Scand J Plast Reconstr Hand Surg 28: 55-62, 1994
ONE-STAGE CLOSURE OF ISOLATED CLEFT PALATE WITH THE
VEAU-WARDILL-KILNER V TO Y PUSHBACK PROCEDURE
OR THE CRONIN MODIFICATION
11. Height, Weight and Comparisori of Dental Arches
Arja Heliovaara,' Anneli Pere' and Reijo Ranta'.3
From the 'Department of Pedodontics and Orthodontics, 'Children's Hospital, University of Helsinki, and
3Cleft Center, Department of Plastic Surgerv, Helsinki University Central Hospital, Finland
(Submitted for publication 20 March, 1992)
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Abstract. The body height and weight, and sizes of
dental arches in 116 patients with isolated cleft palate
were evaluated at 16.9-20.6 years of age. One-stage
closure of the soft and hard palate had been done at
a mean age of 1.8 years using the Veau-Wardill-
Kilner or the Cronin mucoperiosteal palatal V-Y
pushback technique. The height attained in both the
boys (177.6~111)and the girls (165.7cm) was similar
to that in the general adult population, even though
half of the boys had not reached their final height.
The median relative weight for height and sex was
6%. There were no significant differences in dental
arch measurements depending on the method of
operation but the more palatal operations done the
shorter the maxillary and mandibular dental arch
widths. The extent of cleft made a significant dif-
ference, larger clefts having narrower palatal inter-
canine widths. Dental arch dimensions were
consistently larger in boys than in girls.
Key words: cleft palate, surgery, height, weight,
dental arches.
The dimensions of the dental arches and the
prevalence of dental crossbite in children with
isolated cleft palate differ from those among
children who do not have clefts. The reported
incidences of crossbite in the primary, tran-
sitional, and permanent dentition vary
(1, 14,23,30), whereas the sizes of dental
arches in the primary and transitional dentition
are small (2, 18, 19, 20,31). The prevalence of
hypodontia in the permanent dentition of chil-
dren with isolated cleft palate is higher than
in children without clefts (24), and defects in
enamel and abnormalities in shape and size
of deciduous and permanent teeth are more
common (25).
01994 Scandinavian University Prcss. ISSN 0284-4.111
Palatal surgery is thought to be one of the
causes of the underdevelopment of the maxilla
and the reduction in maxillary dental arch width
and associated crossbite. The timing and type
of operation and the skill of the surgeon are
also important. Most of the studies that describe
the effects of operation on the dental arches
and occlusion deal with primary, transitional,
and early permanent dentition. Evaluation of
the long term effects is also needed.
The purpose of this study was to compare the
effects on dental arches of one-stage palatal
closure with the Veau-Wardill-Kilner or the
Cronin V to Y pushback procedure. Cronin
( 5 ) and Brauer (4) pointed out that the scar
contracture of the healing raw area on the nasal
surface could be avoided and mobility of the
velum improved by using additional mucosal
flaps from the floor of the nose. In addition the
effects of sex, extent of cleft at birth, familial
disposition for clefts, associated minor anom-
alies, additional palatal operations, and ortho-
dontic treatment on dental arch dimensions
were evaluated. Height and weight were
measured to assess the size of the dental arches
in more detail.
PATIENTS AND METHODS
The series comprised 116 Finnish patients (48 boys)
with isolated cleft palate, born between 1968-1971
and operated on at the Cleft Center, Department of
Plastic Surgery, Helsinki University Central Hospi-
tal, with the Veau-Wardill-Kilner or the Cronin
mucoperiosteal palatal V-Y pushback techniques.
The former was used during 1969-1971 and the latter
Scand J Plasr Reconsrr Hand Surg 28
 56 A . Heliovaara et al.

