PEDIATRIC/CRANIOFACIAL

Two-Stage Palate Repair with Delayed Hard

Palate Closure Is Related to Favorable Maxillary
Growth in Unilateral Cleft Lip and Palate
Yu-Fang Liao, D.D.S., Ph.D.
I-Ying Yang, D.D.S., M.S.
Ruby Wang, M.A.
Claudia Yun, D.D.S., M.S.
Chiung-Shing Huang, D.D.S.,
Ph.D.
Taipei and Taoyuan, Taiwan
Background: Two-stage palate repair with delayed hard palate closure is gen-
erally advocated because it allows the best possible postoperative maxillary
growth. Nevertheless, in the literature, it has been questioned whether maxillary
growth is better following use of this protocol. The authors therefore aimed to
investigate whether stage of palate repair, one-stage versus two-stage, had a
significant effect on facial growth in patients with unilateral cleft lip and palate.
Methods: Seventy-two patients with nonsyndromic complete unilateral cleft lip
and palate operated on by two different protocols for palate repair, one-stage
versus two-stage with delayed hard palate closure, and their 223 cephalometric
radiographs were available in the retrospective longitudinal study. Clinical notes
were reviewed to record treatment histories. Cephalometry was used to deter-
mine facial morphology and growth rate. Generalized estimating equations
analysis was performed to assess the relationship between (1) facial morphology
at age 20 and (2) facial growth rate, and the stage of palate repair.
Results: Stage of palate repair had a significant effect on the length and pro-
trusion of the maxilla and the anteroposterior jaw relation at age 20, but not on
their growth rates.
Conclusions: The data suggest that in patients with unilateral cleft lip and
palate, two-stage palate repair has a smaller adverse effect than one-stage palate
repair on the growth of the maxilla. This stage effect is on the anteroposterior
development of the maxilla and is attributable to the development being un-
disturbed before closure of the hard palate (i.e., hard palate repair timing
specific). (Plast. Reconstr. Surg. 125: 1503, 2010.)

M
axillary retrusion is often seen in patients
with repaired cleft lip and palate. The
main cause of anteroposterior growth dis-
turbances is almost certainly surgical repair of the
hard palate.1–5 In 1921, Gillies and Fry first men-
tioned the idea of two-stage palate repair in re-
sponse to the poor maxillary growth that was ob-
served in children with repaired clefts. They
advised that surgeons should close the soft palate
only and obturate the hard palate. The Schweck-
endieks have used this procedure since 1939, with
excellent facial growth outcome.6 – 8 With their
From the Craniofacial Center, Chang-Gung Memorial Hos-
pital, and the College of Medicine, Chang Gung University.
Received for publication March 11, 2009; accepted Novem-
ber 12, 2009.
Presented in part at the 65th Annual Meeting of the Amer-
ican Cleft Palate–Craniofacial Association, in Philadelphia,
Pennsylvania, April 14 through 18, 2008.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181d5132a
method, the soft palate is repaired early to allow
for normal speech, but hard palate closure is de-
layed until the age of 12 to 14 years. Since then,
the Zurich team9,10 and the Göteborg team11,12
have also used the two-stage method successfully,
although the timing of hard palate repair differs
(7 and 9 years of age, respectively, for the Zurich
and Göteborg teams). However, not every team
found superior maxillary growth after delayed
hard palate closure.8,13–15 There have also been
reports critical to delayed hard palate closure sug-
gesting negative speech outcome.13,15–18
Reports of good growth results from the Zu-
rich team led the Chang Gung Craniofacial Cen-
ter, Taipei, Taiwan, to develop a protocol of de-
layed hard palate closure with a speech prosthesis
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 1503

