Samuel Berkowitz

The Use of Cranial Bone Grafts in the Closure of Alveolar and Anterior Palatal Clefts

A method is described for harvesting cancellous bone from the diploic space. In our opinion, this is the material of choice for bone grafting alveolar clefts in the 7- to 11-year age group. The procedure could be performed at an earlier age if the maxillary segments are under orthopedic control and in proper alignment. Success of the procedure depends on proper orthodontic preparation of the maxillary segments and careful, complete closure of the soft tissues across the anterior palatal cleft, the nasal lining defect, and the anterior alveolus. Results have been encouraging in terms of bone formation, and tooth migration into the bone graft can be expected if there has been no damage to the dental sac. Closure of the alveolar defect at the time of the primary lip closure would preclude the eventual need for a bone graft, but it cannot be accomplished without early, precise alignment of the maxillary segments if extensive periosteal denudation is to be avoided. The age beyond which periosteal closure alone will be inadequate to provide sufficient bone formation and should be supplemented by a bone graft remains to be established.

A comparison of the effects of the Latham-Millard procedure with those of a conservative treatment approach for dental occlusion and facial aesthetics in unilateral and bilateral complete cleft lip and palate: Part I dental occlusion

The purpose of this study was to compare the effect of the Latham-Millard presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion protocol with conservative treatment (nonpresurgical orthopedics without gingivoperiosteoplasty) for palatal and dental occlusion in complete bilateral and complete unilateral cleft lip and palate. All patients were from the South Florida Cleft Palate Clinic. A retrospective dental occlusal study was conducted using serial dental casts that had been taken of patients from birth to 12 years of age. All surgical procedures, except for the secondary alveolar bone grafts in the conservative, nonpresurgical orthopedics group, were performed by D. Ralph Millard, Jr. Ralph Latham supervised the presurgical orthopedics cases. Samuel Berkowitz collected and analyzed all the serial records from 1960 to 1996. Among the patients with complete unilateral cleft lip and palate, 30 patients were treated with presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (the Latham-Millard protocol) and 51 patients were treated conservatively (i.e., nonpresurgical orthopedics without gingivoperiosteoplasty). Among the patients with complete bilateral cleft lip and palate, 21 patients were treated with the Latham-Millard protocol and 49 patients were treated conservatively. Conservative treatment was performed between 1960 and 1980. In patients with bilateral cleft lip and palate, a head bonnet with an elastic strip was used to ventroflex the protruding premaxilla. In all patients (unilateral and bilateral cleft), lip adhesion was performed at 3 months followed by definitive lip surgery at 6 to 8 months and palatal cleft closure between 18 and 24 months of age, in most cases. The Latham-Millard procedure was performed from 1980 to 1996; in bilateral cleft patients, it involved the use of a fixed palatal orthopedic appliance to bodily retract the protruding premaxilla and align it within the alveolar segments soon after birth. In all patients (unilateral and bilateral cleft), palatal alignment was also followed by gingivoperiosteoplasty and lip adhesion. Definitive lip surgery was performed between 6 and 8 months of age, and palatal closure was performed between 8 and 24 months of age using the von Langenbeck procedure with a modified vomer flap. All of the study participants had cleft lips and palates of either the unilateral or bilateral type; the unilateral and bilateral groups were further subdivided based on whether they had received the Latham-Millard protocol or the conservative treatment. It was then determined how many in each of these four basic groups had either anterior or buccal crossbites at four different age levels, when they were approximately 3, 6, 9, and 12 years of age. Although several children entered the study at or just before age 6, every patient in the 9-year-old and 12-year-old sample groups had been in the 6-year-old group and all of the 12-year-olds had been included in the immediate preceding age sample. Two-by-two chi-square tests were carried out within each cleft type (unilateral or bilateral) at each of the four age levels separately, to test whether the treatment groups (protocol versus conservative) differed in the frequency of cases with a given kind of crossbite (rather than not having that kind of crossbite). At every age level, a greater percentage of patients treated with the Latham-Millard protocol developed crossbites than did those treated more conservatively. This difference existed for both the anterior and buccal crossbites and for both unilateral and bilateral clefts. Chi-square tests of the treatment differences in crossbite frequency showed that in three quarters of the Latham-Millard protocol versus conservative treatment comparisons (12 out of 16), a significantly greater frequency of crossbite cases occurred after the Latham-Millard protocol treatment as compared with after the conservative procedure. The chi-square values for the differences in outcome between the two kinds of treatment procedures were greater for the anterior crossbites than for the buccal crossbites, suggesting that the Latham-Millard protocol, relative to the conservative method, was more likely to have an adverse effect on the anterior crossbites than on the buccal crossbites. For those patients born with a bilateral cleft, the differences in crossbite frequency between the protocol and the conservative treatment were statistically significant for patients with an anterior crossbite but not for patients with a buccal crossbite. The analysis shows that in complete bilateral and unilateral cleft lip and palate, the frequency of the anterior crossbite and (except for ages 3 and 12) the buccal crossbite is significantly higher with the Latham-Millard presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion protocol compared with the conservative, nonpresurgical orthopedics without gingivoperiosteoplasty treatment. The exception in the bilateral buccal case may be attributed to the small experimental sample size, which brings down the confidence level.

