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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 84-88

The effect of surgical correction on craniofacial growth in unilateral cleft lip and palate patients: A prospective study


1 Department of Orthodontics and Dentofacial Orthopedics, Terna Dental College and Hospital, Navi Mumbai, Maharashtra, India
2 Consulting Orthodontist, Eversmile Dental Clinic, Hyderabad, Telangana, India
3 Department of Orthodontics and Dentofacial Orthopedics, Saraswati Dental College, Lucknow, Uttar Pradesh, India
4 Head of Department, Chief Plastic Surgeon, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission11-Feb-2020
Date of Acceptance20-May-2020
Date of Web Publication31-Jul-2020

Correspondence Address:
Dr. Rohit Kulshrestha
Department of Orthodontics and Dentofacial Orthopedics, Terna Dental College and Hospital, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_4_20

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  Abstract 


Aim: The aim of this study was to evaluate the effects of surgical repair on craniofacial growth in patients with complete unilateral cleft lip and palate. Materials and Methods: Forty patients were taken and were divided into two groups: Group 1 consisted of 20 patients presenting with a nonsyndromic complete unilateral cleft lip and palate and Group 2 (control) consisted of 20 patients without any clefts. The lip closure was done by Millard's cleft lip repair technique. Palatal closure was performed by Bardach two-flap palatoplasty. Lateral cephalograms were traced and studied by the same operator. Composite cephalometric analysis was done to measure the various parameters of craniofacial growth. Results: Values of only lower facial height angle and nasion perpendicular to point A were found to be higher in patients with cleft lip and palate as compared to noncleft participants. The values of the rest of the variables were found to be higher in noncleft participants as compared to patients with cleft lip and palate. Differences were found to be statistically significant only for maxillary length (condylion–point A) (P = 0.027), mandibular length (condylion–gnathion) (P = 0.045), upper 1–point A (P = 0.001), lower 1–point A/pogonion (P = 0.039), and upper lip thickness (P = 0.001). Conclusions: Surgical repair of cleft lip and palate affects the growth of maxilla and mandible. There is a restraining effect on the basal part of the premaxilla, and it is influenced by cleft palate and lip repair.

Keywords: Cephalometric analysis, cleft lip and palate, maxillary growth, surgical repair


How to cite this article:
Kulshrestha R, Wajid MA, Singh K, Shenava S, Mathew R, Katpale S, Agarwal A. The effect of surgical correction on craniofacial growth in unilateral cleft lip and palate patients: A prospective study. J Cleft Lip Palate Craniofac Anomal 2020;7:84-8

How to cite this URL:
Kulshrestha R, Wajid MA, Singh K, Shenava S, Mathew R, Katpale S, Agarwal A. The effect of surgical correction on craniofacial growth in unilateral cleft lip and palate patients: A prospective study. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Nov 28];7:84-8. Available from: https://www.jclpca.org/text.asp?2020/7/2/84/291144




  Introduction Top


The impediment of growth and development of the nasomaxillary complex in all treated cleft lip and palate patients is an extensively debated topic. Severe three-dimensional maxillary changes in patients were documented by Grabber[1] in his landmark studies with complete cleft lip and palate after surgery. These patients often present with a tendency toward Class III malocclusion along with anterior, posterior cross-bites and midface deficiency. Johnson et al.[2] repaired patients at 5 and 12 years of age with cleft lip and palate and observed that 40% of the patients at 5 years of age had poor dental arch form and 70% at 12 years of age had midface retrusion. Two factors have been attributed to the abnormal facial morphology in treated cleft patients; intrinsic developmental deficiency and iatrogenic features introduced by treatment.

