British Journal oj’Oral and Maxrllofacial Surgery (1995) 33, 156-165

0 1995 The British Association of Oral and Maxillofacial Surgeons

Primary closure of the cleft alveolus: a functional approach

W. P. Smith, A. F. Markus, J. Delaire

Maxillofacial Unit, Poole Hospital NHS Trust, Poole, Dorset; 8 rue Horace Vernet, Nantes, France

SUMMARY. The growth and development of the premaxilla in both normal and cleft lip and palate subjects is
described and its relevance in surgery of the cleft alveolus discussed. Embryologically, the cleft alveolus results
from failure of fusion of the median nasal and maxillary processes. Consequently, ossification centres in the
premaxilla and maxilla cannot migrate and unite such that normal growth and development in the territory of the
premaxillary-maxillary suture cannot occur. Functional repair of the cleft lip and soft palate encourages spon-
taneous alignment of the alveolar segments, facilitating the introduction of vascularized periosteum across the
bony defect by gingivoperiosteoplasty. Early reconstruction in the region of the premaxillary-maxillary suture
encourages a more normal development of the alveolus, particularly in the bilateral cleft subject.

INTRODUCTION are factors principally responsible for the adverse

Good long term results in cleft lip and palate surgery
can only be consistently achieved if the initial abnor-
malities are totally corrected thereby, establishing
normal balance between the hard and soft tissues.
Standard techniques of primary surgery often fail to
correct these abnormalities such that certain deformit-
ies persist, becoming increasingly significant with
growth. The cleft alveolus is not spared these
unfavourable changes following non-functional pri-
mary repair.
The anatomical size of the premaxilla belittles its
importance in the development of the midface. Any
abnormality or disruption of overlying soft tissues,
adjacent skeletal elements and developing teeth is
likely to influence growth and development of the
premaxilla. This is well illustrated in cleft lip and
palate, particularly in the bilateral cleft where the
premaxilla is underdeveloped, ‘floating’ and
anteriorly projected.
The hallmarks of successful management of the
cleft alveolus are bony continuity with alignment and
stabilization of the anterior maxilla, good alar base
support with nasal symmetry, elimination of oro-
nasal fistula and mucosal recesses and spontaneous
eruption with good periodontal support of teeth into
and adjacent to the cleft alveolus. Two diametrically
opposite protocols have evolved to achieve these
results. Primary alveolar repair corrects at an early
age the underlying deformity encouraging normal
growth and development of the maxilla (and premax-
illa). Primary bone graftingI,’ however, has been
shown to result not only in midface retrusion but
impaired vertical development of the anterior maxilla
with adverse compensatory changes in the mandible,
increasing lower face height.3,4
Disruption of the vomero-premaxillary suture,
vomerine flaps and bone grafts encroaching onto the
hard palate with obliteration of the mid-palatal suture
156
growth seen with this technique.‘-’ Dissatisfaction
with primary bone grafting led to the techniques of
periosteoplasty. Skoog’s periosteal flaplo consistently
deposited bone within the alveolus but the limited
availability of periosteal flap materia111m13 inspired
the introduction of free grafts, including the use of
tibia1 periosteum.14 Several studies14-16 have demon-
strated the high osteogenic potential of periosteum
depositing bone without subsequent resorption, a
finding occasionally encountered in both primary and
secondary bone grafting techniques.14,16 Nevertheless,
secondary or delayed bone grafting remains popu-
lar I7 based on the adverse results reported with
techniques of early alveolar closure. Evidence exists,
however, that deferring surgery until the mixed den-
tition may still impair vertical development of the
anterior maxilla4 a finding challenged by Semb,”
who showed that both antero-posterior and vertical
maxillary growth were unaffected by bone grafting
carried out after 8 years of age. In general, treatment
regimens with early closure of the lip and palate
avoiding vomerine flaps and bone grafts to the
alveolus seem most favourable for maxillary
development. lg
This paper outlines the technique of early alveolar
repair by primary gingivoperiosteoplasty based on,
and respecting the morphological abnormalities of
both the premaxilla and maxillary segments seen in
the unilateral and bilateral cleft lip and palate subject.
ANATOMY AND PHYSIOLOGY OF THE
PREMAXILLA IN THE NON-CLEFT SUBJECT
In humans, unlike animals, the premaxilla does not
develop independently but fuses to the maxillary
processes in the 8th week in utero.20~22 Nevertheless,
the premaxilla may be considered as a separate ‘skel-
etal unit’ as defined by Moss,‘~ having anatomical,
 Primary closure of the cleft alveolus: a functional approach 157