Cleft palate and craniofacial teams in the United States and Canada : A national survey of team organization and standards of care

Objective This study is the first comprehensive national survey of the organization, function, and composition of cleft palate and craniofacial teams in the U.S. and Canada. Complete descriptions of cleft and craniofacial teams are not currently provided in the literature, and this study will provide an overview for health services research and policy use. Conducted by a national organization, this study examines teams in detail using a pretested and standardized methodology. Design All known (n = 296) North American cleft palate and craniofacial teams were contacted for team listing purposes using a self-assessment method developed by an interdisciplinary committee of national stature. Team clinical leaders classified their teams into several possible categories and provided data on team care. The response rate was 83.4% (n = 247). Results The distribution of listed teams was: 105 (42.5%) cleft palate teams, 102 (41.3%) craniofacial teams (including craniofacial teams that are both cleft palate and craniofacial teams), 12 (4.9%) geographically listed teams, and 28 (11.3%) other teams (including interim cleft palate teams, low-density cleft palate teams, and evaluation and treatment review cleft palate teams). Eighty-five percent of all teams systematically collected and stored clinical data on their teams patient population in the past year. Furthermore, 50% of all teams had a quality assurance program in place to measure treatment outcomes. Other findings presented include the annual number of face-to-face team meetings; new and follow-up patient censuses; and surgical rates for initial repair of cleft lip/palate, orthognathic/osteotomy procedures, and intracranial/craniofacial procedures. Conclusions Two of five North American teams classify themselves as having the capacity to provide both cleft palate and craniofacial care. An additional two of five teams limit their primary role to cleft palate care. Issues are raised regarding the distribution of teams, the regionalization of craniofacial services, health policy, and resource allocation.

Timing of cleft palate closure should be based on the ratio of the area of the cleft to that of the palatal segments and not on age alone