since 1971. The operations were done at a mean age
of 1.8 years. mostly by residents in plastic surgery
under training. The operative techniques have been
described in more detail elsewhere (10).
The patients attended regular follow up visits at
which dental casts, cephalograms and speech exam-
inations were taken. In this study we have used the
records of height and weight and dental casts made
at the final follow up visit. During 1988 160 patients
were asked to come for evaluation, 131 (82%))
patients attended, 69/86 who had the Veau-Wardill-
Kilner and 62/74 who had the Cronin operation.
Fifteen patients (8 and 7, respectively) with syn-
dromes (such as Pierre Robin's anomalad) were
excluded. The remaining 116 patients were grouped
depending on which operation they had had. Further
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Wardill-Kilner. and 17.8 (0.59) years in the Cronin
group (t = 14.82, p < 0.001, df = 114).
Orthodontic treatment was received by 104 of the
116 children (90%). The treatment was done to
correct crossbite of the anterior or posterior teeth,
or both, and to eliminate crowding and rotations o f
the permanent teeth during mixed or young per-
manent dentition, or both, using edgewise technique
or removable appliances. In most patients the treat-
ment was carried o u t under the supervision of the
Cleft Center at the local dental health centres by
dentists without specialist orthodontic training. None
of the patients had orthognathic surgery.
Height utid weight usscsstncrit

grouping was done according to sex, extent of cleft
at birth, family history of clefts, associated minor
anomalies and additional palatal operations (Table
I). A qatient had a family history of clefts if one or
more hrst or second order relatives had a cleft.
whatever the type. The group with associated anom-
alies ( n = 14) included children with van der
Woude's syndrome (11 = 5 ) ; hypospadias ( n = 1);
inguinal hernia ( n = 1); syndactyly (n = 1); and
anomalies of the ear ( n = 2). heart ( n = 2 ) , genitals
( n = I ) , and cervical vertebra ( n = I ) . Primary clefts
were defined as complete when the cleft reached the
anterior half of the palate; partial when the cleft
reached the posterior half of the palate; and soft
when the cleft was of the soft palate only (without
affecting the secondary palate at all).
The mean age at the time of the primary operation
was 1.8 years in both groups, the standard deviation
(SD) being 0.18 and 0.41, respectively ( t = -0.46,
ns, df = 72). The mean (SD) age at assessment was
18.8 (1.15) years, 10.7 (0.72) years in the Veau-
The patients were measured and weighed (to the
nearest 0.5cm and 1 kg, respectively) at the Cleft
Center. We used the newly revised growth standard3
based on the study of Sorva et al(28). Relative height
is expressed as the SD score of the current mean
Finnish norms for age and sex, and relative weight
as the percentage deviation from the median weight
for height and sex. The mean height increases 2.1,
1.0, and 0.3 cm after the age of 17.0. 18.0, and 19.0
years among the boys and 0.4,0.0, and 0.0 cm among
the girls. The height of the boys was therefore re-
corded as final when they were 19.0 years or more
( n = 22/48), and that of the girls when they were
17.0 years or more ( n = 66/68).
The heights of both parents were obtained, from
school health surveillance records, for 31 (27%') of
the patients. The parent-specific expected height S D
score was calculated as 0.0611 x father's height
(cm) + 0.0703 x mother's height (cm) - 22.1, as cal-
culated for healthy Finnish children born in 195941
(29).

Table 1. Comparability of the groups

Veau-Wardill-Kilner
pushback operation Cronin modification
Boys Girls Total Boys Girls Total Tot;ll
No of operations
Primary alone 14 30 44 18 26 44 88
Primary and secondary 9 8 17 7 4 11 28
Morphological classification
Complete 2 8 10 5 10 15 25
Partial 16 23 39 9 14 23 62
Cleft of soft palate alone 5 7 12 11 6 17 29
Familial disposition
No 16 26 42 22 23 45 87
Yes 7 12 19 3 7 10 29
Associated anomalies
N0 20 33 53 21 28 49 102
Yes 3 5 8 4 2 6 14
Total 23 38 61 25 30 55 116