Bishara et al.[3] claimed that maxillary deficiency occurs due to intrinsic factors in cleft individuals. However, many authors have mentioned that maxillary deficiency is secondary to surgical repair.[4],[5],[6],[7],[8],[9] If the maxillary deficiency is a complication of the surgical intervention, it is important to determine in terms of timing and the choice of the procedure the optimal conditions for palatal and lip closure. Finding the cause of this growth inhibition has been the object of a large number of studies, yet no true consensus has been reached at this time. The iatrogenic effect of surgical intervention seems to be the most important factor in subsequent cleft lip and palate growth.[10] A relatively small growth alteration is noted in nonoperated cleft cases, and iatrogenic factors have been extensively investigated. According to some authors, the main factor responsible for growth inhibition is palatal surgery, while others concentrate on the effect of lip surgery.[11]

The mean values are usually taken into consideration while evaluating growth in cleft patients that are then correlated to either the normal population or the other cleft samples.[12],[13],[14],[15] Mean values are extremely important to show trends in treatment outcome, but the assessment of individual variability is hindered by these values. The factors responsible for the variations in development have been defined by many authors.[16],[17],[18],[19] These differences could depend on the cleft type, as well as severity. It is still not certain whether a surgical treatment has a direct effect on the restriction of maxillary or mandibular growth. Hence, this study was done in patients with complete unilateral cleft lip and palate to evaluate the effects of cleft lip and palate repair on craniofacial growth.


  Materials and Methods Top


This observational study was carried out at “Swami Vivekananda Polyclinic and Institute of Medical Sciences,” Lucknow, India. Patients who came for cleft lip and palate treatment were selected and were divided into two groups. Forty patients (male: 23, female: 17, mean age: 5.6 ± 2 years) were selected and were divided into two groups. Group 1 consisted of 20 patients (male: 13, female: 7) with average growth pattern. They presented with a nonsyndromic complete unilateral cleft lip and palate and excluded Simonart's bands. The median anterior cleft size was 5.3 mm ± 2.3 mm. Group 2 (control) consisted of 20 skeletal Class I patients (male: 7, female: 13) without any clefts. Facial and dental asymmetry was also seen in the patients with unilateral cleft lip and palate.

The study was approved by the Institutional Ethics Committee of Swami Vivekananda Hospital and Research Centre, Lucknow, India. Informed consent was taken from each parent after an appropriate explanation about the surgery involved and the study.

The medial wall of the cleft segment was retropositioned and laterally displaced. The incisor portion of the noncleft segment was displaced anteriorly. Cleft alveoli were then turned superiorly. The nasal deformity was seen in a few patients. The alar base on the cleft side was retropositioned and was deficient. The forward projection or lateral displacement of the cleft alveolar process and anterior wall of the maxilla was also seen.

According to the principles outlined in the Declaration of Helsinki, all data acquisition and analysis of the present study was performed. No orthodontic treatment was done before the cleft lip and palate surgery. The same surgical team (single operator) operated on all the patients. The Millard's cleft lip repair technique was used for closing the lip. Closure of the cleft was done using the Bardach two-flap palatoplasty in a two-stage operation (soft palate at 3 months and then lip and hard palate at 6 months) for all patients. For a comparative study, multiple cephalometric measurements of the whole sample at 6–7 years (average age, 6 years 7 months) had been performed. The same operator assessed and traced all the lateral cephalograms. To measure the various parameters of craniofacial growth, the composite cephalometric analysis was done. Suitable linear and angular measurements were used and traced on each cephalogram [Figure 1] and [Table 1].
Figure 1: Cephalometric measurements

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Table 1: Linear and angular measurements used

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Statistical analysis

A master file was created with all the data, and the Statistical Package for the Social Sciences software (version 17) (SPSS Inc. Released 2008. Chicago, IL, USA: SPSS Inc.) was used to statistically analyze all the data. Shapiro–Wilk test was performed to assess the normality of data. Normal distribution of data was seen. The data were further subjected to descriptive analysis for mean standard deviation and to denote a statistically significant association and 95% confidence interval. P <0.05 (P > 0.05) was considered. All the measurements were repeated 8 weeks after initial measurement to identify the errors associated with the linear measurements. A paired sample t-test was applied to the first and second measurements, and the differences between measurements were insignificant.