between 1978 and 1982. This protocol involved
staged palate repair with closure of the soft palate
at 1 year of age and the use of a removable speech
prosthesis until closure of the hard palate at the
age of 6 years. Although the reason to institute the
staged repair protocol at the Chang Gung Cranio-
facial Center was to minimize maxillary growth
disturbance, results showed that speech outcome in
terms of articulation was poor in this group of pa-
tients. Speech prostheses were attempted, but they
also were not found to be beneficial.17 Because of
these results, the Chang Gung Craniofacial Center
abandoned the staged repair protocol in 1982. Only
recently, after patients reached skeletal maturity,
could the maxillary growth outcome be fully as-
sessed. We therefore aimed to investigate whether
stage of palate repair, one-stage repair versus two-
stage repair with delayed hard palate closure, had a
significant effect on facial growth in patients with
unilateral cleft lip and palate.
PATIENTS AND METHODS
Patients were selected from the growth archive
of the Chang Gung Craniofacial Center, Taipei,
Taiwan, by using the following criteria: (1) Tai-
wanese patients with nonsyndromic complete uni-
lateral cleft lip and palate who were born between
1978 and 1992 and treated at the Chang Gung
Craniofacial Center, Taipei, Taiwan; (2) lip repair;
(3) palate repair by either two-stage repair with
delayed hard palate closure (1978 to 1982) or
one-stage repair (1988 to 1992; between 1983 and
1987, the palate was repaired in two stages with
early hard and then soft palate repair); (4) no
orthognathic surgery or distraction osteogenesis
before any cephalometric assessment; and (5) at
least one cephalometric assessment after lip and
palate repair.
A total of 72 patients met the selection criteria
and their 223 cephalometric radiographs were
available for the study. These patients were di-
vided into two groups according to the stage of
palate repair: the two-stage group (n ⫽ 41) and the
one-stage group (n ⫽ 31). Table 1 lists the char-
acteristics of the two groups. In the two-stage
group, only the soft palate was closed initially, and
closure of the hard palate was delayed until ap-
proximately 6 years of age using a vomerine mu-
coperiosteal flap. In the one-stage group, the pal-
ate was closed completely in a single procedure at
approximately 1 year of age using a two-flap
technique.19 Nine different surgeons were in-
volved in all primary repairs, but all of them were
trained by the same surgeon (Dr. M. Samuel
Noordhoff). Four of them worked consecutively.
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Plastic and Reconstructive Surgery • May 2010
Treatment History
Two investigators (I.-Y.Y. and R.W.) examined
each patient’s clinical notes. Details of primary
repair were recorded, including the stage of the
repair, the age at the time of repair, the techniques
used, and the grade of surgeons (attending, res-
ident) who performed the repair. Passive infant
orthopedics, full-mouth orthodontic treatment,
presence of a symptomatic oronasal fistula, velo-
pharyngeal function, velopharyngeal flap surgery,
secondary Furlow palatoplasty, secondary alveolar
bone grafting, and need for Le Fort I advance-
ment or distraction were also recorded.
Velopharyngeal function was assessed by two
experienced speech therapists perceptually and
instrumentally. Perceptual data were collected on
a standardized speech sample where every patient
counted from 1 to 10, read or repeated sentences
from Chang Gung Memorial Hospital Mandarin
Chinese Speech Assessment, and engaged in a
brief conversation with the therapist. The key fea-
tures examined included the presence or absence
of nasal emission, grimace, voice disorders, hyper-
nasality, and compensatory articulation disorders.
The patients with symptoms of velopharyngeal
inadequacy underwent nasoendoscopy. Nasoen-
doscopy was carried out by a flexible endoscope.
Patients repeated a series of consonant-vowel com-
binations (e.g., /pipipi/), sentences (baba pau
bu), and counting from 1 to 10. Adequate velo-
pharyngeal function was defined as absence of
nasal emission, grimace, voice disorders; and nor-
mal resonance and articulation characterized by
either normal, developmental errors, or errors not
related to velopharyngeal inadequacy. Patients
with the symptoms of hypernasality and/or com-
pensatory articulation disorders and with velopha-
ryngeal closure less than 0.7 under nasoendoscopy
were considered to have inadequate velopharyn-
geal function. The rest were considered to have
marginal velopharyngeal function.
Cephalometry
Lateral cephalometric radiographs were ob-
tained for each patient at one or several time
points. Every lateral cephalometric radiograph
was taken on the same cephalostat according to
the standardized cephalometric guideline, with
the natural head position and the teeth in centric
occlusion. The enlargement factor was 11 percent.
One investigator (I.-Y.Y.) traced and superim-
posed all of the cephalometric radiographs and
measured the variables without knowing the pa-
tient’s previous treatment history. Superimposi-
Volume 125, Number 5 • Delayed Hard Palate Closure

