Keio Journal of Medicine 34: 139-151, 1985

REVIEW

RECENT TREND OF CLEFT PALATE OPERATION

MITSUHIRO OSADA

Department of Plastic Reconstructive Surgery, School of Medicine,

Tokai University, Boseidai Isehara, Kanagawa, Japan

(Received for publication July 11, 1985)

ABSTRACT

Since the first success to close the cleft palate with muco periosteal flap by

von Langenbeck, many improvements were made not only the technique but

speech therapy, orthodontic treatment and anesthesiology.

The author makes a review on the history of the cleft palate operation, and

present concepts on the treatment of the cleft palate from the standpoint of the

speech results and maxillary growth. Ten years ago, the surgeon made operation

only to gain good speech results, but now he must think of maxillary growth at

the same time.

It is now fell known, that the early operation (1-2 years old) with muco

periosteal flap results mal development of the maxilla. In eastern Europe, late operation (after 3-4 years old) are in common. But in western Europe, United

States and Japan early operation is still prevailing. Several methods were reported

which could preserve maxillary growth, yet problems remain in the speech. The

author wish to introduce these methods, including his two stage method (Osada

method).

INTRODUCTION

The cleft palate is one of a congenital malformation of the face and frequently

seen in daily clinical work. The purpose of the treatment is not only to close the cleft,

but to gain good nasopharyngeal closure to gain normal speech, normal development

of maxilla and good occlusion to enjoy healthy social life.

Since the first success of hard palate closure with bipedicle mucoperiosteal flap

Professor Osada received 1985 Kitajima Prize of School of Medicine, Keio University. This paper is a review of his prize winning work.

139

140 Mitsuhiro Osada

by Langenbeck (1861),' the techniques of cleft palate closure were greatly advanced.

And, those who can gain normal speech with first operation increased with the progress

of the techniques. Especially the studies on the nasopharyngeal closure, articulation

development and anaesthesia had a great role on the speech results.

But the adverse effect of mucoperiosteal flap still used in recent operation is being

apparent which requires hazardous later surgical correction.

The author studied cleft palate and experienced various method, and since 8 years

began new operation, so-called "two stage operation" (Osaka method). This time the

author wish to make a review of recent progress on the treatment of the cleft palate.

[

1] The history of the clett palate operations.

In the era of Greece, Rome and Dark Ages,' cleft were covered with gold plate

or sponge, and its technique developed to present prosthodontia.

Successful closure of the soft palate was performed by Le Monniere1 (1876), and

in 19th century relaxation incision were performed on the lateral wall of the soft palate

to avoid tension. Ultimatily Diffenmachl made long incision including muscle accord

ing to the lateral wall of the soft palate.

It was the Bernard von Langenbeck1 who firstly noticed the necessities to use hard

palate mucosa and periosteum to close the hard palate, and used bilameller muconeriosteal flan which could provide a satisfactory method of performing uranoplasty.

Soon the technique of soft and hard palate closure became widely common, and

the aim of the surgery began to change.

Passavant (1862)1 noticed that the speech after Langenbeck's procedure omen lor

lowed nasal speech. He emphasized the necessity of gaining naso-pharyngeal closure

to gain good speech and attached the soft palate to posterior pharyngeal wall to gain

good nasopharyngeal closure. Since that time efforts were focused to push back the

palate.

Ganzer (1862)1 used single pedicle mucoperisteal flap, and pushed back the palate

by using V-V procedure. Victor Veau (1934)2 separated and sutured mucous mem

brane of the nasal side, and hard palate mucosa was fixed on it.

At present, most widely known method is the modified method of Wardill.s The

nrocedures are as follows:

(1) Elevation of the single pedicle mucoperiosteal flap.

(2) Separation of neurovascular bundle near the greater palatine foramen.

(3) Sectioning the hamullar process.

(4) Separation of the cleft muscle from posterior spine so as enable to reconstruct muscle sling of the soft palate.

(5) Sectioning the mucous membrane of nasal side near the posterior spine to

push back the soft palate.

(6) Sutures are done with 3 layers.

Recent Trend of Cleft Palate Operation 141

Through these procedures, the speech results were greatly improved as compared

with classical Langenbeck's procedure. And it is undeniable that the progress of anes

thesiology made possible to operate early before the learning of the speech.

Recently, more radical methods were reported, such as Cronin's,4 Millard's5 and

Manchester's6 methods which can prevent the scar contractures on nasal side, which

made more apparent the maldevelopment of the maxilla being susceptible to surgical

invasion.

In view of these matters, the cleft palate operation is now shifting from past push

back method to the new techniques to preserve the maxillary growth.

[2] Optimum time for cleft palate operation.

The optimum time to cleft palate operation should be considered from the stand

point of articulation development and maxillary growth.

ú@) From the standpoint of the articulation development.

