Evaluation of the effect of palate repair timing on maxillary transverse width and anterior position in cleft lip and palate patients using radiological methods

Evaluation of the Effect of Palate Repair Timing on Maxillary Transverse Width and Anterior Position in Cleft Lip and Palate Patients Using Radiological Methods Objective: In this study, the effects of palate repair timing (early: 9–12 months, late: 13–24 months) on maxillary transverse width and anterior position in patients with cleft lip and palate were evaluated using radiological methods. The aim was to identify differences in maxillary development according to the timing of palatal repair and to contribute to the development of optimal surgical timing protocols. Materials and Methods: The study included a total of 71 patients (27 bilateral complete cleft lip and palate, 37 unilateral complete cleft lip and palate, 7 cleft lip/alveolus only) retrospectively identified from the archives of Çukurova University Faculty of Medicine. Patients were divided into early repair (9–12 months) and late repair (13–24 months) groups according to the age of palatoplasty. Maxillofacial development was evaluated using SNA, SNB, and ANB angles obtained from lateral cephalometric radiographs, as well as maxillary and mandibular skeletal measurements. The transverse width of the maxilla was analyzed using posterior (intermolar distance difference, IMDD) and anterior (foramen mentale (Fm)–foramen incisivum (Fi) difference) measurements from cone beam computed tomography images. Furthermore, the presence of oronasal fistula (ONF) formed after palatal repair was recorded, and the effects of ONF development on skeletal growth were examined using subgroup analyses. Results: The timing of palatoplasty was found to create significant differences, particularly in maxillary development. While there was no significant difference in the sagittal position of the maxilla between the bilateral groups undergoing early and late palate repair (Groups 1A and 1B), the IMMF was found to be significantly higher in the late repair group (p = 0.005). Within the unilateral group (Groups 2A and 2B), the SNA value was significantly higher in the early repair group (p = 0.038). In unilateral cleft cases, the maxillary arch width was relatively narrower in both the anterior and posterior segments in the delayed repair group; however, the posterior width difference was at the threshold of statistical significance (p≈0.05). Overall, the SNB angle, a mandibular development parameter, did not show a statistically significant difference between the early and delayed repair groups. In patients with UKDDY (unilateral complete cleft lip and palate) who developed an oronasal fistula, maxillary transverse narrowing was significantly greater compared to those who did not develop ONF (p = 0.011). The Class II malocclusion rate was significantly higher in the bilateral complete cleft lip and palate (BKDDY) and unilateral complete cleft lip and alveolar (UKDAY) groups (p<0.001). In contrast, Class III malocclusion was significantly more prevalent in the UKDDY group (p<0.05). Furthermore, maxillary development parameters were found to be more advanced in both the transverse and sagittal directions in patients with cleft lip and alveolus but without cleft palate compared to the other groups. Conclusion: The timing of palatal repair significantly affects maxillary growth in cleft lip and palate patients in both the sagittal and transverse planes. Palatal repair performed in the early period (within 9-12 months) supports the anterior position of the maxilla, particularly in unilateral clefts, and maintains a higher SNA angle. In both unilateral and bilateral cleft lip and palate patients, palatal repairs performed in the late period (13-24 months) have been associated with marked transverse narrowing of the maxilla; this effect is more pronounced in bilateral cleft cases, leading to a significant restriction in the posterior width of the maxilla. On the other hand, depending on the timing of palatal repair (early and late) and the type of cleft, mandibular development is thought to follow the maxilla in the sagittal direction. In light of these data, when determining the timing of palatoplasty in surgical treatment planning, preservation of the anterior position of the maxilla and avoidance of transverse width restriction should be considered. Furthermore, avoiding palatal fistula development is critically important in ensuring maxillary growth, particularly in the transverse direction. Keywords: cleft lip and palate; palatal repair; maxillofacial development; cephalometry; cone beam computed tomography (CBCT)