physiological and pathological individuality capable

of functional adaptation. 24 Fusion of the premaxilla
to the maxilla commences on the surface of the
primordial facial ectomesenchyme, external to the
dental lamina in the region of the future canine tooth.
This fusion then extends over the outer .surface of
the premaxilla around the pyriform aperture. At
birth, the premaxilla remains distinct from the max-
illa, separated by the premaxillary-maxillary suture
which remains visible on the palate and floor of nose
(Fig. 1).
During the first few years of life, the suture con-
tracts but nevertheless remains open. It is visible on
the anterior palatal surface extending from either side
of the nasopalatine canal into the periodontal liga-
ment of the deciduous canine teeth (Fig. 2) and in
the nasal floor, from the nasopalatine canal to the
lateral margins of the pyriform aperture, on either
side. From the age of 6-7 years, the suture closes

Fig. 3 -Adult skull-the premaxillary-maxillary suture, although

much reduced, is still visible close to the mid-line.

from the canine region toward the nasopalatine canal,

closure being gradual and incomplete. The suture
persists into adulthood, and can be seen on either
side of the nasopalatine canal (Fig. 3). Vertically,
closure takes place from the nasal to the oral surface.
The premaxillary-maxillary suture represents a true
suture and not an embryological vestige of the fusion
of the medial nasal and maxillary processes. Fusion
occurs on or about the 36th day of gestation whilst
ossification does not commence until the 40th day.
Like other ‘true sutures’, the premaxillary-maxillary
suture is a site of active and pivotal osteogenesis,
influenced by local bio-dynamic conditions.25.26
Nonetheless, it differs from other craniofacial sutures
in that closure commences at its lateral external
aspect and progresses towards the midline on either
side. Parts of the suture can continue to move and
the further away from the point of fusion, the greater
Fig. 1 -Skull-21 days. Note the width of the premaxillary- the mobility. It can be deduced from its mor-
maxillary suture, with ossification laterally. phology,25,27 that the premaxilla hinged on its exter-

Fig. 4 - Growth of the premaxilla in the horizontal plane.

