Why the Repaired Midface Grows Backward

The maxilla is the upper jaw and the bone of the midface, the region under the eyes and around the upper lip. In a child born with a cleft, two forces together hold this midface back as the child grows: an intrinsic tendency, where the cleft maxilla simply grows poorly forward on its own, and a scar effect, where the scar left on the roof of the mouth by palate surgery adds a restraining, tethering pull on forward growth. The result is a flat, set-back midface, called maxillary hypoplasia or midface retrusion.

The scar effect is not just a theory. A multicenter functional study of children with complete cleft lip and palate compared palate-repair techniques. A pushback (Veau-Wardill-Killner) palatoplasty was associated with MORE transverse maxillary deficiency, a more constricted, deficient upper jaw. A two-stage protocol with a Sommerlad veloplasty had LESS negative impact on maxillary growth. Separately, cleft patients who screened positive for sleep-disordered breathing were more likely to have a Class III bite with maxillary retrusion.

So the more a repair scars or shortens the palate, the more the midface tends to be held back, and a set-back midface and a narrowed airway tend to travel together. A reminder from last lesson: the alveolar bone graft did not significantly change whether a patient later needed major jaw-advancement surgery. The midface growth problem is a separate consequence the team must track and plan to correct on its own.