Table 1. Summary of Patient Characteristics

Characteristic One-Stage (n ⴝ 31) (%) Two-Stage (n ⴝ 41) (%) p*
Sex
Male 58 (18) 68 (28) NS
Female 42 (13) 32 (13)
Distribution of cleft
Right 35 (11) 27 (11) NS
Left 65 (20) 73 (30)
No. of cephalometric assessments per patient
One 10 (3) 23 (9) 0.02
Two 6 (2) 34 (14)
Three 26 (8) 17 (7)
Four 22 (7) 17 (7)
Five 26 (8) 7 (3)
Six 10 (3) 2 (1)
Age at cephalometric assessment, years
Mean ⫾ SD 9.6 ⫾ 3.4 10.7 ⫾ 4.8 NS†
Range 5–18 5–22
Passive infant orthopedics
Yes 77 (24) 44 (18) 0.02
No 16 (5) 37 (15)
Not recorded 7 (2) 19 (8)
Lip repair
Age at definite repair, years
Median 0.4 1.2 ⬍0.001‡
IQR 0.3–0.8 0.7–2.3
Range 0.3–1.3 0.2–4.7
Technique
Modified rotation-advancement 100 (31) 100 (41) NS
Surgeon grade
Attending 81 (25) 49 (20) 0.006
Resident 19 (6) 51 (21)
Soft palate repair
Age at repair, years
Median 1.0 1.6 ⬍0.001‡
IQR 1–1.2 1.5–1.7
Range 1–1.3 0.6–2.7
Technique
Widmaier 0 (0) 100 (41) ⬍0.001
Two-flap 100 (31) 0 (0)
Surgeon grade
Attending 97 (30) 44 (18) ⬍0.001
Resident 3 (1) 56 (23)
Hard palate repair
Age at repair, years ⬍0.001‡
Median 1.0 5.6
IQR 1–1.2 5.1–6.0
Range 1–1.3 4.8–7.8
Technique
Vomerine mucoperiosteal flap 0 (0) 100 (41) ⬍0.001
Palatal mucoperiosteal flap§ 100 (31) 0 (0)
Surgeon grade
Attending 97 (30) 73 (30) 0.008
Resident 3 (1) 27 (11)
Secondary alveolar bone grafting
Yes 55 (17) 54 (22) NS
No 45 (14) 46 (19)
Velopharyngeal flap
Yes 0 (0) 27 (11) ⬍0.001
No 100 (100) 41 (17)
Not recorded 0 (0) 22 (13)
Full-mouth orthodontic treatment
Yes 36 (11) 54 (22) NS
No 52 (16) 27 (11)
Not recorded 12 (4) 19 (8)
NS, not significant; IQR, interquartile range.
*␹2 test except where otherwise indicated.
†Independent t test.
‡Mann-Whitney U test.
§Two-flap technique.