When a baby is born, he makes the initial cry, which is reflective movement and

being made automatically through inspiration and expiration. Within 3 months the baby

learns to control his crying and express his feeling of hunger, pain and joy. Then he

begins of sound vowels and consonants. At first they are consists of vowel, semi-vowels

and small number of consonants. At the age of 6 months, the frequency of vowels and

consonants become almost equal and consonants become more frequent after 6 months.

After 8 months, the baby has a developmental stage, enjoing to sound various con

sonants, which is called jargon.7-11

After 1 years of age, the baby begins to repeat the sounds of the parents and begins

to repeat the words.

But in case of cleft palate children.12 Before operation the children do not sounds

the consonants which demand intraoral pressure. And the number and variety of the

consonants do not increase as normal children. But after the operation, the development

of the articulation differ according to the patient, Takehisa et al. studied the articulation

development after the cleft palate operation among groups operated at the age of 1 year,

1 year and half and 2 years old.13

Those group operated 1 year old did not show remarkable increase in the con

sonants sounding, but with the coming of echolalia (in this study "echolalia" is the

developmental stage in which the baby actively repeat the sounds which contain 2 or

more syllablalies) the children began to repeat the words of the mothers and others

persons unconsciously. Those who operated 1.5 years old began to repeat soon after the operation. Those who operated 2 years Id began to repeat immediately after the

operation. The average age of the coming the echolalia is 1 year and 11 months and

in 70% of the patients the echolalia appeared between 1 year 10 months and 2 years

old.14

So, those who operated during or after the echolalia remain some errors in articula-

142 Mitsuhiro Osada

tion which they learned before gaining the naso nharvngeal closure.

Those patients operated before echolaria and remained the errors in articulation

and made speech therapy were 5%. Those who were made operation during the "echol

alia", and made speech therapy were 26% and those who operated after the period

of echolaria and made the speech therapy were 95%.

The optimum time for cleft palate operation from the stand point of articulation

development should be decided not on the age of the children, but on the development

of the children which differ on every patients, yet 1 year and half is the optimum

time for the majority of the patient, because on 70;% of the patient echolalia come in

1 year and 11 months.

Fig. 1 Distribution of the "Echo

lalia" among the cleft-palate chil

dren.

úA) Optimum time of cleft palate operation from the stand point of maxillary

The growth of the face are performed by separation and ossification of bony

sutures. In case of the growth of the maxilla, the separation of the pterygomaxillary

suture take an important role, and the role of the periostem of facial wall is very small.

The growth of the face is performed very rapidly immediately after the birth, and

about 70% of the facial growth is performed within 3 years old.15,1

6 According to Ross,17 the cleft palate operation using mucoperiosteal flap since

Langenbeck's method make scar contractures according to the defect of the tissue which

is made after the closure of the cleft, especially on the pterygomaxillary suture, and

make a condition so-called "maxillary ankylosis." This maxillary ankylosis disturbs the

separation and ossification of the sutures. The degree of the ankylosis depends upon

the age of operation, operation method, frequency of operation and techniques of the

operators. The more progress of the technique, the heavier the scar tissue formation,

which disturb the maxillary growth.

Recent Trend of Cleft Palate Operation 143

[3] The new concepts to avoid maldevelopment of the maxilla due to the operation.

In order to avoid maldevelopment of the maxilla after the operation, there are

two ways of concepts. One is to postpone hard palate operation after 3-4 years old,

another is to perform cleft palate operation at the age of 1-1.5 years old with minimum

surgical invasion.

Cleft palate operations are performed in East Germany", at the age of 3 years old,

in Czechoslovakia19 4 years old and in Reningrad20 in USSR at the age of 7 years old.

In western Europe, Graber21,22 recommended to operate after 6 years old, through

his study of maxillary development of the patients operated with mucoperiosteum flap

method.

Slaughter23 recommends to reconstruct muscle sling and close the hard palate after

6 years old. Schweckendiek24,25 close the soft palate at half year old, and then cover

the hard palate with obturators, and surgical closure of the hard palate is recommended

at the age of 11.

Through these method, the maxillary growth are very good as compared with

early push back operation generally performed 1 2 years old. But problem remain

in speech.

In socialistic countries, the patient are asked to attend kindergarden in early age

and they are trained the blowing exercise or others which relate to speech training

through kindergarden life, and ready to start the speech training immediately after the

operation. Still they consume much time and energy for speech training. In order to

perform this way of treatment, many speech pathologists are necessary to give enough

training to the patients.

Another concept is to make the operation at 1.5-2.0 years old with less surgical

invasion.

ú@) Langenbeck's method.

In 1964, Lewin26 send the letters to the plastic surgeons of U.S. and gained the

answer that nearly half of the plastic surgeon use Langenbeck's procedure.

The evaluation of Langenbeck's procedure still divided, some reports for its

superiority to push back methods not only maxillary growth27,28 but speech results.