Fig. 2 - Skull-4.5 years. The premaxillary-maxillary suture is still (I) Global anterior growth) (II) Bone deposition anteriorally;
open except in the canine region. (III) Lateral growth.
 158 British Journal of Oral and Maxillofacial
nal aspect, opens like a swing bridge and, in so doing,
the inter-incisive suture is widened (Fig. 4). The
human premaxilla cannot move forward as freely as
it can in animals. It is not surprising that studies on
sagittal disjunction,” have failed (except after frac-
ture of the outer cortex in the canine region and then
only observed in the first year of life). However, it is
incorrect to say that the premaxilla can never move
as a result of its early unification with the maxillazg
or because rapid sagittal disjunction is impossible
after one year. 28 Despite early fusion, antero-
posterior development of the premaxilla continues
until the 5-6th year and is influenced by a number
of other factors including the intrinsic activity of
membranous bone, the ‘median septal system’, tongue
function, tooth development and dental occlusion.
Membranous bones, including the premaxilla, are
characterized by the relative independence of their
outer and inner bony cortices. This is well demon-
strated in the vault of the skull where the inner cortex
adapts to intracranial changes e.g. hydrocephalus
whilst the outer cortex is influenced by posture and
function including mastication.” Each hemi-
premaxilla is pyramidal with it’s base facing inwards
toward the midline.30 It’s three remaining surfaces,
the palatine (inner) cortex, the labial (outer) cortex
and the nasal (upper) cortex are influenced by adjac-
ent soft tissues in addition to the developing teeth.
In the foetus and first years of life, premaxillary
development occurs uniformly over all surfaces. The
labial (outer) cortex is greatly influenced by the
activity of the overlying tissues including the nasolab-
ial muscles and develops further forwards than the
other premaxillary surfaces, Consequently, later pre-
maxillary development (after 6 years of age) occurs
principally at the labial (outer) cortex. The anterior
maxillary alveolar arch develops as a result of global
anterior rotation of each hemi-premaxilla around an
axis in the canine region, anterior rotation of the
labial cortical plates and separation of the maxillary
bones (Fig. 4). These complex movements activate
and widen the inter-incisive suture in both the trans-
Fig. 5 - Growth of the premaxilla in the vertical
of rotation between the premaxilla and the anterior
secondary palate; S: The premaxillary-maxillary
Surgerv
verse and sagittal planes so lengthening the premax-
illa. In the vertical plane (Fig. 5) premaxillary
movement can occur by upward tilting of the premax-
illa, widening the premaxillary-maxillary suture on
its palatal aspect, a phenomenon which explains the
delayed and incomplete closure at this level.
The median septal system is an important structure
influencing premaxillary development. The nasolabial
muscles, in particular transverse nasalis, superficial
and deep elevators of the upper lip including alaeque
nasi and orbicularis of the upper lip converge on
each side toward the anterior nasal spine and insert
directly and indirectly onto the antero-inferior aspect
of the septal cartilage, thereby forming a ‘musculo-
periosteal tent’. Their symmetrical insertion aligns
the septal cartilage with the inter-incisive suture so
that balanced growth of the median septal system
pulls the ‘musculo-periosteal tent’ anteriorly thereby
encouraging growth of the maxilla and anterior nasal
spine.30-33
The tongue influences the anterior part of the
palatal vault in the antero-posterior, transverse and
vertical directions. Reduced tongue function especi-
ally if at a very early stage is, therefore, likely to
influence premaxillary development, Kriens34
observed in neonates with isolated cleft palate that
the base of the tongue was lower and further forward
than normal which could result in reduced tongue
pressure on the anterior palate.
Tooth development also influences the growth of
the premaxilla. The developing anterior maxillary
tooth buds exert pressure on the surrounding struc-
tures resulting in deformation of the premaxillary-
maxillary suture and the appearance, albeit transient
of secondary sutures between the teeth. Larger tooth
buds will induce greater premaxillary expansion
whereas premaxillary underdevelopment is more
likely when the maxillary incisors are absent. Occlusal
forces, in the non-cleft subject, directly influence
maxillary incisor and canine tooth position and
indirectly premaxillary development. This is apparent
where reduced occlusal forces are associated with
premaxillary hypoplasia e.g. the class III dental
occlusion, premature loss of deciduous incisors and
delayed eruption of permanent incisors.
Maximal premaxillary growth occurs between the
Sth-21st week in utero.35 Transverse maxillary
growth, as measured by increasing intercanine dis-
tance, progresses rapidly in the first 12 months. From
3.5 to 9910 years, growth is still active. Based on
measurements taken at various stages36-40 it is poss-
ible to estimate the intercanine distance. This
increases by an average of 3.5 mm from birth to 3.5
years and by 3.5 mm from 3.5 to 9-10 years.41 After
this age the intercanine distance increases very little
and may even decrease. During the same period, the
length of the premaxilla increases by about 2 mm
from birth to 3.5 years, then by about 3 mm between
3.5 and 12 years. This transverse and antero-posterior
growth results in an increase in the diameter of the
plane. C: Centre
anterior arch of the premaxilla, the size of which is
surface of the certainly difficult to quantify (owing to the migration
suture. of teeth) but can be estimated at about 6 mm from
 Primarv closure of the cleft alveolus: a functional approach 159

birth to 3.5 years and about the same from 3.5 to 12

years. The increases in the premaxillary region are
usually attributed entirely to oblique development of
the alveolar processes. This explanation is untenable
when there is, for example, a Class II division 2
malocclusion with retroclination of the upper incisors
and a well-developed premaxilla. Lateral radiographs
taken at different ages demonstrate premaxillary
growth in the sagittal plane in children and again
during puberty, when it is mainly in the region of the
anterior nasal spine.