1505

tion of the radiographs was performed according
to the structural method20 to ensure the accuracy
of each landmark through the ages. To describe
the facial morphology, a total of 19 variables were
used (Fig. 1).
The error of the method was assessed through
repetitive tracing, superimposition, and measure-
ment of 10 randomly selected radiographs at least
1 month apart by the same investigator. The error
of the method, s(i), was calculated by using Dahl-
berg’s formula.21 The mean of s(i) was 0.4 ⫾ 0.1
mm (range, 0.2 to 0.6 mm) for all linear variables
and 0.5 ⫾ 0.3 degrees (range, 0.2 to 0.8 degrees)
for all angular variables.
Fig. 1. Landmarks and reference lines or planes used on a lateral
cephalometric radiograph. A, A point; ANS, anterior nasal spine;
Ar, articulare; B, B point; Ba, basion; Gn, gnathion; Go, gonion; GoI,
gonion intersection, the intersection of the MP and RL; Men, men-
ton; MP, mandibular plane, a line from the menton tangent to the
posteroinferior border of the mandible; n, nasion; PMP, posterior
maxillary point, a construct created by dropping a perpendicular
to the line from the ANS passing through the posterior hard pal-
ate from the PTM; PP, palatal plane, a line through the PMP and
ANS; Pog, pogonion; PTM, pterygomaxillary fissure; R, registra-
tion point, point of crossing of the greater wing of the sphenoid
and the planum sphenoidale; RL, ramus line, a line from the Ar
tangent to the posteroinferior border of the mandible; S, sella
turcica; SN, sella-nasion line.
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Plastic and Reconstructive Surgery • May 2010
Statistical Analysis
Descriptive analysis was performed for the pur-
pose of summary statistics. Inferential analysis was
performed using the chi-square test, general lin-
ear model, and generalized estimating equations.
The chi-square test was used to compare the
speech outcome and percentage of patients with
an oronasal fistula, anterior cross-bite, and re-
quirement for Le Fort I advancement between the
groups. The general linear model was used to
compare the SNA angle and ANB angle between
the groups after adjusting for gender and age.
Generalized estimating equations were used to
assess whether stage of palate repair, one-stage
versus two-stage, had a significant effect on facial
growth adjusted for appropriate covariates. The
generalized estimating equations method is able
to handle a data set with missing values and is
capable of incorporating unequal time intervals
into the analysis.22 The analysis can be conceived
of as a growth curve–fitting technique. The main
purpose is to assess whether (1) facial morphology
at age 20 years (intercept), and (2) facial growth
rate (slope), which depend on ages at assessments,
are related to the stage of palate repair (i.e., sig-
nificant stage of palate repair ⫻ age interaction).
With generalized estimating equations, the
growth curve of the dependent variable is mod-
eled as a function of age, stage of palate repair,
stage of palate repair ⫻ age interaction, and other
appropriate covariates. For computation, the age
variable was centered at age 20 years (i.e., age at
assessment in years minus 20), so the intercept
indicates the mean of the dependent variable at
age 20 years. The choice of other covariates for the
final models reflected both theoretical and ana-
lytical considerations. For example, gender was
included as a covariate in the final models because
gender is a known determinant of facial growth.
Cranial base size (Ba-N) was included as a covari-
ate in the final models of the maxillary and the
mandibular linear measurements because abso-
lute facial linear measurements can be affected by
cranial base size variation, as developed in the
Discussion section. The remaining potential co-
variates were passive infant orthopedics (yes versus
no), stage of lip repair (one-stage versus two-stage),
timing of lip repair, surgeon performing lip repair
(attending versus resident), surgeon performing
hard palate repair (attending versus resident), sec-
ondary alveolar bone grafting (yes versus no), velo-
pharyngeal flaps (yes versus no), and full-mouth
orthodontic treatment (yes versus no). They were
retained in the final model if their inclusion altered
Volume 125, Number 5 • Delayed Hard Palate Closure

the unadjusted regression coefficient for any covari- RESULTS

ate in the model by more than 10 percent. In addi-
tion to the stage of palate repair ⫻ age interaction,
interactions that were significant at the 0.05 level
were retained in the final model.
The results were presented as regression co-
efficients with 95 percent confidence intervals.
Each regression coefficient for the stage of palate
repair is the effect of stage of palate repair on the
facial morphology at age 20 years (intercept) and
is related to the mean difference (millimeters or
degrees) of the dependent variable at age 20 years
between one- and two-stage palate repairs (two-
stage minus one-stage). Each regression coeffi-
cient for the stage of palate repair ⫻ age interac-
tion is the effect of stage of palate repair on the
facial growth rate (slope) and is related to the
difference in the growth rate (millimeters or de-
grees per year) of the dependent variable between
one- and two-stage palate repair (two-stage minus
one-stage). The p values were two-sided and sig-
nificant for values of p ⱕ 0.05.
The results showed that stage of palate repair
had a significant effect on the means of the length
of the posterior cranial base (S-Ba, p ⫽ 0.05), the
length and protrusion of the maxilla (PMP-A, p ⬍
0.05; and SNA, p ⬍ 0.05, respectively), and the an-
teroposterior jaw relation (ANS-N-Pog, p ⬍ 0.01; and
ANB, p ⬍ 0.01) at age 20 years (intercept) but not
on the growth rates. The stage of palate repair had
a marginally significant effect on the mean of the
length of the cranial base (Ba-N, p ⫽ 0.07) at age 20
years but not on the growth rate. The stage of palate
repair significantly affected the mean of the length
of the mandible (Ar-Gn, p ⫽ 0.05) at age 20 years and
the growth rate (p ⬍ 0.05). Also, neither the means
of the other craniofacial measurements at age 20
years nor their growth rates were significantly asso-
ciated with the stage of palate repair (p ⬎ 0.05 for
all) (Table 2).
Fistula was not seen in one-stage patients as com-
pared with 10 percent of two-stage patients (p ⬍ 0.001).
Speech outcome in terms of velopharyngeal function

Table 2. Association between Facial Growth and Stage of Palate Repair in Patients with Unilateral Cleft Lip and
Palate Adjusted for Gender and Ages at Assessments
Stage of Palate Repair Stage of Palate Repair ⴛ Age