Others complains the reverse results.29,30 Recently even in Japan, some authors31 are

trying this method, yet final results are not yet reported. Issiki32 use Langenbeck's

bipedicle flap for small segment, and Wardill's mono pedicle flap for large segment in

order to minimize scar contracture.

The author has an opinion through his experience, those who made affirmative

answer to Langenbeck method have a system of good orthodontic treatment after

surgery.

úA) Dunn's vomer flan method.30

In 1959 Dunn reported a method; hard palate is closed with vomer flap, and soft

144 Mitsuhiro Osada

palate is closed with simple suture without relaxation incision. The fistel remained

at the boundary of the hard and soft palate is closed small bibepedicle flap from both

sides secondarily.

In 1974 Stenstrom33 made vomer flap. And he made skingraft to the raw surface

both vomer and flap side, then the flap was returned to former place. After 2 weeks,

hard palate was closed with the vomer flap which has skin graft. Soft palate was closed

with relaxation incision without sectioning of the hamullar process. These methods are

considered to be excellent in maxillary growth, but remain problems in speech results.

úB) One stage closure of the cleft palate with mucous flap.

Widmaire34 closed hard palate with vomer flap, and closed the soft palate with

mucosal flap taken from hard palate. As neurovascular bundle of the hard palate and

periosteum were preserved in this method, remarkable scar tissue were not remained on maxillary tuberosities. The maxillary growth was excellent. Kamiishi35 reported

new designed flap to cover pterygomaxillary junction, and lengthened soft palate with

two Z-planties. And reported the results of 5 years follow-up. The results were ex

cellent.

The author36 closed hard palate with vomer flap, and closed the soft palate with

modified Widmair's method. Push-back of the soft palate was done and the defect at

nasal side was covered with Kaplan's cheek flap, and then covered all raw-surface at

oral side with skin graft.

Perko37 reported to make mucosal flap from hard palate to close the cleft, but as

it was difficult to make long random pattern flap in oral cavity, so the results of opera

tion were not satisfactory.

úC) The author's two stage method. (Osada method)38

This method is mainly for complete cleft lip and palate patients. Soft palate is

closed at the age of 3 months, weighing 6 kg with cleft lip operation simultaneously.

Incision is made to soft palate, and cleft muscle is separated from posterior spine,

and muscle sling is being reconstructed.

In case of the high tension due to wide cleft, mucouse membrane is separated at

the border of the soft and hard palate. After the soft palate closure, the patients are

followed at out-patient clinic every 3 or 4 months, and being examined nasopharyngeal

closure by gag reflex with posterior nasopharyngo scope and mental development is

checked.

The nasopharyngeal closure are scored in three grade.

A) good•¨ prefect closure •¨ about 50%

B) border line •¨ space within 1 or 2 mm is observed by gag reflex

about 30%

C) poor space more than 3 or 4 mm is observed by gag reflex •¨

about 20%

Recent Trend of Cleft Palate Operation 145

Fig. 2 Soft palate closure with

musle sling reconstruction.

Hard palate is closed 1.5-2 years old, before echolalia. Those who belong to Class

A, vomer flap is used to close hard palate and skin graft is performed to the oral raw

surface to prevent scar contracture.

Those who belong class C, pharyngeal flap is performed simultaneously. As the

pharyngeal flap is combined according to the nasopharyngeal closuse, the results of

speech is very excellent. And as nosurgical invasion is performed on maxillary tuber

osities, the growth of the maxilla are also very good.

CONCLUSION

(1) The cleft palate operation experienced the ara only to close the cleft, the ara

to think of the speech and now it is going to change to think of speech and maxillary

growth.

(2) The optimum time for cleft palate operation has two way of thinking, one

146 Mitsuhiro Osada

Fig. 3 Before operation.

Fig. 4 After soft palate closure.

Recent Trend of Cleft Palate Operation 147

Fig. 5 Hard palate closure with vomer flap

and skin graft.

Fig. 6 Before hard palate closure.

is to think of speech results (early operation), the other is to think of maxillary growth

(late operation).

(3) The optimum time for early operation is before "echolalia", which comes

average 1 year and 11 months.

(4) The optimum time for late operation is after 3 or 4 years old. In this cases speech therapy is necessary after the operation.

(5) In western countries, less invasive techniques especially on maxillary tuberosities are under study. But it is difficult to fulfill both speech and maxillary growth.

The author reported a method so-called two stage operation (Osada method)

which could fulfill the both. Speech and maxillary growth after the study of 8 years.

148 Mitsuhiro Osada

Fig. 7 Hard palate is closed with vomer flap.

Fig. 8 Skin graft with many stab hole is placeed, and fixed with tie-over dressing.

Recent Trend of Cleft Palate Operation 149

Fig. 9 4 years after hard palate closure. Skin graft is taken well.

Fig. 10 4 years after operation.

Maxillary growth and occlusion is

quite excellent.

150 Mitsuhiro Osada

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