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					Scandinavian Journal of Surgery 92: 269–273, 2003


J. Lilja
Department of Plastic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
Key words: Cleft lip; cleft palate; bone grafting; titanium implants

Clefts of the lip, alveolus and/or palate are highly      be surgical addressed in different ways depending
complicated malformations and should be treated in        on the severity (Fig. 1).
a multidisciplinary team. Specialised corrective sur-
gery in the early months of life is necessary to im-
prove function and appearance. Subsequent impair-         SURGICAL PROCEDURES
ment of facial and dental development speech and
hearing are common and may be accompanied by              COMPLETE UNILATERAL CLEFT LIP AND PALATE (UCLP)
social-psychological maladjustment. A large number
of specialist services are necessary if the child’s po-   The surgical procedures addressing the problems
tential is to be maximised. It has been shown that        with the unilateral cleft lip and palate do all include
decentralised care with a low number of patients that     a technique for lengthening the skin of the lip in the
are taken care of by different specialists not working    cleft area. This procedure can vary according to the
in a cleft team has inferior outcome (10).                preference of the surgeon. The best known are those
   Surgery is in most centres performed in many ses-      according to Millard, Tennison and Skoog. The im-
sions, starting with lip-nose repair and soft or hard     portant part of lip repair is, however, reconstruction
palate and then continuing with final closure of the      the muscles entering the lip. This repair should in-
palate. This primary surgery is often completed with-     clude a reconstruction of the zygomatic and nasal
in the first year. The team specialists regarding         muscles separated from the lower part of the orbicu-
growth, speech, hearing and occlusion then follow         lar muscle of the lip (9) (Fig. 2).
the patients. There are general agreements that pa-          In Göteborg we have developed a technique us-
tients that have a cleft in the alveolar process should   ing half of Cupid’s bow as a yardstick. The skin inci-
be treated with bone grafting to the alveolar cleft.
After bone grafting, it is possible to perform ortho-
dontic treatment and a full dental rehabilitation can
be achieved. In those instances where there are miss-
ing teeth and orthodontic treatment not suitable or
possible, prosthodontic treatment is performed, ei-
ther with conventional crowns or bridges or by tita-
nium implants. The patients are followed up to adult-
hood and usually secondary corrective procedures
are performed before treatment is finished.


Cleft lip and palate is a common malformation that
occurs in about 2 in 1000 live births. The cleft can
vary from a hardly visible furrow in the palate or on
one side of the lip to bilateral complete clefts of the
lip alveolus and palate. The different cleft types can

  Jan Lilja, M.D.
  Department of Plastic Surgery                           Fig. 1. Patient with unilateral complete cleft lip and palate. The
  Sahlgrenska University Hospital                         columella is distorted and the alveolar process on the cleft side is
  SE - 413 45 Göteborg, Sweden                            rotated out into the cleft area. Vomer is attached to the palate on
  Email:                           the non cleft side.
270                                                                  J. Lilja

Fig. 2. The most important part of lip repair is the, reconstruction       Fig. 4. Result at four years of age in a boy with complete unilater-
of the muscles entering the lip. This repair should include a re-          al cleft lip and palate.
construction of the zygomatic- and nasal muscles separated from
the orbicular muscle of the lip.