Regression Coefficient* Regression Coefficient†

Dependent Variable (95% Confidence Limits) p (95% Confidence Limits) p
Cranial base
S-N, mm ⫺0.5 (⫺3.1, 2.0) 0.64 0.03 (⫺0.1, 0.2) 0.76
S-Ba, mm ⫺2.7 (⫺5.2, ⫺0.1) 0.05 ⫺0.2 (⫺0.4, 0.04) 0.13
Ba-N, mm ⫺3.8 (⫺7.8, 0.3) 0.07 ⫺0.2 (⫺0.5, 0.1) 0.21
N-S-Ba, degrees ⫺1.3 (⫺4.0, ⫺1.4) 0.35 ⫺0.1 (⫺0.2, 0.1) 0.45
Maxilla
Ba-PMP, mm‡ ⫺1.7 (⫺4.0, 0.6) 0.14 ⫺0.2 (⫺0.4, 0.1) 0.16
PMP-ANS, mm‡ 1.9 (⫺0.1, 4.0) 0.06 0.02 (⫺0.1, 0.2) 0.77
PMP-A, mm‡ 2.1 (0.1, 4.2) 0.04 0.06 (⫺0.1, 0.2) 0.42
S-N-ANS, degrees§ 2.1 (⫺0.6, 4.7) 0.13 ⫺0.03 (⫺0.3, 0.2) 0.79
SNA, degrees§ 2.9 (0.4, 5.3) 0.02 0.02 (⫺0.2, 0.2) 0.86
N-ANS, mm‡ 0.1 (⫺2.6, 2.8) 0.94 ⫺0.03 (⫺0.2, 0.1) 0.74
R-PMP, mm‡ ⫺0.1 (⫺3.5, 1.4) 0.41 ⫺0.1 (⫺0.3, 0.1) 0.18
SN-PP, degrees 0.0 (⫺2.5, 2.5) 0.99 0.02 (⫺0.2, 0.2) 0.85
Mandible
Ar-Gn, mm‡ ⫺4.4 (⫺8.8, 0.1) 0.05 ⫺0.3 (⫺0.6, ⫺0.03) 0.03
SNB, degrees§ ⫺0.8 (⫺3.5, 2.0) 0.57 ⫺0.04 (⫺0.2, 0.1) 0.59
S-N-Pog, degrees§ ⫺2.0 (⫺5.2, 1.1) 0.20 ⫺0.1 (⫺0.3, 0.1) 0.33
SN-MP, degrees 2.5 (⫺1.6, 6.5) 0.23 0.07 (⫺0.2, 0.3) 0.56
Ar-Go-Gn, degrees 0.5 (⫺2.8, 3.9) 0.75 0.03 (⫺0.2, 0.2) 0.81
Jaw relation
ANS-N-Pog, degrees§ 4.5 (1.8, 7.1) 0.001 0.1 (⫺0.04, 0.3) 0.12
ANB, degrees§ 3.3 (0.7, 5.8) 0.01 0.03 (⫺0.2, 0.2) 0.79
*The regression coefficient indicates the difference in the mean (millimeters or degrees) of the dependent variable at age 20 years between
one- and two-stage palate repair (two-stage minus one-stage). A positive value indicates a larger value for two-stage repair as compared with
one-stage repair.
†The regression coefficient indicates the difference in the growth rate (millimeters or degrees per year) of the dependent variable between
one- and two-stage palate repair (two-stage minus one-stage). A positive value indicates faster growth for two-stage repair as compared with
one-stage repair.
‡Adjusted for cranial base length (Ba-N).
§Adjusted for full-mouth orthodontic treatment.

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 Plastic and Reconstructive Surgery • May 2010

