Timing of Cleft Palate Closure Should Be Based on the Ratio of the Area of the Cleft to That of the Palatal Segments and Not on Age Alone Samuel Berkowitz, D.D.S., M.S., F.I.C.D., Robert Duncan, Ph.D., Carla Evans, D.D.S., D.M.Sc., Hans Friede, D.D.S.(Ortho.), Anne Marie Kuijpers-Jagtman, D.D.S., Ph.D.(Ortho.), Birte Prahl-Anderson, D.D.S., Ph.D.(Ortho.), and Sheldon Rosenstein, D.D.S., M.S.D. Miami, Fla. Background: Retrospective and prospec- tive serial spatiotemporal investigations were carried out primarily to determine whether the ratio of the size of the posterior cleft space rel- ative to the palatal surface area limited laterally by the alveolar ridges can be used to select the appropriate time for surgical closure of the pal- atal cleft space. Two subsamples were com- pared to determine whether the size of the palate and velocity of palatal development in well growing cases differ from those in cases treated by vomer flap surgery. The prospective investigation asked whether presurgical ortho- pedics increases the rate of palatal growth and palatal size. Methods: Using the palatal casts of 242 male and female individuals from eight insti- tutions in the United States and Western Eu- rope that followed a variety of treatment pro- tocols, separate serial analyses were conducted of well growing cases with excellent aesthetics, dental occlusion, and speech and a control se- ries of 17 cases of various clefts of the lip and alveolus and/or soft palate but no clefts in the hard palate. Twelve groupings of cases were established depending on their institutional lo- cation and type of cleft. Results: Among the various institutions in the study, palatal growth rates and size were statistically similar. Growth in the various clin- ical series (size, mm 2 ) was less than that of the control series. The ratio of cleft space size to palatal surface area medial to the alveolar ridges was 10 percent or less at 18 months of age in most cases. There was no statistical difference in total surface size between groups, except for one series whose total growth size was least of all. Right and left lateral palatal segments, whether large or small, grew at the same rate. The sample of bilateral cases was too small for statistical comparisons. Presurgical orthopedics did not stimulate palatal growth. The coeffi- cient of variance was less than 10 percent in all measurements. Conclusions: Delaying all cleft closure surgery until 5 years of age and older is un- necessary to maximize palatal growth. The best time to close the palatal cleft space is when the palatal cleft size is 10 percent or less of the total palatal surface area bounded lat- erally by the alveolar ridges. The 10 percent ratio generally occurs between 18 and 24 months but can occur earlier or later. There is more than one good type of palatal cleft closure surgery. (Plast. Reconstr. Surg. 115: 1483, 2005.) Diagnosis and surgical treatment planning in both medicine and dentistry are most fre- From the South Florida Cleft Palate Clinic, University of Miami School of Medicine, and the Miami Craniofacial Anomalies Foundation. Received for publication July 21, 2003; revised January 29, 2004. Presented at the Ninth International Congress on Cleft Palate and Related Craniofacial Anomalies, in Go ¨teborg, Sweden, June of 2001, and at the Annual Meeting of the American Cleft Palate–Craniofacial Association, in Seattle, Wash., April 30, 2002. DOI: 10.1097/01.PRS.0000161673.31770.23 1483