Background: Retrospective and prospective serial spatiotemporal investigations were carried out primarily to determine whether the ratio of the size of the posterior cleft space relative to the palatal surface area limited laterally by the alveolar ridges can be used to select the appropriate time for surgical closure of the palatal cleft space. Two subsamples were compared to determine whether the size of the palate and velocity of palatal development in well growing cases differ from those in cases treated by vomer flap surgery. The prospective investigation asked whether presurgical orthopedics increases the rate of palatal growth and palatal size. Methods: Using the palatal casts of 242 male and female individuals from eight institutions in the United States and Western Europe that followed a variety of treatment protocols, separate serial analyses were conducted of well growing cases with excellent aesthetics, dental occlusion, and speech and a control series of 17 cases of various clefts of the lip and alveolus and/or soft palate but no clefts in the hard palate. Twelve groupings of cases were established depending on their institutional location and type of cleft. Results: Among the various institutions in the study, palatal growth rates and size were statistically similar. Growth in the various clinical series (size, mm2) was less than that of the control series. The ratio of cleft space size to palatal surface area medial to the alveolar ridges was 10 percent or less at 18 months of age in most cases. There was no statistical difference in total surface size between groups, except for one series whose total growth size was least of all. Right and left lateral palatal segments, whether large or small, grew at the same rate. The sample of bilateral cases was too small for statistical comparisons. Presurgical orthopedics did not stimulate palatal growth. The coefficient of variance was less than 10 percent in all measurements. Conclusions: Delaying all cleft closure surgery until 5 years of age and older is unnecessary to maximize palatal growth. The best time to close the palatal cleft space is when the palatal cleft size is 10 percent or less of the total palatal surface area bounded laterally by the alveolar ridges. The 10 percent ratio generally occurs between 18 and 24 months but can occur earlier or later. There is more than one good type of palatal cleft closure surgery.

A Multicenter Retrospective 3D Study of Serial Complete Unilateral Cleft Lip and Palate and Complete Bilateral Cleft Lip and Palate Casts to Evaluate Treatment: Part 1—The Participating Institutions and Research Aims

OBJECTIVEnTo compare the multicenter retrospective and prospective spatiotemporal (4D) serial analyses of complete unilateral (CUCLP) and complete bilateral (CBCLP) cleft lip and palate casts that had undergone different treatment procedures. The involved institutions are Miami Craniofacial Anomalies Foundation, South Florida Cleft Palate Clinic; University Hospital of Nijmegen Cleft Palate Center; Free University of Amsterdam Cleft Palate Center; Academic Hospital (Dijkzigt/Sophia) Rotterdam Cleft Palate Center; Center for Craniofacial Anomalies, University of Illinois College of Medicine; Cleft Palate Center, Sahlgrenska University Hospital, Göteborg, Sweden; and Childrens Memorial Medical Center, Northwestern University Cleft Palate Institute.nnnDESIGNnUsing serial casts of the upper jaw and an electromechanical digitizer with special Cad-Cam software (CadKey), the occlusal relationships and morphometric palatal growth changes that occur under the influence of presurgical orthopedics and various surgical procedures will be studied. It is anticipated that 3D geometric data extracted from serial casts will identify the important geometric palatal parameters present before cleft surgical closure, which will supply objective criteria for establishing a scientific basis for improved surgical therapy. This research study will test three hypotheses: (1) Conservative (varying the timing of surgical cleft closure according to the size of the cleft space) lip and palatal surgery will permit catch-up palatal growth and normalize palatal growth and development. (2) The amount of mucoperiosteal tissue relative to the size of the cleft space is important in determining the timing of palatal surgery, as it influences the degree of scarring and ultimately the palates adult size and form. (3) Presurgical orthopedics (the use of appliances soon after birth) can stimulate palatal growth beyond its normal growth potential.nnnRESULTSnIn a previous project and again after reviewing the data already collected during the first year of this study, it has been shown that incremental changes in size of palatal segments in CUCLP and CBCLP cases prior to surgery vary slightly. The CBCLP cases grow slightly faster than CUCLP cases before surgery, but growth of the CBCLP cases decreases in acceleration after surgery. Reasons for these differences will be determined when more cases are analyzed and subjected to biostatistical analysis.

Shape changes in the cleft palate maxilla: a longitudinal study.