or secondary procedure for velopharyngeal inade- maxilla, as evidenced by the significant association
quacy was worse in the two-stage group than in the between the length of the maxilla (PMP-A) at age
one-stage group (p ⬍ 0.001 and p ⫽ 0.001, respectively) 20 years and the stage of palate repair. Palate
(Table 3). There was no significant difference in the repair is known to inhibit the anteroposterior de-
percentage of patients with anterior cross-bite between velopment of the maxilla.4,10 In addition, one
the groups (p ⬎ 0.05). However, the adjusted mean study suggests that a later hard palate repair results
SNA in the one-stage group was 75.6 degrees, and in a longer maxilla.5 It was also found that the
that in two-stage group was 78.6 degrees (p ⫽ 0.001). association was not modulated by age, as evi-
Normative data for the SNA may range from 80 to denced by the nonsignificant association between
83 degrees. A Le Fort I advancement or distraction the growth rate of the length of the maxilla and
was required in 58 percent of one-stage patients the stage of palate repair. The lack of association
compared with 27 percent of two-stage patients (p ⬍ with age indicates that the observed length differ-
0.05) (Table 4). ences in the maxilla at age 20 years between the
stages is attributable to their baseline differences
DISCUSSION (i.e., differential development being undisturbed
Effect of Stage of Palate Repair before closure of the hard palate). In other words,
This study demonstrated that the stage of pal- the stage effect is hard palate repair timing specific
ate repair significantly affected the length of the rather than a function of a later hard palate repair
being less traumatic than an early repair. Previous
studies have also shown that an unoperated hard
Table 3. Comparison of Speech Outcome between
palate leads to superior anteroposterior develop-
the Groups
ment of the maxilla,8,23–25 and that the difference
One-Stage Two-Stage in the length of the maxilla between early and late
(n ⴝ 31) (n ⴝ 41)
(%) (%) p hard palate repair remains relatively constant over
time.5,11 However, the finding is in contrast to the
Velopharyngeal function ⬍0.001
Adequate 48 (15) 22 (7) work of Owman-Moll et al.,26 who speculated that
Marginal 52 (16) 7 (9) by starting closure of the soft palate, the size of the
Inadequate 0 (0) 29 (12) remaining cleft narrows spontaneously, thus facil-
Not recorded 0 (0) 32 (13)
Secondary procedure itating a smaller, less traumatic, later hard palate
for velopharyngeal repair. The explanation for these discrepant re-
inadequacy 0.001 sults is unclear, although a previous study has
Yes 19 (6*) 27 (11†)
No 81 (25) 41 (17) failed to find the narrowing of the residual cleft
Not recorded 0 (0) 22 (13) after closure of the soft palate.27 Whether this re-
*Furlow palatoplasty. lates to technique (a posterior vomer flap versus
†Pharyngeal flap. no posterior vomer flap incorporation) or other
variables is unclear at this time. As a result, the
Table 4. Comparison of Incisor Occlusion, SNA, ANB, stage of palate repair had a significant effect on
and Need for Le Fort I Advancement or Distraction the protrusion of the maxilla (SNA) and antero-
between the Groups posterior jaw relation (ANS-N-Pog, ANB).
One-Stage Two-stage This study also confirmed previous reports
(n ⴝ 31) (n ⴝ 41) that either the downward growth of the basal
(%) (%) p
maxilla28,29 or the growth of the mandible15,25,28 –32
Anterior cross-bite* was unrelated to the stage of palate repair, given
Yes 23 (7) 37 (15) NS
No 77 (24) 63 (26) the evidence that palate repair has no effect on
Adjusted mean SNA, either the downward growth of the basal maxilla4,5
degrees† 75.6 78.6 0.001 or the growth of the mandible.4,5,28,30,31 One could
Adjusted mean ANB,
degrees† ⫺1.9 1.3 0.001 argue that the stage of palate repair affects the
Need for Le Fort I growth of the mandible based on the finding of
advancement or significant association between the length of the
distraction
Yes 58 (18) 27 (11) mandible and the stage of palate repair. However,
No 39 (12) 61 (25) 0.02 the p values were not very small. Also, none of the
Not recorded 3 (1) 12 (5) other variables that were implemented to assess
NS, not significant. the growth of the mandible (e.g., SNB or S-N-Pog)
*Based on the latest cephalometric assessment.
†Based on the latest cephalometric assessment after adjusting for sex were close to a statistically significant association
and age. with the stage of repair (Table 2). Therefore, the

