group opposing ‘¿�earlyand traumatic― palatal surgery, there hasbeen some attempt to conform to this standard in regard to stating the age at operation.Over one-third of the postoperative patientsstudied were reported to have had palatalsurgery within the first 6 months of life. Themost serious facial deformities were foundin these cases. It is obvious that the surgical techniques of Brophy are heavily represented in these studies. Brophy's conception of the cleft palate is as follows:

“¿�Thedeformity, the statements of many authors to the contrary notwithstanding, is notthe result of congenital deficiencies of the partsin question, nor arrested growth of the palate.All children who have congenital cleft palate,with rare exceptions, have in ‘¿�thepalate atbirth the normal amount of tissue. The palatalplates, however, are misplaced upwards andununited in the middle line. The palate is cleft.

Later in lifethe tissuesmay atrophy for want

of use. Therefore, a cleft palate is a fissure,

a now-union of well developed parts,not, with

rare exceptions, the result of arrested development nor failure of a normal quantity of tissue to enter into its structure.―8

Brophy's statements to the contrary notwithstanding, the modern view recognizesthat the parts fail to grow to adequate size.Thus, fundamentals are involved, rather

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T )e*No.CasesMean

Age atTime ofPa.latal

Repair

(mo)Mean

Age atTime of

Lip

Repair

(mo)Mean

Age atTime ofExami

nation

(yr)Type

I & II,ITnop.12——20.4Type

I & II,

Postop.2473.5—14.3fTypeIII,Unop.

1,NormalGroup12 12—23.9 —¿�20.920.9@Type

III,Postop.

1@NormalGroup36 3632.2 —¿�2.9 —¿�14.214.5TypeIV,Unop.5—@4.723.2TypeIV,Postop.10@26.12.1123

ARTICLES 389

that there was a favorable trend in regardto normality among these children, and thatthe anteroposterior and vertical growth ofthe maxilla were essentially the same asseen in the control group.

Jolleys'T reported his findings in the cephalometric examination of 94 postoperative cases of cleft palate. The types of surgical technique under study were: 1) theLangenbeck, 2) the Veau, and 3) the Wardill procedures, all of a soft-tissue type.The major classes of original cleft-palatedefect were compared individually. Thoseoperated upon under 2 years of age showedno more restriction of growth than did thoseoperated upon between 3 and 5 years ofage. As a resultof his studies,the author

recommended palatal repair at 18 monthsof age, using the simplest operation possible.

MacCollum'8 reviewed postoperative results in 112 patients whose cleft palates hadbeen surgically repaired by the use of asoft-tissue technique carried out primarilyduring the first 2 years of life. All of theseoperative procedures were done by a singlesurgeon. Analysis of the facial growth revealed no statistical differences between the

cases under examination and a group ofnormals.

In addition, a preliminary report by Peeret al.―outlined the results of cephalometricexamination of 138 cases (94 bone-flap, 44soft-tissue techniques), and reported no remarkable underdevelopment of the maxillain the postoperative cases of cleft palate ineither group.

SUBJECTS AND PROCEDURES

In the present study, a group of 99 subjectswith cleft palates was compared with a groupof 99 subjectswith normal palates.The groups

were equated as to age and race, but not sex.°There were no severe cranio-facial deviations

0Each subject with cleft palate less than 20

years of age has a corresponding normal subject ofthe same race and within 10 months of the sameage. As the head does not change in size after 20yearsof age,the same carewas not takenwithadult subjects.

other than cleft lip or cleft palate in eithergroup.

The subjectswith cleftpalatein thisstudywere the first99 patientsseen for completeevaluation at the Cleft Lip and Cleft PalateCenter,Medical CollegeHospital,Charleston,South Carolina. These subjects came fromthroughout the state, and those who were postoperative had, for the most part, been operated

upon by generalsurgeonsin the State.The

usual operativeprocedure had been a modified Langenbeck or soft-tissue technique.

In Table I is seen the distribution of casesaccording to the operative state and originaldefect, together with the mean ages of operative repair and mean ages of both the cleftpalate and normal groups at the time of examination for this investigation. Type I represents cleft of the soft palate, Type II cleft ofthe softand hard palate,Type IIIcleftof theentirepalateand alveolarridgeunilateral,and

Type IV represents cleft of the entire palateand alveolar ridge bilateral. The age range ofthe unoperated, Type III group was 6.7 to 37.9years. The age range of the corresponding nor

TABLE I

DISTRIBUTION OF CASES ACCORDING TO THE ORIGINAL

DEFEC-F AND OPERATIVE STATE, WITH MEAN

AGES OF OPERATIVE REPAIR

* Type I represents cleft of the soft palate; Type II

cleft of the soft and hard palate; Type III cleft of theentire palate and alveolar ridge unilateral; and Type

IV cleft of entire palate and alveolar ridge, bilateral.