ANATOMY AND PHYSIOLOGY OF THE CLEFT

PREMAXILLA

The dento-skeletal abnormalities encountered in the

cleft alveolus result from disturbance of the structures
involved in premaxillary growth with subsequent
disorganisation and underdevelopment of the associ-
ated hard and soft tissues. The nasolabial muscles,
normally inserted into the region of the nasal septum
and anterior nasal spine, lie lateral to the cleft
alveolus, underdeveloped and collapsed against the
anterior aspect of the lesser segment. This is recog-
nised in both the unilateral and bilateral forms but
best demonstrated in the bilateral cleft.
In the unilateral cleft (Fig. 6), there is a failure of
fusion of the medial nasal and maxillary process.
Consequently, ossification centres in the premaxilla
and maxilla cannot migrate and unite in the region
of the premaxillary-maxillary suture. The nasal
septum and interincisive suture deviate to the non-
cleft side due to the unopposed activity of the nor-
mally inserted nasolabial muscles. This deformity
involves the components of the ‘median septal system’
which are invariably present albeit displaced and
deviated. The premaxilla (anterior part of the greater
segment) is displaced antero-superiorly with the hemi-
premaxilla, adjacent to the cleft margin, underdevel-
oped as a result of abnormal nasolabial muscle
activity. The lateral incisor tooth buds are frequently
missing and the lower lip trapped behind the premax-
illa. These abnormalities tend to encourage and exag-
gerate forward development in the region of the
premaxillary-maxillary suture.
In the bilateral cleft (Fig. 7), there is a failure of
fusion of the median nasal and maxillary processes
on both sides. The ‘median septal system’ usually
remains in the midline but lack of nasolabial muscle
function overlying the premaxilla allows unrestrained
growth at the vomero-premaxillary suture42,43
resulting in a protrusive premaxilla. Transverse pre-
maxillary growth is also inhibited due to disruption
and widening of the premaxillary-maxillary suture.
Rotational elements of premaxillary growth are
impaired, visible as premature obliteration of the
inter-incisive suture. The tooth buds in the premaxilla,

Fig. 6 - Unilateral cleft lip, alveolus and palate, (A) Clinical view
age 6 months; (B) Diagram of skeletal abnormalities; (C) Occlusal
radiograph.
C
 160 British Journal of Oral and Maxillofacial Surgerv
Fig. 7 - Bilateral cleft lip and alveolus. (A) Lateral view of dried skull
skeletal abnormalities-left: diagram, right: occlusal radiograph.
with inadequate space for correct alignment and
abnormal muscle activity, become spaced out and
proclined. The lower lip, trapped behind the premax-
illa further exaggerates forward displacement of the
premaxilla and proclination of the incisor teeth as
well as encouraging anterior development at the
premaxillary-vomerine suture. The columella, the
inferior part of which is deformed by the displaced
tooth buds, is reduced in height, with the vermilion
being replaced by an area of dry mucosa, described
by Veau44 as ‘sterile’. Conversely, the labial fraenum
and the underlying median cellular septum appear
normal other than they lack the insertion of the
nasolabial muscles.
Primary surgery must aim to re-insert the nasolab-
ial muscles into the nasal septum and anterior nasal
spine, preserving all the elements of the median septal
septum. Functional repair will spontaneously align
aged 8 months-left: skull, right: radiograph; (B) Horizontal view of
the anterior maxillary arch thereby facilitating the
reconstitution of the bony defect with viable
periosteum.
SURGICAL REPAIR OF THE CLEFT
ALVEOLUS
Unless the alveolar defect is very narrow, we repair
the anterior palate and alveolus using a two stage
technique. Meticulous nasolabial muscle reconstruc-
tion is performed at 6 months for the unilateral cleft
and 4-5 months in the bilateral cleft. The inferior
surface of the reconstituted nasal floor is covered
with the reconstructed transverse nasalis muscle and
where necessary, a modified Muir flap. Primary clos-
ure of the lip and floor of the nose is carried out, in
the case of complete clefts, at the same time as closure