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Volume 125, Number 5 • Delayed Hard Palate Closure
significant association was probably observed sim-
ply on the basis of chance alone.
A difference in the growth of the cranial base
has also been found between the stages in this
study. It was found that a one-stage repair resulted
in longer adult length of the cranial base than a
two-stage repair. It seems unlikely that palate re-
pair should affect the growth of the cranial base
because of its distance from the field of surgery. A
possible explanation for this disagreement is dif-
ferences in body height, which is related to length
of the cranial base,5,33,34 and change in body height
may be attributed to the secular trend. The trend for
adult height has increased since at least the mid
nineteenth century. The trend is driven by social
conditions, mainly because of improved nutrition,
control of infectious disease, and increased availabil-
ity of health and medical care.35 The assumption that
the trend for adult height was responsible for the
adult length differences in the cranial base between
the stages is based on the fact of varied year of birth
in patients with two- and one-stage repair (1976 to
1982 and 1988 to 1992, respectively).
One- or Two-Stage Palate Repair?
Although the results of this study suggest that
two-stage repair has a smaller adverse effect on the
growth of the maxilla than one-stage repair, the
delayed hard palate closure protocol was aban-
doned in 1982 in favor of one-stage repair at the
Chang Gung Craniofacial Center because of the
worse speech outcome in terms of more articula-
tion errors before closure of the hard palate.17 Our
observation also follows previous studies that con-
sistently demonstrated significant speech impair-
ment when hard palate closure was delayed after
4 years of age.13,16 –18 This abandonment and ad-
aptation was based on the philosophy that speech
considerations should be the main determinant in
surgical protocol of cleft palate repair (Table 5).
Although the delayed closure amounting to 5 years
Table 5. Summary of Significant Differences
between One- and Two-Stage Palate Repairs
One-Stage/Two-Stage
Midfacial growth, degrees
Adjusted mean SNA 75.6/78.6*
Le Fort I osteotomy rate, % 58/27*
Speech outcome, %
Velopharyngeal inadequacy 0/29†
Secondary procedure for
velopharyngeal inadequacy 19/27†
Oronasal fistula rate, % 0/10†
*Favor two-stage.
†Favor one-stage.
(i.e., from 1 to 6 years of age) provides a maxillary
growth advantage (2.9 degrees in SNA) (Table 2)
and 31 percent less need for Le Fort I advancement
or distraction (Table 4), it is not possible to state
whether a shorter time interval (e.g., 2 years) would
yield the similarly clinically significant growth ad-
vantage. Further work is needed in this area.
Limitations of the Study
This study has several limitations. First, be-
cause this is a retrospective long-term study, the
bias of gradual changes of surgical experiences
within the same surgeons could be introduced.
However, if this was a factor, the results would not
be affected because the earlier surgical protocol
(two-stage repair with delayed hard palate clo-
sure) resulted in better maxillary growth than the
late surgical protocol (one-stage repair). Second,
the size of the initial cleft, which might be asso-
ciated with subsequent facial growth outcome,
could not be assessed because infant maxillary
dental casts were not available. However, there was
no bias in allocating the patients to either one- or
two-stage repair. That is, consecutive patients with
various cleft sizes were treated with the same sur-
gical protocol during the same period. Third, fa-
cial growth outcome may be hard palate repair
technique sensitive. Although the present study
did not take this factor into account, the data
showed that the technique of hard palate repair
had no significant impact on facial growth because
maxillary growth rate after hard palate closure was
similar between the stages. Previous studies have also
found no maxillary growth advantage with a partic-
ular technique of hard palate repair.5,28,36 However,
further work is needed. Finally, variation in the skill
of the surgeon may influence the facial growth out-
come. To avoid this problem, the surgeon perform-
ing lip and hard palate repair was included as a
potential covariate in the analysis. In the end, the
surgeon performing lip and hard palate repair was
not adjusted because there was no significant sur-
geon effect. This finding is consistent with most of
the reported literature5,28,36; however, this might be
a reflection of difficulty of case mix that could not be
confirmed in a retrospective study.
From the results, we conclude that in patients
with unilateral cleft lip and palate, stage of palate
repair, one-stage versus two-stage with delayed hard
palate closure, has a significant adverse effect on the
growth of the maxilla. Two-stage repair has a smaller
adverse effect on the growth of the maxilla than
one-stage repair. This stage effect is on the antero-
posterior development of the maxilla and is attrib-
1509

utable to the development being undisturbed before
closure of the hard palate (i.e., hard palate repair
timing specific). Stage of palate repair does not sig-
nificantly affect the growth of the mandible.
Yu-Fang Liao, D.D.S., Ph.D.
Division of Craniofacial Orthodontics
Department of Dentistry
Chang Gung Memorial Hospital
199 Tung-Hwa North Road
Taipei 105, Taiwan
yufang@cgmh.org.tw
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