                                                                           of the lip in the cleft areas and as with the unilateral
                                                                           complete cleft lip and palate this procedure can vary
                                                                           according to the preference of the surgeon. The best
                                                                           known are those according to Millard and Manches-
                                                                           ter. Also in the bilateral clefts the important part of
                                                                           the lip repair is the muscle reconstruction. Since the
                                                                           premaxilla and prolabium do not contain any mus-
                                                                           cular tissue, the Orbicularis muscle has to be dissect-
                                                                           ed from the lateral parts of the lip and brought over
                                                                           and united over the premaxilla. In very protruding
                                                                           premaxilla this procedure might be very difficult and
                                                                           therefore the premaxilla usually is repositioned pos-
                                                                           teriorly by dental plates and rubber bands before lip
                                                                           surgery. Another method is to perform a lip adhe-
                                                                           sion, which unites the skin and mucosa but not the
                                                                           muscles. This simple procedure will bring the pre-
                                                                           maxilla posterior aligning the dental arches, facilitat-
                                                                           ing final lip nose repair.
                                                                              In Göteborg the bilateral cleft lip repair starts with
                                                                           a lip adhesion followed by bilateral lip-nose repair
Fig. 3. Half of Cupid’s bow can be used as a yardstick when plan-          at twelve months of age. We then use the same tech-
ning the skin incisions. After measuring half of Cupid’s bow and           nique as with the UCLP using half of Cupid’s bow
keeping this measurement in a calliper the distance can be used            as a yardstick but on both sides.
when the incision lines are drawn (a). After making the incisions
the created flaps can be raised (b). The flaps will fit when sutured,
lengthening the lip in the cleft area (c). The resulting scar will have    Secondary procedures
a zig-zag shape giving less risk for later shortening (d).
                                                                           Since the primary treatment is done very early in life
                                                                           the result will be affected by growth. In most pa-
                                                                           tients, therefore, secondary procedures have to be
sions give sufficient lengthening and at the same time                     performed. These corrections start at pre-school age
muscular reconstruction can be achieved in a proper                        and the last correction will be done after completed
way. Surgery is initiated at 4–6 months of age (Fig. 3).                   growth when the patients are 19 years old. The most
                                                                           common procedures are lip-nose corrections and also
COMPLETE BILATERAL CLEFT LIP AND PALATE (BCLP)                             maxillofacial surgery correcting the anomalies in the
                                                                           jaw relationship (4) (Fig. 4).
The surgical procedures addressing the problems
with the bilateral cleft lip can be divided into those
that includes reconstruction of the orbicularis oris                       PALATE REPAIR
muscle over the premaxilla and those that only leave
the muscles attached to the prolabium on each side.                        In the literature regarding cleft palate treatment,
They all include a procedure for lengthening the skin                      most studies include the treatment of both isolated
                                               Cleft lip and palate surgery                                        271