Scand J PIast Reconstr Hand Surg 28


Fig. 1. Maxillary intercanine arch width 13-23: dis-
tance between cusp tips o f the upper permanent
canines.
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Mandibular intercanine arch width 33-43: distance
between cusp tips of the lower permanent canines.
Maxillary intermolar arch width 1 6 2 6 : distance
between the mesiolingual cusp tips of the upper first
permanent molars.
Mandibular intermolar arch width 36-46: distance
between the mesiolingual cusp tips of the lower first
permanent molars.
Upper arch length: distance between a tangent to
the middle area of the labial surfaces of the upper
central incisors, and a line connecting the most pos-
terior points on the distal surfaces of the upper first
permanent molars.
Lower arch length: distance between a tangent to
the middle area o f the labial surfaces of the lower
central incisors, and a line connecting the most pos-
terior points on the distal surfaces of the lower first
permanent molars.
Detitul urck t?ieasiirPt?icrits
Alginate impressions of maxillary and mandibular
dental arches were taken. The measuring methods
and points for the arch widths were those described
by Moorrees (16) and Moorrees et al. (17). The
dental arch widths and lengths are shown in Fig. 1.
One cast of the mandible was broken and was
excluded. Six patients had a missing upper and one
patient a missing lower permanent canine. and the
measurement was taken from the tooth that had
replaced the canine. The measurements were taken
with a sliding digital caliper (MITUTOYO) by the
same person. Two measurements were taken for 24
patients, and Students t test showed that there were
no significant differences hetween the two measure-
ments.
When comparing those treated orthodontically
with the rest, the number o f missing teeth and assess-
ment of crowding were also included. The number
of missing teeth represents the total number of teeth
extracted and congenitally missing excluding the
third permanent molars. Crowding was estimated
between the mesial surfaces of the first permanent
molars.
Height, weight, dental arches in cleft palate 57
Stutistical methods
Multivariate discriminant function analysis, multiple
linear regression analysis, Students t test and Mann-
Whitney U test were used. Probabilities of less than
0.05 were considered as significant.
It is known that height is virtually normally dis-
tributed. but weight is skewed t o the right. Students
t test could therefore be used in the analysis of height
hiit the non-parametric Mann-Whitney U test was
used in the analysis of weight. When using the multi-
variate methods only the patients treated ortho-
dontically (n = 104) were included. The dental arch
dimensions used in both the multivariate analyses
were the same. A forward stepping multivariate dis-
criminant function analysis (Biomedical Data Pack-
age (BMDP)7M) ( 3 ) was used to distinguish the two
operations. Boys and girls were analysed together.
In the multiple linear regression analysis (BMDP-
1R) dental arch measurements were regarded as
dependent variables. The independent variables
were operation. sex. extent of cleft at birth, family
history of clefts, associated minor anomalies. and
additional palatal operations. The independent vari-
able cleft size was represented in the model by
chosen dummy variables and one o f the three cat-
egories was always ignored.
RESULTS
Relative height and weight were first compared
between two groups of the patients. Com-
parisons were done between the two operations
and between patients with total and soft palate
clefts and patients who did and did not have
additional palatal operations, a family history
of clefts, and associated anomalies. There were
no significant differences between the groups,
so the patients could be combined for further
analyses of growth.
For all the patients, the mean height SD score
was 0.0 (SD 1 .O, range -2.4 to 1.3). The mean
(SD) height of the boys who were assumed to
have stopped growing (age 19 years o r more,
ti = 22) was 176.4 (5.2) cm, range 167-185, and
of those boys who had not stopped growing
(age less than 19 years, n = 26) 178.7 (6.7)
cm, range 163-191. Although the younger boys
were taller than the older boys, they were
shorter compared with their expected final
height (obtained for 11 of the 26 boys), the
mean being 2.7 (5.2) cm below the final height
predicted from the heights of the parents. Only
two of the 68 girls had not definitely stopped
growing (age less than 17 years) and their
exclusion did not affect the mean (SD) height
Scand J Plmr Reconsrr Hand S i q 28
 58 A . Heliovaara et al.