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Type IllTypeIllUnop.

Norm.Postop.Norm.Caliper

measurementsAPLat

Filmmeasurements

APLat18.47

18.9614.48 14.57

19.04 20.3815.80 15.8518.36

18.3514.50 14.13

19.23 19.4616.20 15.98

390 CLEFT LIP

TABLE II

MEAN ANTEROPOSTERIOR AND LATERAL I)IMENSI0NS

OF SKULL (IN CM)

used in this study, are shown in Figures 1-3.The anterior extensions of the upper and lowerlips were measured in reference to point ANSby projection of these points along FH. Thecross-sectionalareaof the lips(Fig.4), aboveand below lines drawn through points A andB parallel to FH, was measured with a rollingdisc planimeter.

Because clefts of the soft and hard palate,which do notextendthroughthealveolarridge,

are not usually associated with marked abnormalities of facial contour, groups of Type Iand II were not subjected to statistical analysis.In addition, the Type IV group was set asidebecause the premaxilla in this group frequentlybecomes trapped in an anterior position or, insome cases, is resected, making comparativestudies difficult of interpretation. The TypeIII groups were studied in detail, both postoperative and unoperated, and compared withnormal groups matched as to age and race. All12 of the unoperated cases of cleft palate hadrepaired complete unilateral cleft lips. Thirtythree of the 36 postoperative cases of cleftpalate had repaired complete unilateral cleftlips; the remaining three had repaired unilateral incomplete clefts of the lip.

RESULTS

The results of this study are shown inTable III in which the measurements andangles found in the Type III groups, bothpostoperative and unoperated, are recordedand comparisons made with normal groupsmatched as to age and race, and with eachother. The results of t tests are included.Linear measurements of bony growth (1 to5 inclusive) fail to reveal any marked differences between the unoperated and postoperative cases of cleft palate. However,when compared with normals in regard tothe anteroposterior growth of the maxilla,they both show a small but definite reduction. The facial angles and angles of convexity (6 and 7), reliable yardsticks of bonyfacial contour, fail to reveal any significant

differences among the postoperative, unoperated, and matched normal groups. Examination of the various angles involving theincisor teeth (9 to 12 inclusive) reveals amarked and significant lingual version ofthe upper and lower incisor teeth in the

Caliper measurements were obtained with standardx-raycalipers;filmmeasurementsfrom roentgenograms

of the skull along supraorbital and nasion-sella planes.

ma! group was 6.9 to 40.0 years. The age rangeof the postoperative, Type III group was 5.8to 30.0 years, and the range of the corresponding norma! group was 6.9 to 37.9 years.

During the past 2 years, series of roentgenograms of the skulls of normal subjects havebeen collected similar to those taken routinelyin the casesof cleftpalate.The purpose ofthishas been to providea fileof informationon normals for studies of this nature. The normal subjects were obtained from this file. Nosubjects are used in whom there are apparentbony or cosmetic craniofacial deformities. Forthe most part the normal subjects in this studywere clinic outpatients, members of the hospital staff, or relatives of staff members.

In order to determine what differences, ifany, existed between the head sizes of thegroups studied, anteroposterior and lateral dimensions were obtained using standard x-raycalipers. Comparison of the groups by examination of the results disclosed no appreciable differences. In corroboration of these findings,comparison of anteroposterior and lateral dimensions of the skull taken from the films alongthe supra-orbital and nasion-sella planes, respectively, showed only minute differences(Table II).

From conventional and soft-tissue cephalometric roentgenograms,tracingswere made

of the teeth, the pertinent bony outlines, andthe softtissueprofilesof the lips.From thesetracings,measurcments and angleswere takenas ouflined by Wylie.@°The points of reference,together with linear and angular measurements

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ARTICLES 391

0 0FIGS. 1, 2, 3. Diagrams showing derivation of linear and angular measurements.

FIG. 4. Diagram showing derivation of linear and cross-sectional measurements of lips.

postoperative group of cases of cleft palateas compared with the other two groups.Soft tissue studies of the lips (13 to 16 inclusive) show a lack of normal projectionof the upper lip and a significant increasein the cross-sectional area of the lower lip

only in the postoperative group of cases ofcleft palate.