cleft palates and bilateral and unilateral complete            cases. The speech result differs depending on the type
cleft lip and palate. There are, however, reasons to           of cleft and if the patient has a syndrome or other
regard the isolated cleft palate as an entity on its           concomitant malformation. If there is a persisting
own.                                                           speech problem based on morphological deficiencies,
   Cleft palate is embryological and genetically dif-          this can be surgically corrected by either a palato-
ferent from cleft lip and palate. Compared to cleft lip        pharyngeal flap or a pharyngoplasty. Both methods
and palate, the isolated cleft palate seems, in a high-        reduce the opening from the oropharynx to the nose.
er degree, to be associated with other malformations.          Secondary speech improving surgical procedures
   It is generally said that early palate repair is asso-      were very common with the Veau-Wardil-Kilner
ciated with better speech results. Surgery in the hard         technique. In some studies up to 50 % had to have a
palate has a tendency to produce more severe de-               secondary procedure to improve the speech. With
formities to the occlusion. The potential benefits of          modern techniques this figure has been reduced to
early cleft palate repair from the standpoint of speech        less than 10 % of the patients.
and hearing therefore must be weighed against the
increased technical difficulty of the procedure at
younger age and the possible adverse effect of max-            BONE GRAFTING
illary growth. However, it seems that the important
thing in early palate repair is not the complete clo-          PRIMARY BONE GRAFTING
sure but the functional repair of the muscular sling.
There are no studies that show that the speech re-             Primary and early secondary bone grafting were
sults after complete closure attained by 3 months,             practised mainly in the 1950s and 1960s by a whole
6 months, 1 year or 2 years is better than complete            generation of cleft surgeons.
closure attained at the age of 3 years. It has also been         The indication for primary bone grafting was elim-
noted that the relative size of the cleft as a percent-        ination of bone deficiency, stabilisation of the pre-
age of total palatal area decreases on average 7 % be-         maxilla, creation of new bone matrix for eruption of
tween the ages of 3 months and 17 months. This de-             teeth in the cleft area and augmentation of the alar
crease is secondary to palatal growth and not dimin-           base. There were also expectations of normalisation
ished palatal height or medial collapse of the maxil-          or even stimulation of maxillary growth.
lary arch. A logical step thus would be to operate ear-          Since 1964 many publications suggested that graft-
ly on the soft palate, reconstructing the muscular             ing at this early stage causes serious growth distur-
sling and delay the closure of the hard palate await-          bances of the middle third of the facial skeleton. The
ing optimal spontaneous reduction of the residual              operative technique that involves the vomero-pre-
cleft.                                                         maxillary suture was found to cause inhibition of
   The most common surgical techniques used in the             maxillary growth (4). Though a few centres still per-
world today were developed by von Langenbeck in                form the early bone grafting procedure it was aban-
the 19th century and Veau-Wardil-Kilner about 60               doned in most cleft lip and palate centres world-
years ago. However, follow-up studies have indicat-            wide.
ed that these techniques, especially if they are used
on young children, will give maxillary retrusion and           SECONDARY BONE GRAFTING
also affect the occlusion resulting in cross bites. In
recent years it has been more and more clear that              Secondary bone grafting, meaning bone grafting in
only closure and lengthening of the palate is not              the mixed dentition became, after abandoning prima-
enough. The results can be much improved if the re-            ry bone grafting, an established procedure. Prereq-
pair also includes a functional repair of the muscu-           uisites were precise timing, operating technique, and
lar sling in the soft palate. This can be achieved with        sufficiently vascularised soft tissue, thus the advan-
modern techniques, where the muscles are closed                tages of primary bone grafting allowing tooth erup-
with a Z-plasty, thus reconstructing the levator mus-          tion through the grafted bone could be maintained.
cle and lengthening the palate (5).                            Furthermore, secondary bone grafting can stabilise
   Another possibility is to dissect the levator mus-          the dental maxillary arch, improving the conditions
cles on both sides down to their insertions, then mov-         for prosthodontic treatment such as crowns, bridges
ing them posteriorly and suturing them at the poste-           and implants. It will also facilitate eruption of teeth
rior part of the soft palate (6). In Göteborg we have          increasing the amount of bony tissue on the alveolar
combined the latter method with a delayed closure              crest allowing orthodontic treatment. Bony support
of the hard palate until 3 years of age. The early clo-        to teeth neighbouring the cleft is a prerequisite for
sure of the soft palate with a correct muscle repair           orthodontic closure of the teeth in the cleft region.
will then make it possible for the child to start work-        Thereby more favourable hygienic conditions will be
ing with the palatal muscles during speech produc-             achieved reducing caries and periodontal inflamma-
tion. The residual cleft in the hard palate will then          tion. Speech problems caused by irregular tooth po-
reduce in size up to around 3 years of age. The cleft          sition, or escape of air via the oronasal communica-
in the hard palate can then be closed with a minor             tion may also be improved. Secondary bone grafting
surgical procedure.                                            can also be used to augment the alar base of the nose
   With modern techniques the surgical closure is              to symmetry with the non-cleft side improving fa-
successful in about 90 % of the patients. Dehiscence           cial appearance (Fig. 5).
is rare and fistulas will occur in about 10 % of the              Survival of the donor tissue is an important aspect
272                                                                 J. Lilja