Table 11. Results of multiple linear regression analysis

SE of P
Mean n SD Coefficient coefficient value
Maxillary intercanine width 13-23
( n = 104; R2 = 0.13):
Operation: Veau-Wardill-Kilner 31.1 55 4.02 -0.09 0.81 0.y1
Cronin 30.8 49 4.14
Sex: Male 31.6 44 3.62 -0.50 0.83 0.55
Female 30.5 60 4.32
Cleft: Complete 29.1 24 4.72 -3.68 1.20 0.00
Partial 31.2 55 3.60 -1.18 0.98 0.23
Soft 32.3 25 3.86 variable not used
Family history: No 31.1 78 3.66 -0.20 0.95 0.84
Yes 30.7 26 5.16
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Associated anomalies: No 31.2 93 3.94 -2.01 1.31 0.13

Yes 29.6 11 4.91
Additional palatal operations: No 30.8 79 4.13 1.31 1.01 0.20
Yes 31.5 25 3.08
Maxillary intermolar width 16-26
(n = 104; R2 = 0.10):
Operation: Veau-Wardill-Kilner 34.8 55 4.00 -0.48 0.84 0.56
Cronin 34.6 49 4.31
Sex: Male 35.4 44 4.33 -1.58 0.86 0.07
Female 34.1 60 3.92
Cleft: Complete 33.4 24 3.36 variable not used
Partial 34.7 55 3.89 0.33 1 .09 0.76
Soft 35.9 25 5.10 1.48 1.23 0.23
Family history: No 34.8 78 4.06 0.24 0.98 0.81
Yes 34.4 26 4.41
Associated anomalies: No 34.6 93 4.18 -0.17 1.35 0.90
Yes 35.0 11 3.85
Additional palatal operations: No 35.2 79 3.93 -2.23 1.04 0.03
Yes 33.1 25 4.46
Upper arch length
( n = 104; R2 = 0.09):
Operation: Veau-Wardill-Kilner 34.6 55 2.49 -0.51 0.54 0.35
Cronin 34.1 49 2.80
Sex: Male 34.9 44 2.36 -0.65 0.55 0.24
Female 34.0 60 2.78
Cleft: Complete 33.5 24 2.96 -1.40 0.79 0.08
Partial 34.4 55 2.52 -0.63 0.64 0.33
Soft 35.0 25 2.43 variable not used
Family history: N o 34.5 78 2.46 -0.88 0.63 0.16
Yes 33.8 26 3.08
Associated anomalies: No 34.3 93 2.65 0.76 0.86 0.38
Yes 35.0 11 2.54
Additional palatal operations: No 34.3 79 2.61 0.55 0.67 0.41
Yes 34.5 25 2.75
Mandibular intercanine width 33-43
( n = 103; R2 = 0.02):
Operation: Veau-Wardill-Kilner 24.9 54 2.51 0.04 0.52 0.93
Cronin 25.0 49 2.38
Sex: Male 25.2 44 2.83 -0.26 0.53 0.63
Female 24.7 59 2.11
Cleft: Complete 25.0 23 2.58 variable not used
Partial 24.8 55 2.48 -0.14 0.68 0.84
Soft 25.1 25 2.30 0.18 0.76 0.82
Family history: No 24.9 77 2.34 0.01 0.61 0.99
Yes 25.0 26 2.76
contd

Scand J PIast Reconsir Hand Surg 28

 Height, weight, dental arches in cleft palate 59

Table 11. continued

SE of P
Mean II SD Coefficient coefficient value
Associated anomalies: No 24.9 92 2.53 0.33 0.83 0.69
Yes 25.2 11 1.56
Additional palatal operations: No 24.8 79 2.37 0.61 0.65 0.35
Yes 25.4 24 2.65
Mandibular intermolar width 3646
(n = 103; R = 0.20):
Operation: Veau-Wardill-Kilner 31.4 54 3.58 -0.70 0.70 0.32
Cronin 30.7 19 3.70
Sex: Male 32.0 44 3.68 -1.99 0.72 0.01
Female 30.3 59 3.48
Cleft: Complete 29.5 23 2.84 -0.72 0.92 0.43
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Partial 31.3 55 3.58 variable not used

