Impact of Timing of Hard Palate Closure on Maxillary Growth in Cleft Lip, Alveolus, and Palate Patients: A Comprehensive Review

Highlights

• Comparable anteroposterior maxillary growth is observed following early (around 12 months) and delayed (9-12 years) hard palate closure (HPC) in unilateral cleft lip, alveolus, and palate (CLAP) patients.
• Gingivoperiosteoplasty (GPP) at 1.5 years can reduce the need for secondary alveolar bone grafting without compromising maxillary development.
• The incidence of Le Fort I (LF I) osteotomy post-primary surgery is influenced by cleft type and timing of HPC, with no significant increase following delayed closure protocols.
• Velopharyngoplasty does not exert a measurable detrimental effect on maxillary growth after HPC.

Background

Cleft lip, alveolus, and palate (CLAP) represent complex congenital deformities with significant functional and aesthetic challenges. Restoration strategies aim to achieve optimal speech, feeding, and facial growth outcomes. Timing of hard palate closure (HPC) remains a contentious aspect, balancing early anatomical correction against potential iatrogenic growth inhibition. Multiple protocols have evolved, ranging from early closure within the first 1–2 years of life to delayed closure coinciding with secondary alveolar repair in late childhood or early adolescence. Understanding effects on maxillary morphological development and consequent need for orthognathic surgery is essential to guide clinical decision-making.

Key Content

Chronological Development of Evidence on HPC Timing and Maxillary Growth

The seminal work by Haj et al. (2026) retrospectively evaluated 133 patients with CLAP who underwent delayed HPC at a mean age of 10.3 years, concurrent with secondary alveolar repair. Lateral cephalometry at ages 6, 9, and 17 assessed SNA, SNB, and ANB angles as markers of anteroposterior maxillary and mandibular growth. Their findings demonstrated no statistical difference in maxillary (SNA) and mandibular (SNB) angles when compared with cohorts who underwent early HPC at about 12 months. However, both groups exhibited significant maxillary hypoplasia relative to unaffected controls. Notably, 36.8% of patients underwent velopharyngoplasty post-HPC, which did not impact maxillary growth trajectories. Le Fort I osteotomy was needed in 13.5% of the cohort, a rate congruent with prior literature on early closure protocols.

Evidence from Gingivoperiosteoplasty and Alveolar Bone Grafting Literature

A prospective cohort study by Komatsu et al. (2024) assessed the effects of gingivoperiosteoplasty (GPP) performed at 1.5 years during hard palate closure in unilateral cleft lip and palate (UCLP). This intervention induced bone bridge formation at the alveolar cleft in 92% of patients and obviated secondary alveolar bone grafting (sABG) in over half the cases. Importantly, cephalometric analyses at 12 years revealed no detrimental effect on maxillary anteroposterior length or angular relationships. This supports incorporation of GPP into early two-stage palatoplasty as a strategy minimizing surgical interventions without compromising growth.

Comparative Morphometric Studies on Early Versus Late Closure Protocols

A morphometric study by Al Imran et al. (2019) compared palatal shapes between two cleft management protocols using three-dimensional cone-beam computed tomography (CBCT) in children at 5 years. Protocol 1 involved early lip closure (1-3 months) with secondary soft and hard palate closure by 9 months; Protocol 2 delayed hard palate closure to 18 months following lip and soft palate repair. Though both groups were studied at the same age, protocol 2 demonstrated larger inter-canine distances and more physiological premaxillary position, suggestive of better maxillary arch form preservation. While early closure is traditionally favored for speech outcomes, these morphometric data emphasize the potential benefit of delayed HPC on maxillary morphology.

Incidence of Orthognathic Surgery and Influence of Surgical Protocols

A systematic review framed by van der Meer et al. (2020) reported that maxillary osteotomy rates after primary cleft surgery varied between 20-21% in both one-stage and two-stage palatoplasty protocols. Their retrospective cohort of 51 patients had a lower incidence of maxillary repositioning surgery (4%), underscoring variability depending on surgical technique and patient factors. The timing of HPC, cleft type, and orthodontic regimen were independent predictors of the need for orthognathic intervention. These data resonate with Haj et al.’s findings that delayed HPC does not elevate the likelihood of Le Fort I osteotomy.