OBJECTIVEnThe purpose of this study was to compare the shape of the maxilla in Norma lateralis of cleft lip and palate (CLP) patients with non-CLP controls matched for sex and age. This study utilized elliptical Fourier functions to assess the presence of residual shape changes in the cleft palate maxilla after treatment, compared with controls.nnnDESIGNnLongitudinal data (n = 25) were available from the Miami Craniofacial Anomalies Foundation. From these data, two samples were selected: group I (mean age and SD, 5.06 +/- 1.82 years) after lip surgery and the initiation of palate surgery and group II (16.58 +/- 2.42 years) well after the conclusion of surgery. Twenty-two of these patients were matched with controls (5.11 +/- 1.33 and 15.91 +/- 2.25 years, respectively). The maxillary outline as seen on the lateral radiograph was (1) traced, (2) fitted with a series of 48 closely placed points, (3) digitized, and (4) submitted to a specially written routine that computes elliptical Fourier functions (EFFs). These EFFs are close analogs of the bounded maxillary outline as judged by the residual or difference between the observed points and the predicted points generated by the Fourier function. Each maxillary outline was subsequently standardized for size and corrected for positioning in two-dimensional space.nnnRESULTS AND CONCLUSIONSnUtilizing a three-way multivariate analysis of variance, statistically significant shape differences were obtained for both young and older groups, as well as between the CLP and controls. No significant gender differences were found. Morphological differences consisted of a posterior repositioning of the nasal crest aspect in the CLP cases. These results suggest that although a clinically satisfactory treatment result was obtained, differences in maxillary shape remain.

Palatal surface area of maxillary plaster casts--a comparison between two-dimensional and three-dimensional measurements.

Objective: To investigate the relationship between corresponding two-dimensional and three-dimensional measurements on maxillary plaster casts taken from photographs and three-dimensional surface scans, respectively. Materials and Methods: Corresponding two-dimensional and three-dimensional measurements of selected linear distances, curve lengths, and (surface) areas were carried out on maxillary plaster casts from individuals with unilateral or bilateral cleft lip and palate. The relationship between two-dimensional and three-dimensional measurements was investigated using linear regression. Results and Conclusions: Error sources in the measurement of three-dimensional palatal segment surface area from a two-dimensional photograph were identified as photographic distortion (2.7%), interobserver error (3.3%), variability in the orientation of the plaster cast (3.2%), and natural shape variation (4.6%). The total error of determining the cleft area/palate surface area ratio was 15%. In population studies, the effect of using two-dimensional measurements is a decrease of discriminating power. In well-calibrated setups, a two-dimensional measurement of the cleft area/palate surface area ratio may be converted to a three-dimensional measurement by use of a multiplication factor of 0.75.

Core curriculum for cleft lip/palate and other craniofacial anomalies: A guide for educators

Alphonse R. Burdi, PhD, Anatomy Samuel Berkowitz, DDS, MS, Orthodontics Mary L. Breen, MS, RN, Nursing Noreen Clarke-Sheehan, MSN, RN, Nursing Virginia M. Curtin, RN, MS, PNP, Nursing Linda L. D’Antonio, PhD, Speech-Language Pathology Craig D. Friedman, MD, Otolaryngology/Head & Neck Surgery Ann Tucker Gleason, PhD, CCC-A, Audiology Donald V. Huebener, DDS, MS, Pediatric Dentistry Marilyn C. Jones, MD, Pediatrics Austin I. Mehrhof, DDS, MD, Plastic Surgery Sharron A. Newton, BSN, Nursing Lynn C. Richman, PhD, Psychology John E. Riski, PhD, Speech-Language Pathology R. Bruce Ross, DDS, MSc, Orthodontics James D. Sidman, MD, Otolaryngology/Head & Neck Surgery Barry Steinberg, PhD, DDS, MD, Oral/Maxillofacial Surgery Sandra Sulprizio, MSPA, Speech-Language Pathology Ruth Trivelpiece, MEd, Speech-Language Pathology Kim S. Uhrich, MSW, CCSW, Social Work Carol R. Ursich, BSN, Nursing Linda D.Vallino-Napoli, PhD, Speech-Language Pathology Leslie A. Will, DMD, MSD, Orthodontics Isaac L. Wornom, III, MD, Plastic Surgery EDITED BY THE 2002–2003 EDUCATION COMMITTEE