Soft 31.9 25 4.09 0.58 0.84 0.49
Family history: N o 30.7 77 3.38 1S O 0.82 0.07
Yes 32.0 26 4.25
Associated anomalies: No 30.7 92 3.56 1.82 1.12 0.11
Yes 33.4 11 3.54
Additional palatal operations: No 31.3 79 3.54 -1.90 0.88 0.03
Yes 30.0 24 3.84
Lower arch length
(n = 103; RZ= 0.09):
Operation: Veau-Wardill-Kilner 30.5 54 3.05 -0.03 0.65 0.97
Cronin 30.3 49 3.32
Sex: Male 30.9 44 3.31 -0.95 0.67 0.16
Female 30.1 59 3.03
Cleft: Complete 29.3 23 3.01 -0.90 0.96 0.35
Partial 30.7 55 3.22 0.11 0.78 0.89
Soft 30.8 25 3.05 variable not used
Family history: N o 30.3 77 3.16 0.68 0.77 0.42
Yes 30.8 26 3.22
Associated anomalies: No 30.2 92 3.22 1.31 1.04 0.21
Yes 32.0 11 2.15
Additional palatal operations: No 30.6 79 3.30 -0.88 0.82 0.28
Yes 29.8 24 2.53

of all the girls: 165.7 (6.3) cm, range 148.5-178.
The difference between height and expected
final height was determined for 17 of the girls:
-0.6 (5.8) cm.
The median relative weight for both sexes
was 6% (range -21 to 44). In the boys, there
was a tendency for it to increase with age;
of the variance in relative weight, 19% was
explained by the variance in age. Eight (two
boys) were overweight (relative weight more
than 30%), and none were underweight (rela-
tive weight less than -25%).
The dental cast measurements of the patients
who had had orthodontic treatment (104/116)
differed significantly from those of the patients
who had not (12/116), and the differences were
most pronounced in the maxilla. The upper
intermolar width and both the maxillary and
mandibular dental arch lengths were sig-
nificantly greater in the untreated patients. The
latter also had less missing teeth in both jaws
and there was less (although not significantly
less) crowding. Because of these differences
the multivariate statistics were used only for
patients who had undergone orthodontic treat-
ment.
The multivariate discriminant function analy-
sis, with the operation method as grouping vari-
able, gave no discriminating variables at the
tolerance of 0.01 and F-to-enter 4.00. The
results of the multiple linear regression are
shown in Table 11. The R2 (R-square) values
Scand J PIast Reconstr Hand Surg 28
 60 A . Heliooaara et al.
indicate that 2-20% of the independent vari-
ables' variance was explained. Method of
operation had no significant effect on any of
the variables, but additional palatal operations
had a significant effect on both maxillary and
mandibular intermolar widths. The patients
who had been reoperated on had the shortest
widths. The influence of sex was constantly in
the same direction, with boys having higher
values, but only the difference in mandibular
width 36-46 was significant. The effect of extent
of cleft was significant for maxillary width 13-
23. The values were least in the patients who
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originally had the most extensive clefts. With
regard to the other independent variables (fam-
ily history of clefts and associated minor anom-
alies) there were no significant differences.
DISCUSSION
It has been reported that adults who have had
clefts of the lip and palate are shorter than
those who have not had (6). The results of the
present study suggest that isolated cleft palate
is not detrimental to final height, although age
was used as the sole criterion for cessation of
growth. Information on maturation and annual
growth increments would be needed for more
precise determination of cessation of growth
(26). Jensen et al, (13) found that 48 Danish
boys with combined cleft lip and palate were
slightly shorter than controls at ages between 6
and 18 years. The pubertal spurt occurred about
0.5 years later and was less pronounced.
According to Day (8) the slightly delayed
puberty does not seem to reduce final height.
Menius et al (15) studied bone maturation in
48 children at ages between 4.8 and 18.9 years
and Geier and Dahlman (9) studied 96 children
at ages between 6.6-15; in both studies matu-
ration was retarded, especially among 'boys.
Delayed tooth formation in the permanent den-
tition has also been reported; in 251 Finnish
children with isolated cleft palate the mean
delay was 0.7 years (25). Even if the children
in the present study had had retarded matu-
ration, it did not affect their growth at the last
visit.
The Finnish growth standards are based on
children most of whom were still growing, and
Scand J Plmt Heconstr Hand Surg 28