DISCUSSION

It is well known that many people havinga cleft extending through the palate, alveo

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Postop., @\ormalI. f nop.. .\ ormalIt:Postop.&Unop.1.PCtoANS92.5mm97.2mm2.187*92.6mm98.9mm1.4180.03562.Ptm

toANS52.5 mm55.5 mm2.213*52.7 mm58.3mm@2.578*0.0873.Ptm

to ANS%

PC toANS56.76%57.09%0.45656.90%59.0%2.109*0.1564.PCtoPg116.8mm114.6mm0.669112.9mm117.9mm0.960.9865.ANStoN54.7 11111154.9 mm0.11555.9 IHI1156.51111110.2220.5506.Angleofcon

vexity(NA-PgA)1.23°3.51°1.1084.13°2.17°0.7141.3257.Facialangle(NPg-FH)79.47°80.38°0.85280.5°82.29°0.9860.7268.Mandibular.plane

angle(FH-M)35.8°30.83°3.36.5**33.5°26.96°2.802*1.2859.Inter-incisalangle140.15°128.74°3.619**134.17°132.92°0.1911.11410.Max.

inc.-FHplaneangle97.58°105.42°3.618**101.0°104.88°0.9610.96711.Man.

inc.-FHplaneangle58.09°53.92°2.235*55.0°57.42°-0.5971.05612.Man.

inc.-man.plane

angle84.7°95.0°5.467**91.04°95.46°1.1811.90313.Projectionofupper

lip12.1 IflIfl15.8 mm3.702**12.6 mm14.2mm0.8670.33714.Projectionoflower

lip11.0mm9.2mm1.42511.8mm10.1mm0.6110.39815.Cross-sectionalarea

of upper lip353.0 sq.mm368.0 sq. mm0.589314.0 sq.mm369.0 sq.mumI .5401.49716.Cross-sectionalarea

of lower lip336.0 sq. mm288.0 sq. mm2.248*290.0 sq. mm284.0 sq.mm0.2131 .671

392 CLEFT LIP

TABLE III

MEANS OF LINEAR AND ANGULAR MEASUREMENTS OF THE TYPE III IJNOPERATED AND POSTOPERATIVE

CLEF-F-PALATE GROUPS AND THEIR CORRESPONDING NORMAL GROUPS, WITH

VALUES OF THE DIFFERENCES

* Denotes significance at 5% level.

** Denotes significance at 1% level.

lar ridge and lip, have an abnormality offacial contour characterized by a depression or flattening of the mid-face. This hasbeen ascribed by some to the injurious effect of palatal surgery on the growth of themaxilla. In this study no marked differencesin bone growth were seen between the postoperative and unoperated cases of cleft palate (Figs. 5-7). The abnormality of facialcontour which was seen, therefore, cannotbe ascribed to a lack of maxillary growthresulting from conventional soft-tissue palatal surgery.

On the other hand, lingual version of theincisor teeth, both maxillary and mandibu

lar, was a significant finding in the postoperative cases of cleft palate, but not in theunoperated cases. It is difficult to see howpalatal surgery could be responsible for thisresult. If one considers the age at which thelips were repaired, however, an importantfactor comes to light. In the unoperatedcases of cleft palate, the cleft lips were

closed at a mean age of about 24 months.Apparently the same factors which were inforce to prevent palatal surgery affected adelay in lip repair in these cases. As a result

of this delay, the infants were appreciablylarger, with a resultant simplification of thelip surgery for the surgeon. Perhaps other

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393ARTICLES

TVP[fl[POSTOP-@NORMAL -

0

TYPEifi UNOP—¿�NORMAL0

TYPEJilUNOPTYPEIUPOSTOI?

•¿�Fics. 5, 6, 7. Superimposed profiles representing averagemeasurements of the Type III group of postoperative cases

of cleft palate, and the Type III group of unoperated casesof cleft palate, and their corresponding normal groups.

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394 CLEFT LIP

factors, such as the maturity of the dentition and the extent of the calcification of themaxilla at the time of lip surgery, also playa role in the eventual facial contour.

The postoperative cases of cleft palatehad lip repair carried out at a mean age of3 months. To effect a loose full lip in smallinfants of this age requires considerable surgical skill, coupled with a sound plan ofplastic repair. Small technical errors, withfailure to utilize all possible tissue, can leadto gross irregularities and a tight lip in ensuing years.