The Present State of Treatment in Cleft Palate: What Still Needs to Be Done

In my personal review, cleft palate treatment has entered a new era of evidence-based practice, and society is demanding that clinicians deliver treatment that has been proven to be cost-effective. Although randomized clinical trials in cleft palate have never been performed, there is still excellent evidence from serial studies starting at birth that can be translated into clinical practice. This information will provide evidence for establishing public health policy and treatment planning to maximize good long-term outcome at reduced state and parent costs. The following information describes the essence of how team care should be given by trained and knowledgeable specialists who come together to supply appropriate care in all physical and emotional areas.

Parents' satisfaction with repair of paediatric cleft lip/palate in Honduras

The report by Rivera and co-authors of a thirdworld retrospective study of a limited number of newborns with clefts (incomplete cleft lip and palate and isolated cleft palate) and those with (facial/ palatal) surgical revisions at various ages was well designed but, unfortunately, no significant conclusions can be drawn. The degree of parent expectation and satisfaction with surgical outcome was generally good because the newborn defect was always corrected by 6 months of age. The study demonstrates that surgical facial lip revisions can result in some degree of parent satisfaction, depending on their realistic expectations. Unfortunately, in some instances they wished to see more improvement than was possible. This is generally true when a newborn child’s palatal cleft is closed 6 months after birth. The investigators made every attempt to evaluate the level of surgical satisfaction but owing to the time limit between the newborn surgery and post-surgical evaluation, one cannot conclude that the initial satisfaction will remain the same years later as the face completes development. The authors concluded that expectations in most cases are realistic but that the initial level of satisfaction may change with time. The difficulty of undertaking a scientific study under uncontrolled circumstances is well appreciated. As a Past President of the American Cleft Palate Association’s Educational Foundation and an orthodontist involved in treating children with all forms of facial anomalies, I feel it is important to stress that only trained and knowledgeable surgeons should assume this missionary role in third-world countries. There is no question that a parent with a child with a cleft of the lip and/or palate is anxious about the structural and functional problems and would favour any surgical procedure to correct the defect as soon as possible. The parents usually think that the facial lip defect is ‘torn’ and that the cleft in the palate is a ‘hole’ that needs to be closed. This is no different from what most surgeons thought decades ago and some still believe it even today. Yet, after extensive long-term clinical studies in Europe and the USA, many surgeons now have different views on what needs to be done and when. They have gone from wanting immediate aesthetic satisfaction to the long-term achievement of good speech and dental occlusion as well as good facial aesthetics. They have found that trying to achieve ‘good’ anatomic form soon after birth has often led to poor facial skeletal relationships and function such as a recessive midface with poor speech and dental occlusion. As a result, many clinicians who go to third-world countries whenever possible have changed their initial treatment goals and suggest to parents that the longterm benefits of doing two or three spaced surgeries for the first 3–4 years is more physiological than attaining the immediate results of improved appearance and closure of the palatal ‘hole’ at the expense of good future facial development and function. Missionary surgeons do not usually inform parents of the long-term consequences of one-stage surgery so they remain unaware of these future problems. It is equally unjustifiable that untrained surgeons should participate in surgery that they cannot skillfully perform. Every attempt should be made to convince parents of the long-term benefits when more than one surgical procedure is necessary, and to ensure that they attend the clinic more than once. For example, when treating a child with a complete unilateral cleft lip and palate or complete bilateral cleft lip and palate, the first operation should be lip adhesion to connect each part to obtain lip forces which will reduce the over-expanded palatal segments (termed moulding), thus reducing the size of the cleft palatal space. A year or so later, the reduced cleft space will have changed in size owing to growth of the palatal segments as well as a change in their relationships. Palatal surgery will cause less scarring and result in improved midfacial growth, speech and dental occlusion. Therefore, there will be no change from Corresponding to: S Berkowitz, 11035 Paradela Street, Coral Gables, Florida 33156, USA. Email: SBerk3140@aol.com