who were several years younger than the
patients in the present study. This difference in
age may partly explain why the patients were
somewhat heavy for their height (median rela-
tive weight = 6%). A tendency of the relative
weight to increase with age was noticed in the
boys: the median among those under and of
those over 19 years was 3% and 996, respect-
ively. The prevalence of obesity (relative weight
30% or more) was slightly increased; eight of
the 116 patients were obese. Weight may,
though, reflect the greater influence of environ-
mental and psychosocial factors ( 8 ) .
The results of this study suggest that the
method of operation does not significantly
affect the size of dental arches. The Cronin
modification of the pushback is technically
more difficult to d o and results in larger surfaces
of denuded bone which could have been
expected to cause more disturbance in growth.
Other studies have reported similar findings in
palatal surgery. Nystrom and Ranta (19) found
that dental arch dimensions in 180 children with
clefts at 3 years of age were not related to the
timing or the method (Veau-Wardill-Kilner or
Cronin) used for palatal closure. Jakobsson (12)
found only one variable, dental arch width at
55-65, to be significantly affected by the choice
of the surgical method (one-stage o r two-stage)
in 68 8-year-old children born with isolated cleft
palate. Previous studies, however, have found
significant differences in the prevalence of
crossbite and the choice of surgical technique
(7,21).
The number of palatal operations, unlike the
method of operation, was associated with
decreased widths of maxillary and mandibular
arches. The constricted maxillary arch may
influence the mandibular arch dimensions to
some degree (2). Ross and Johnson (27) con-
cluded that multiple operations to the hard
palate cause severe disturbances to maxillary
growth. On the other hand, the patients most
likely to have additional palatial operations are
the ones who had the largest clefts in the first
place (10).
In this study, the larger the cleft at birth, the
smaller the intercanine width. Hellquist et al,
(1 1) studied the deciduous dentition in 99 chil-
dren with isolated cleft palate and recorded the
 Height, weight, dental arches in cleft palate
smallest intercanine and intermolar widths in
patients with large clefts. Nystriim and Ranta
(20) reported the smallest dental arch dimen-
sions in those with complete clefts ( n = 13/60)
at the age of 6 years, and Jakobsson (12) at the
age o f X years. Jonsson and Thilander (14)
studied 55 children with clefts of the secondary
palate from 4 to 1 1 years of age. They concluded
that dental arch dimensions and craniofacial
morphology were influenced by the size of the
cleft, though the occlusion was not, and Dahls
cephalometric findings support this (6). H e
found a systematic tendency for morphological
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changes to be most pronounced in extensive
clefts. A n increase in hypodontia that parallels
with the severity of isolated cleft palate has also
been reported (24).
In the present study a quarter of the patients
had a family history of clefts. T h e bizygomatic
head width of the patients with affected rela-
tives was larger in anteroposterior cephalo-
grams (unpublished observation) but this did
not seem to influence the size of dental arches.
ProchrizkovA and TolarovA (22) have reported
that the mothers ( n = 20) of children with cleft
palate have wider palates between canines.
The intermolar widths of both those who had
been treated orthodontically and those who had
not appeared to be small compared with those
of 17-19 year-old patients without clefts
reported by Moorrees (16); he found maxillary
intermolar widths of 41.7 mm ( n = 37) among
boys and 39.2 mm ( n = 37) among girls. T h e
mandibular intermolar widths were 35.4 mm
( n = 32) and 34.8 m m ( n = 31), respectively. It
is true that the Finnish patients may differ from
those of Moorrees, but the dimensions of the
dental arches in the primary a n d transitional
dentition are smaller than in children without
clefts (2, 18, 19,20, 31). T h e patients in the
present study were of average height and weight
and so the dental arch widths d o not reflect a
smaller body size.
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Correspondence to:
Arja Heliovaara
Kuukiventie 9 C 17
SF-00840 Helsinki
Finland