If it is true that the lingual version of theincisor teeth in these cases is a result of atight postoperative cleft lip, then one wouldexpect to see a protuberant lower lip. It appears to be a general finding in cases of thistype that the tighter the upper lip themore protuberant and redundant the lowerlip. As an indication of this, one can shortenhis upper lip between his fingers and thereby produce an abnormal fullness and projection of the lower lip. Corrective surgeryof a tight upper lip, by rotating a flap fromthe redundant lower lip (the Abbé-Estlander procedure), is frequently used to correct this anatomic phenomenon. The decreased anterior projection of the upper lipin the postoperative group most probablyrepresents the lack of support provided bythe lingually displaced maxillary incisorteeth, since the cross-sectional area of thelip is not reduced. An increased cross-sectional area of the lower lip is found in thisgroup of cases only, and gives further substance to the argument that a tight upperlip contributes significantly to this deformity. The possibility that a tight upper lipmay play a role in limiting anteroposteriorgrowth of the maxilla must also be kept inmind, especially in view of the fact that ina recent study 18 Type III cases, almost entirely unoperated in regard to both lip andpalate, were found to have no abnormalitiesof the angle of convexity or the facial angle.33

CONCLUSIONIn studies of facial contour one must con

sider all the elements concerned: the bony

structures, the teeth and the overlying softtissues. A severe deficiency in any one ofthese three elements,or partialdeficiencies

in two or more of them, can lead to obvious

abnormalitiesof appearance. In thisstudy,

as in severalothers,the bony contribution

to facialcontour was not seen to be mark

edly deficient by conventional linear andangular measurements. The bone growth inthe postoperative cases of cleft palate subjected to conventional soft-tissue palatal

surgery did not differ significantly fromthat of the unoperated cases of cleft palate.There was some lag, however, in anteropostenor maxillary growth in both the postoperative and unoperated cases of cleftpalate. This limitation was quite similarin the two groups and may representan ab

normality fundamental to the congenitaldefect or the compressive effect of tight lipsurgery. If this is true, attention should bedirected to that field where improvement insurgical technique will enhance facial contour, that is, to lip surgery. The recession ofthe mid-face seen in so many conventionallyrepaired clefts involving the entire palate,alveolar ridge and lip may be due, to somedegree, to an inherent limitation of anteroposterior growth of the maxilla, which atthe present time is not subject to correction.

Surgery of the lip, however, is subject to

improvement and plays a most importantrole in facial contour. A tight upper lip hasa compressive effect on the growing maxillary teeth, producing lingual version bysteady pressure. The upper lip, from lack ofsupport, comes to lie in a posterior position,while the lower lip becomes rather full andredundant.

In recent years, important advances in lipsurgery have been made. A full loose lip

can be secured by the complete utilizationof all tissues.31 The use of a palatal bar toprevent collapse of the dental arch at thetime of lip closure is an important adjunct.32In conventional surgery for the repair ofcleft lip and palate, it is the surgery of thelip which should be given primary consideration to obtain the best possible facial contour.

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395ARTICLES

Northwestern Univ. M. School, 23:153,1949.

2. Idem: A cephalometnic analysis of the developmental pattern and facial morphology in cleft palate. Angle Orthodont.,19:91, 1949.

3. Idem: Craniofacial morphology in cleftpalateand cleftlip deformities.Surg.Gynec. & Obst., 88:359, 1949.

4. Idem: Orthodontics for the cleft lip andcleft palate patient. Fort. Rev. ChicagoD. Soc., 18:9, 1949.

5. Idem: Changing philosophies in cleft palatemanagement. J.Pediat.,37:400,1950.

6. Idem: Oral and nasal structures in cleftpalate speech. J.A.D.A., 53:693, 1956.

7. Idem: Problems and limitations of cephalometricanalysisinorthodontics.J.A.D.A.,53:439, 1956.

8. Idem: The role of the orthodontist in acleft palate team. Plast. & Reconstruct.Sung., 14:10, 1954.

9. Idem: The multidiscipline approach to thetreatmentof cleftpalatein children.J.Internat. Coll. Surgeons, 24:370, 1955.

10. Slaughter, W. B., Pruzansky, S., and Harris,H. L.: Cleft lip and cleft palate. Pediat.Clin. North America, November, 1956,pp. 1029-1047.

11. Pruzansky, S.: Factors determining archforms in clefts of the lip and palate. Am.J. Orthodontics, 41:827, 1955.

12. Slaughter, W. B.: Harelip and cleft palatedefects.Sung. Clin. North America,February, 1952, pp. 165-174.

13. Cooper, H. (reported by Spencer, S. M.):“¿�They'renot afraidto look in mirrorsnow.―Saturday Evening Post, 224:28,Oct. 6, 1951.