of the soft palate. This encourages narrowing of the
alveolar and hard palatal defect with good maxillary
arch alignment without the use of pre-surgical ortho-
paedics. At the age of about 14 months, the second
stage of primary closure is carried out by means of a
gingivoperiosteoplasty (Fig. 8).45,46 Mucoperiosteal
flaps are mobilized and advanced across the alveolar
defect on the labial aspect by wide subperiosteal
undermining. Subperiosteal dissection extends, on the
cleft side, over the anterior surface of the maxilla,
superiorly to the infra-orbital rim and posteriorly to
the zygomatic buttress. Periosteal relieving incisions
at the periphery of the undermining may be required
where advancement of the mucoperiosteal flap across
the cleft alveolus proves difficult. Palatal closure is
achieved by the dissection of all mucoperiosteal tissue
out of the alveolar cleft into the anterior palate. The
void created between the labial and palatal flaps is
packed with Lyostypt (Lyostypt-Ethicon) to oblit-
erate the dead space and encourage bone forma-
tion.13.47 In patients with a complete cleft of lip and
palate, the residual hard palate defect that narrows
spontaneously by functional repair of lip and soft
palate is closed at the time of gingivoperiosteoplasty.
Two layered closure of the hard palate is achieved in
continuity with the gingivoperiosteoplasty, respecting
the three zones of palatal fibromucosa.48 The success
of this approach is best demonstrated in the complete
bilateral cleft lip and palate where the maxillary
processes frequently collapse behind a protrusive
B the largest of clefts.
Fig. 8 - Technique of gingivoperiosteoplasty. (A) When carried
out at the age of 14 months; (B) When carried out as part of a
functional revision.
Primary closure of the cleft alveolus: a functionai approach 161
premaxilla. Functional nasolabial muscle reconstruc-
tion combined with simultaneous soft palate repair
encourages alignment of the premaxilla and the maxil-
lary processes (Figs 9 & 10). In a very wide cleft lip,
the only possibility may be to convert it from a
complete to an incomplete cleft at the first operation,
restoring function of the nasal muscles and muscles
forming the nasal sill, completing the repair at 7-8
months.
DISCUSSION
Many techniques to repair the cleft alveolus have
been described the majority of which lack a morpho-
logical and functional basis and do not, therefore,
have successful outcome in terms of mid-facial devel-
opment. Millard49 suggested that the best time to
reconstruct the anterior part of the floor of the nose
is at the same time as primary closure of the lip as it
allows optimal operative access. Veau5’ was the first
to carry out this approach to primary reconstruction.
With this technique, the nasal layer was formed by
the muco-perichondrium of the nasal septum and the
muco-periosteum overlying the lesser alveolar seg-
ment. The oral layer was formed by a flap of palatal
mucosa swung medially so that its anterior extremity
covered the exposed surface of the nasal layer. There
are, however, major problems associated with this
technique including a tendency for the mucosa of the
nasal floor to retract, resulting in persistent oro-nasal
fistulae, retraction due to scarring anteriorly which
exaggerates collapse of the segments, and a denuded
zone of the hard palate laterally due to medial
displacement of the palatal flap, further exaggerating
the displacement of the lesser segment. Better cover-
age of the anterior part of the reconstructed nasal
layer was achieved by Burian” using a flap of mucosa
from the buccal sulcus. The disadvantages of this flap
were a reduction in the depth of the buccal sulcus,
tightness of the mucosal surface of the lip and result-
ant tethering. There is also a tendency to palato-