                                                                          erated in the mixed dentition. In most centres more
                                                                          than 95 % of the patients will heal without compli-
                                                                          cations. After bone grafting the teeth neighbouring
                                                                          the cleft area can erupt through the grafted bone and
                                                                          a full upper arch can be achieved by orthodontic
                                                                          means in about 90 % of the patients. The remaining
Fig. 5. Bone grafting to the cleft in the alveolar process is general-    10 % of the patients have to be rehabilitated by con-
ly performed at the time of mixed dentition. The permanent ca-            ventional prosthodontics or crowns on titanium im-
nine is erupting into the cleft area. The crown is still covered by a     plants.
thin shell of bone. It is now time for the bone grafting (a). The
grafted bone has healed and the canine can erupt through the
grafted bone into position in the dental arch (b). The canine has         DONOR SITES FOR HARVESTING BONE GRAFTS
erupted and it has been brought to position by orthodontic
means (c).                                                                Various donor sites for harvesting bone grafts have
                                                                          been used. Autogenous cancellous bone from anteri-
                                                                          or iliac crest is used in many centres. Cancellous bone
on bone grafting. Under optimal conditions, the os-                       can also be harvested from tibia and to a smaller ex-
teogenic cells survive the surgical procedure. It has                     tent from the mandible. Cranial bone and rib has also
been proved in histological and microradiographic                         been used but tooth eruption through these grafts has
clinical and experimental studies, that cancellous au-                    not been demonstrated as successfully as with iliac
togenous bone grafts, harvested from either tibia or                      and tibial bone. Also bone-inducing techniques have
iliac crest, are transformed to the same structure as                     been demonstrated using pedicled periosteum or free
the surrounding maxillary bone. After six months it                       tibial periosteal grafts with moderate results.
is not possible either microradiographically or mor-                         The source of the bone graft does not seem to pri-
phologically to distinguish a biopsy sample from the                      marily influence the success of the outcomes. How-
graft region from one taken from a normal palate at                       ever, disagreement exists about different donor sites
the same age. Furthermore, the architecture of the                        regarding the viability of autogenous bone, morbid-
graft appears to have been adapted to the functional                      ity, amount of bone required, type of bone needed
requirements.                                                             (cortical or cancellous), and expected biological be-
   Cancellous bone: The formation of new bone starts                      haviour (neovascularisation and resorption). Further-
on the surface of the pre-existing trabeculae. Cancel-                    more, the procedure should aim for optimal physio-
lous bone is more vascular, has more spaces, and con-                     logical and psychological function causing minimal
tains more bone regeneration and better ingrowth of                       impairment of growth and development in the max-
new bone from adjacent bone segments. In principle,                       illofacial complex.
cancellous autografts heal primarily by osteogenesis,                        Possible complications from the iliac crest may be
followed considerably later by resorption of the bone                     excessive blood loss, haematoma, delayed wound
trabeculae in the transferred donor tissue.                               healing, pain lasting for 2 weeks to 2 months, long
   Cortical bone: Early establishment of nutrition to                     adherent, and painful scars under belts or clothing
cortical bone cells requires restoration of flow                          and hypoesthesia or anaesthesia over the distribution
through existing vessels or canaliculi and ingrowth                       of the lateral femoral cutaneous nerve. In the crani-
of capillaries. A cortical graft will usually die and be                  um there is a risk for penetration of the inner table
replaced by invasion of bone cells originating from                       and harvesting bone graft from the mandible may
the recipient site. The metabolic turnover and remod-                     cause damage to the roots of the canine and incisor
elling/transformation of cortical bone are much                           and injury of the mental nerve. With taking rib grafts
slower than in cancellous bone, making the re-estab-                      there is a risk for postoperative chest infections and
lishment of the tooth-bearing function of the alveo-                      pneumothorax
lar process in the cortical graft unfeasible (1).

SOFT TISSUE COVERAGE                                                      TITANIUM DENTAL IMPLANTS

Boyne and Sands 1972 (2), were the first to stress the                    Alloplastic materials have been used throughout his-
importance of flap design with the gingival muco-                         tory to replace missing teeth. One of the oldest evi-
periosteal flaps in secondary bone grafting to maxil-                     dences of oral implants emanates from an archaeo-
lary clefts. The gingiva, or masticatory mucosa, con-                     logical find (600 BC) where three mandibular inci-
sists histologically of a layer of keratinised stratified                 sors had been replaced by tooth imitations made
squamous epithelium and dense and firm lamina                             from shells. Other implant materials have been tried
propria with immovable attachments to underlying                          through the centuries, but the outcomes were unsuc-
teeth and bone. The gingiva, therefore, is a suitable                     cessful, and it was not until the last few decades that
surface to support the masticatory load and protect                       clinically acceptable results for oral implants have
against chemical and bacterial damage. The gingival                       been documented. Implant treatment complications
mucoperiosteal flaps, which have a broad base and                         and failures engendered an air of disbelief, which
excellent vascularity and provide, after adequate                         was not dispelled until the successful outcome of
mobilisation, a tension-free closure (7).                                 treatments with osseointegrated implants was pre-
   Bone grafting to the alveolar cleft is a safe proce-                   sented at the Toronto conference in 1982 (11). The
dure with a high success rate if the patients are op-                     documented success of the Brånemark osseointegra-
                                                        Cleft lip and palate surgery                                                   273

Fig. 6. In some patients the lateral incisor or other teeth are missing. If the problem cannot be solved by orthodontic treatment, titanium
dental implants can be used. Patient operated for a complete cleft lip and palate with a lateral incisor missing (a). A titanium implant
inserted (b). Result after rehabilitation with a crown (arrow) on the implant (c).