Long-Term Facial Growth Outcomes from Surgical-Orthodontic Protocols

An extensive retrospective analysis by Nakamura et al. (2003) evaluated over 100 patients treated with an early comprehensive surgical-orthodontic protocol, including lip closure, primary osteoplasty, and early palate closure within the first year. Their findings indicated facial growth comparable to non-primary osteoplasty groups, with an 18% orthognathic surgery rate and favorable lateral incisor status adjacent to the cleft. These results underscore that precise timing and sequencing in surgical protocols can mitigate facial growth impairment.

Expert Commentary

The balance between early anatomical correction for speech and feeding and the preservation of maxillary growth remains a core dilemma in cleft surgery. The evidence synthesized suggests that delayed HPC, particularly when coordinated with secondary alveolar repair, achieves comparable maxillary anteroposterior dimensions as early closure protocols without increased surgical burden from orthognathic procedures. This aligns with mechanistic insights that early hard palate closure disrupts maxillary sutural growth centers, whereas delayed closure allows for more natural maxillary development before the scar-forming surgery.

Gingivoperiosteoplasty introduced during early HPC confers the advantage of alveolar bone bridge formation, reducing secondary grafting without impairing growth. Morphometric assessments reveal that delayed or two-stage protocols favor improved palatal morphology at mid-childhood, likely translating to functional and aesthetic benefits. However, long-term assessments through skeletal maturity remain necessary to conclusively delineate growth trajectories.

The role of adjunct procedures such as velopharyngoplasty, frequently required for velopharyngeal insufficiency, does not appear to negatively influence maxillary growth, alleviating concerns about compounded surgical impact. Nevertheless, interindividual variation in cleft severity, genetic growth potential, and orthodontic management complicate standardized recommendations.

Current cleft care guidelines emphasize multidisciplinary individualized planning, with timing decisions tailored to patient needs and resource availability. The reviewed data advocate for flexibility in HPC timing, supporting delayed closure strategies without compromising maxillary development or increasing secondary surgical requirements.

Conclusion

The timing of hard palate closure in patients with cleft lip, alveolus, and palate significantly influences maxillary growth, though recent evidence indicates that delayed closure between 9 to 12 years can yield maxillary outcomes comparable to early closure at around 12 months. Adjunct procedures such as gingivoperiosteoplasty enhance alveolar bone formation and may reduce the need for further grafting. The frequency of Le Fort I osteotomy does not appear elevated following delayed HPC, and velopharyngoplasty does not adversely affect maxillary dimensions.

Future prospective, multicenter randomized trials with long-term follow-up are needed to refine optimal surgical timing and protocols further. Integration of advanced imaging modalities and morphometric analyses will augment understanding of growth patterns and functional outcomes, ultimately guiding precision cleft care.

References

• Haj M, Bouter AR, Tjoa STH, Versnel SL, Koudstaal MJ, Wolvius EB. Effect of different timing of hard palate closure on maxillary growth in patients with cleft lip, alveolus and palate. Plast Reconstr Surg. 2026 Jul 22;[Epub ahead of print]. PMID: 42489645.
• Komatsu T, et al. Clinical outcomes of gingivoperiosteoplasty for unilateral cleft lip and palate performed in early childhood. J Plast Reconstr Aesthet Surg. 2024 Oct;97:268-274. doi: 10.1016/j.bjps.2024.07.067. PMID: 39173578.
• van der Meer WJ, et al. The need for maxillary osteotomy after primary cleft surgery: A systematic review framing a retrospective study. J Craniomaxillofac Surg. 2020 Oct;48(10):919-927. doi: 10.1016/j.jcms.2020.07.005. PMID: 32768251.
• Al Imran A, et al. Maxillary shape after primary cleft closure and before alveolar bone graft in two different management protocols: A comparative morphometric study. J Stomatol Oral Maxillofac Surg. 2019 Nov;120(5):406-409. doi: 10.1016/j.jormas.2019.02.001. PMID: 30763782.
• Nakamura N, et al. A long-term retrospective outcome assessment of facial growth, secondary surgical need, and maxillary lateral incisor status in a surgical-orthodontic protocol for complete clefts. Plast Reconstr Surg. 2003 Jan;111(1):1-13; discussion 14-6. doi: 10.1097/01.PRS.0000037680.39989.74. PMID: 12496560.