occlusion of the canine teeth. Stellmach52 suggested
using a vomerine flap-based anteriorly and folded
over from behind forwards. Petit and Psaumes3 felt
that the problems with development secondary to
Veau’s technique were such that they advised against
any undermining of the palatal mucosa. They sug-
gested closure of the anterior palate should be in one
plane only using nasal and vomerine mucosa and this
technique was further developed by Malek.54
Methods have been used to overcome the inherent
risks of single layer closure. A mucosal flap from the
free lateral margin of the cleft lip as described by
Muir” can be used and unlike the Burian flap, it
does not have an adverse effect on the buccal sulcus.
This was later modified by Millard to have an inferior
gingivo-alveolar base instead of a superior labial and
vestibular base and its dimensions allow it to bridge
The observed mid-facial hypoplasia seen in cleft
lip and palate subjects may be related more to an
interaction of disrupted anatomy with normal intrin-
162 British Journal of Oral and Maxillofacial Surgerv
sic growth mechanisms rather than to either initial
mesenchymal tissue deficiencies or abnormal midfa-
cial growth mechanisms.56 Accordingly, the preser-
vation of existing normal structures together with
surgical techniques aimed at the restoration of normal
anatomy is a rational approach in cleft surgery.
Pritchard et a&” state that sutures of the craniofacial
skeleton are not only active sites of growth but also
integral structures essential for normal three dimen-
sional development of the facial skeleton. Disruption
or delay in restoring continuity of a craniofacial
suture (including the premaxillary-maxillary suture)
is likely to hinder local growth and development.
Embryologically, the cleft alveolus represents a failure
Fig. 9 - Complete bilateral cleft lip and palate. (A) Age 2 months; (B) left and right age 6.5 years; (C) left: age 6 months, right: age 2 years;
(D) left: 4 years, right: 6.5 years. Note ossification at the site of the cleft following primary functional cheilorhinoplasty and
gingivoperiosteoplasty.
of fusion of the median nasal and maxillary pro-
cess(es) in the region of the premaxillary-maxillary
suture. The migration and fusion of ossification
centres in the premaxilla and the maxilla cannot
occur and this adversely influences growth and devel-
opment of the anterior maxilla.
If closure of the alveolus is delayed, the anterior
maxilla is unable to develop normally as the premaxil-
lary-maxillary suture remains separated. However,
the technique of delayed or secondary bone grafting,s7
is popular and successful with 90% of patients ulti-
mately obtaining an adequate bony alveolus.
Witsenberg17 commented that the success of second-
ary bone grafting has been overemphasised.
Complications of mucosal breakdown with loss of
bone, resorption of the bone graft, root resorption,
failed tooth eruption and donor site morbidity have
been documented.‘* Ross4 concluded that growth
and development of the anterior maxilla (and premax-
illa) is impaired to a variable degree in all forms of
bone grafting techniques. Bone grafting at any age
creates an unphysiological environment within the
alveolar defect, frequently disrupting the vomero-
premaxillary suture and resulting in early synostosis
at the premaxillary-maxillary suture.
Although primary bone grafting has largely been
abandoned,3 the techniques of periosteal grafting
produce variable but often acceptable
results.13-15,47,59 In infants and children, the high
osteogenic potential of periosteum in the maxillofacial
skeleton is well documented61s6’ and success relies
heavily on the integrity and vascularity of the perios-
 Primary closure of the cleft alveolus: a functional approach 163