tion concept was the beginning of a new era for im-                     formed. Titanium implants could therefore be recom-
plant treatment.                                                        mended as the routine treatment in CLP patients
   The Brånemark studies focused on the implant/                        when closure of the dental arch could not be
tissue interface, the purpose being to study the pos-                   achieved by orthodontic means (8) (Fig. 6).
sibility of achieving permanent tissue integration in
a fixed prosthesis. The studies demonstrated direct
contact between anchoring bone tissue and a pure ti-                    REFERENCES
tanium implant surface (3). The bone/titanium con-
nection was named osseointegration by Branemark                         01. Albrektsson T: Healing of bone grafts. In vivo studies of tis-
and defined as “a direct structural and functional                          sue reactions at autografting of bone in the rabbit tibia. The-
                                                                            sis. 1979. Göteborg
connection between ordered, living bone and the sur-                    02. Boyne PJ, Sands NR: Secondary bone grafting of residual al-
face of a load-carrying implant” in the first textbook                      veolar and palatal clefts. J Oral Surg 1972;30:87–92
on osseointegration (Branemark et al. 1985).                            03. Branemark P-I, Hansson BO, Adell R, et al.: Osseointegrated
                                                                            implants in the treatment of the edentulous jaw: experience
                                                                            from a 10-year period. A description of a new procedure for
TITANIUM IMPLANTS IN CLEFT PATIENTS                                         rehabilitation of the edentulous patient and a clinical report
                                                                            of 235 jaws in 211 consecutive cases treated during 1965–1975
One of the first patients with CLP to receive fixtures                      with installation of 1618 titanium fixtures supporting perma-
to replace missing maxillary teeth had surgery per-                         nently bone anchored bridges. Scand J Plast Reconstr Surg
formed at the Department of Plastic Surgery Sahlg-                      04. Friede H: The vomero-premaxillary suture – A neglected
renska University Hospital in Göteborg in co-opera-                         growth site in mid-facial development of unilateral cleft lip
tion with Professor P. I. Branemark. Dental rehabili-                       and palate patients. Cleft Palate J 1978;15:398–404
tation using titanium implants has gradually merged                     05. Furlow LT: Cleft palate repair by double opposing Z-plasty.
                                                                            Plast Reconstr Surg 1986;78(6):724–738
into the routine treatment for patients with CLP. The                   06. Kriens O: Data-objective diagnosis of infant cleft lip, alveo-
surgical technique and the results in 16 consecutive                        lus, and palate. Morphologic data guiding understanding and
patients were reported in 1998 (8). The result showed                       treatment concepts. Cleft Palate Craniofac J 1991;28(2):157–168
that of a total of 31 fixtures, all except two were                     07. Lilja J, Amin K, Friede H, Elander A: Combined bone grafting
osseointegrated at the time of abutment connection                          and delayed closure of the hard palate in cleft lipand palate
                                                                            patients. Cleft Palate Craniofac J 2000;37(1):98–105
and the remaining 29 have all been functional dur-                      08. Lilja J, Yontchev E, Friede H, Elander A: Use of titanium den-
ing the observation period, giving a success rate of                        tal implants as an integrated part of a CLP-protocol. Scand
93 %. All fixtures (100 %) in the group, who did not                        J Plast Reconstr Surg Hand Surg 1998;32:213–219
need any additional bone grafting in connection with                    09. Millard DR Jr: Rotation-advancement method for cleft lip.
                                                                            J Am Med Womens Assoc 1966;21(11):913–915
fixture installation, were osseointegrated. The mean                    10. The Eurocleft Project 1996–2000 Eds; Bill Shaw, Gunvor Semb,
follow-up time after fixture installation was 6 years                       Pauline Nelson, Viveca Brattström, Kirsten Mølsted, Birte
and 3 months and the mean observation time with                             Prahl-Andersen: Publisher IOS Press Nieuwe Hemweg 6b;
loaded fixtures was 5 years and 6 months. The pa-                           1013BG Amsterdam; The Netherlands
                                                                        11. Zarb GA (ed): (1983) Proceedings of the Toronto conference
tients are still coming for follow-ups and now, after                       on osseointegration in clinical dentistry. Reprint from J Pros-
more than 10 years, all fixtures are active and                             thet Dent 49 No. 6 and 1983; 50 Nos. 1, 2, 3. The CV Mosby
integrated. It was concluded that treatment with ti-                        Company, StLouis
tanium dental implants was a safe procedure with
many advantages in CLP patients compared to when
earlier traditional prosthodontic treatment was per-                    Received: July 11, 2003

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