14. Psychology: Cleft palate parents. Sc. NewsLetter,July25, 1953.

15. Dentistry: Cleft palate repair at age foursucceeds better. Sc. News Letter, April10, 1954.

16. Todd, T. W.: Facialgrowth and mandibular adjustment. Internat. J. Orthodont.,16:1243,1930.

17. Graber, T. M. L.: The congenital cleftpalate deformity. J.A.D.A., 48:375,

1954.18. Brophy, T. W.: Cleft Lip and Palate. Phila

delphia, Blakiston, 1923, p. 73.19. Brophy,T. W.: Surgicaltreatmentofpala

tal defects. Dental Cosmos, 43:317,1901.

20. Logan, W. H. G.: Surgery of cleft palateand cleftlip.J.A.D.A.,14:1095, 1927.

21. Blair, V. P.: The treatment of cleft palateand harelip in early infancy. Intemat.Clin., 4:211, 1916.

SUMMARY

Ninety-nine cases of cleft palate were

studied with conventional and soft tissue

cephalometnic roentgenograms. The Type

III cases (clefts of the entire palate, alveolarridge and lip) were studied in detail andstatistically evaluated. No gross differences

were seen in bony growth of the postoperative and unoperated cases of cleft palate ofthis group. In the postoperative cases ofcleft palate, where the lips had been repaired at an average age of 3 months, therewas a significant lingual version of the incisor teeth, posterior displacement of theupper lip, and exaggerated fullness of thelower lip. This was not seen in the unoperated cases of cleft palate, where the lips

were closed at an average age of 2 years.These contoural abnormalities are believedto be related to a tight, early, lip closureand not to the effects of palatal surgery. Ingeneral, facial contoural abnormalities incases of cleft lip and cleft palate after conventional surgery are believed to be morethe direct result of a tight lip following unsatisfactory surgical repair, resulting in a

collapse of the supporting incisor teeth,than the result of interference with maxillary growth centers by palatal surgery. It isbelieved that surgical techniques developedin recent years will be most effectivein

helping to eliminate such results.In view of the foregoing, it would appear

that conventional palatal surgery can becarried out before the end of the secondyear of life without detriment to the facialcontour, and with maximal opportimity forthe development of good speech. It is mostimportant to effect a loose lip-closure to obtain a more normal facial contour.

Acknowledgment

This work was carriedout in closecoopera

tion with Drs. Wendell L. Wylie and Clarence

E. Calcote, to whom we are deeply indebted.

REFERENCES

1. Graber, T. M.: An appraisal of the developmental deformities in cleft-palateand cleft-lip individuals. Quart. Bull.

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396 CLEFT LIP

22. Ulrich, J.: Fifty-six cases of cleft palatetreated by operation, with special reference to the various methods of operation, and the after-results. Proc. Roy.Soc. Med., 4 (Part III):173, Session1910-1911.

23. Federspiel, M. N.: Hare-lip and cleft palate. Laryngoscope, 32:909, 1922.

24. Kirkman, H. L. D.: Dentition in cleft palate cases. Internat. J. Orthodont., 17:1076, 1931.

25. Rayner, H. H.: The operative treatmentof cleft-palate. Lancet, 1:816, 1925.

26. Ponterio, A. E.: A cephalometric appraisalof the facial pattern of children withclefts of the palate as compared to normal children. Thesis, MS. Dent., Univ.Washington, 1952.

27. Jolleys, A.: A review of the results of operations on cleft palates with referenceto maxillary growth and speech func

tion. Brit. J. Plast. Surg., 7:229, 1954.28. MacCollum, D. W., Richardson, 5. 0.,

and Swanson, L. T.: Habilitation of thecleft palate patient. New England J.Med., 254:299, 1956.

29. Peer, L. A., Hagerty, R. F., Hoffmeister,F. S. and Collito, M. B.: Repair of cleftpalate by the bone flap method. J. Internat. Coil. Surgeons, 22:463, 1954.

30. Wylie, W. L.: Cephalometric syllabus foistudents, 1957. Unpublished.

31. Hagerty, R. F.: Unilateral cleft lip repair.Surg. Gynec. & Obst., 106:119, 1958.

32. Hagerty, R. F.: Cleft lip repair, its orthodontic significance. Angle Orthodont.,27:1, 1957.

33. Ortiz-Monasterio, F., Rebeil, A. S., Valderrama, M., and Cruz, R.: Cephalometricmeasurements on adult patients withnonoperated cleft palates. Plast. & Reconstruct. Surg., 24:53, 1959.

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1960;26;387Pediatrics Robert F. Hagerty and Milton J. Hill

PALATEMID-FACIAL CONTOUR IN PATIENTS WITH CLEFT LIP AND CLEFT

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