periosteum, in addition to an intrinsic system of

vessels within the superficial fibrous layer, arises from
fascial attachments (where present) and overlying
muscles. Free anastomosis of vessels in the periosteum
is found at sites of muscle origin and insertion where
the muscle is fused to the periosteum, although
communicating vessels do exist in other musculo-
periosteal regions. 65 Techniques of free periosteal
grafts13 and periosteal flaps47 where sub and supra-
periosteal dissection is required, deprive the
periosteum of much of its vascularity and hence its
osteogenic potential. Gingivo,Teriosteoplasty restores
at an early age, physiological mtinuity across the
Fig. 10 -Complete bilateral cleft lip and palate. (A) Age 5 months;
(B) left: age 7 years, right: age 7 years. Note position of
alveolus so that ossification m occur in the region
premaxilla, achieved without any orthodontic treatment, (C) left: of the premaxillary-maxillary s dre. Wide subperios-
age 7 months, right: age 10 months; (D) top: age 5 years, bottom: teal undermining introduces vascularised periosteum
age 8 years. with good osteogenic potential across the cleft
alveolus allowing haematoma formation between the
teal envelope. Periosteum consists of two layers, an labial and palatal periosteal layers. Early physiologi-
outer fibrous layer and an inner osteogenic layer, cal bone deposition in the cleft alveolus13,‘4,47 can
adjacent to the bone and containing pre-osteoblasts occur, encouraging normal development of the cleft
and osteoblasts.63,64 The principal blood supply to premaxilla and adjacent maxillary process(es). The
 164 British Journal of Oral and Maxillofacial Suruerv

technique is successful and preliminary results are 13. Ritsila V, Alhopuro S, Gylling U, Rintala A. The use of free
satisfactory.66 Secondary bone grafting is usually periosteum for bone formation in congenital clefts of the
maxilla. Stand J Plast Reconstr Surg 1972; 6: 57-60.
avoided and residual defects that occur may require 14. Ritsila V, Alhopuro S, Rintala A. Bone formation with free
only a small graft using mandibular symphyseal periosteum. Stand J Plast Reconstr Surg 1972; 6: 51-56.
bone67 which has a common embryological origin 15 Azzolini A, Riberti C, Roseeli D, Standoli L. Tibia1 periosteal
with reliable and predictable behaviour.68,69 graft in repair of cleft lip and palate. Ann Plast Surg 1982; 9:
105-112.
In the bilateral cleft lip and palate, the management 16. Hellquist R, Svardstrom K, Ponten BA. Longitudinal study of
of the premaxilla remains problematical. Forceful delayed periosteoplasty to the cleft alveolus. Cleft Palate
repositioning of the premaxilla by pre-surgical ortho- J 1983; 20: 2777288.
paedics buckles the nasal septum7’ whilst premaxillec- 17. Witsenberg B. The reconstruction of the anterior residual bone
defects in patients with cleft lip, alveolus and palate. J Maxfac
tomy is to be wholly condemned.71 Early premaxillary Surg 1985; 13: 197-208.
setback produces late midface retrusion7’ whilst 18. Semb G. Effect of alveolar bone grafting on maxillary growth
delaying setback, although less detrimental,73 still in unilateral cleft lip and palate patients, Cleft Palate J 1988;
disrupts the vomerine-premaxillary suture and 25: 288-295.
restricts premaxillary development.43,74 19. Brattsom V, McWilliam J, Larson 0, Semb G. Craniofacial
Development in children with unilateral clefts of the lip,
Careful primary reconstruction of the nasolabial alveolus and palate treated according to four different
and soft palate musculature, followed by restoration regimens. Stand J Plast Reconstr Surg 1991; 25: 259-267.
of continuity between maxillary fragments by gingivo- 20. Thibult J. Variations de forme et de dimensions du
periosteoplasty aims to restore normal anatomy, with premaxillaire dans l’ttude ttltradiographique sagittal. 1973;
University of Nantes, Nantes, France.
normal development of the premaxilla, particularly 21. Thibult J. Contribution a l’ttude du premaxillaire. 1978;
in the bilateral cleft. These techniques which are University of Nantes, Nantes, France.
based on anatomical and physiological findings 22. Vallois HE, Cadenat E. Le development du premaxillaire chez
appear superior to the commonly used techniques l’homme. Arch Biol 1926;
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matrices in facial growth. Am J Orthod 1969; 55: 5666577.
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a bone graft at a later date. chez l’homme. Rev Stomatoll974: 75: 951-970.
25. Pritchard JJ, Scott JH, Girgis FG.‘The structure and
development of cranial and facial sutures. J Anat 1956; 90:
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