  Results Top


The values were collected from patients with complete unilateral cleft lip and palate and were compared with noncleft participants. Values of only lower facial height and nasion perpendicular to point A were found to be higher in patients with cleft lip and palate when compared to noncleft participants, respectively (P = 0.089) (P = 0.779). The values of the rest of the variables were found to be higher in noncleft participants when compared to patients with cleft lip and palate. Differences were found to be statistically significant only for maxillary length (condylion–point A) (P = 0.027), mandibular length (condylion–gnathion) (P = 0.045), upper 1–point A (P = 0.001), lower 1–point A to pogonion (P = 0.039), upper lip thickness (P < 0.001), and upper lip strain (P < 0.001) [Table 2]. There was no association between cleft size and its effect on maxillary retrusion.
Table 2: Comparison of cephalometric variables among cleft lip palate patients and normal controls

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  Discussion Top


In this study, patients with similar values of nasolabial angles were presented when compared to noncleft participants. Lower values of nasolabial angle are reported in a group of patients with clefts and might be a result of nasal and lip deformations, its flattening, and its curvature to the cleft side. These deformities are usually accompanied by a shift of the point columella down, closer to the lips.[20] This angle in patients with clefts is sharper, but it does not lie within the reference values of 90°–120°. The lack of difference which is seen between patients with cleft and noncleft might be caused by a larger deformity and retraction of the upper lip due to the reconstructive surgical procedures or retrusion of upper incisors and flattening of the subnasal region. Whereas, other studies show a flattening of maxillary convexity resulting in smaller values of sella nasion point A angle.[21] Other researchers have confirmed the retrusion of the upper incisors in cleft patients.[22],[23] The intercanine distance in the maxillary arch is lesser in patients with clefts than in noncleft participants; this, in turn, may result in more differentiation in nasolabial angle values.[24],[25] Orthodontic treatment should be individualized, as the smaller value of nasolabial angle might suggest that tooth extractions in the upper arch might be required, though patients with clefts show different malocclusions than noncleft patients (predominantly Class III malocclusions and crossbite rather than Class II malocclusions).

The growth of maxilla is restrained (condylion–point A length decreased) in patients with cleft lip and palate when compared with noncleft patients. The midfacial hypoplasia which is observed in the cleft group may be the outcome of the surgical intervention. In surgically treated patients, inhibition of the normal development of the maxilla has been attributed to scar tissue which is formed.[26] There may be no damage to the bone itself because of surgery, but the fibrous scar tissue formed near the bony growth sites prevents the normal maxillary remodeling and development of maxilla in a downward and forward direction. The extent of interference is mainly related to the severity of the cleft because more extensive procedures have to be performed to mobilize tissue to close a large defect, resulted in large scar tissue, and retarded growth of the maxilla.

When compared between the two groups, a statistically significant difference was found in mandibular length (condylion–gnathion). This showed that mandibular spatial position and length were greatly affected by surgical procedures which were done. These findings are similar to previous studies.[14],[18],[21] These findings are also in agreement with studies which were conducted by Hayashi et al.[27] and Fudalej et al.[28] The data reveal that although the mandible was of normal length, the chin was posteriorly displaced. This retroposition of the chin was the result of mandibular rotation with a subsequent remodeling of the muscle attachments in the gonial area (indicated by the increased gonial angle and mandibular inclination) and may have been a functional response to the altered maxillary complex. The normal mandible and tongue established a satisfactory relationship with a small and shallow-vaulted maxilla. The changes may also have been induced by mouth breathing which is a common finding. An excess vertical growth tendency was showed by the face height measurements in the cleft patients. The lower anterior facial height (angle) was increased when compared with the noncleft controls. Earlier, similar results have been mentioned by other authors.[3],[28],[29] The increase in anterior facial height (angle) maybe because of increased anterior maxillary growth or decreased posterior maxillary growth, but may also reflect the intrinsic mandibular growth pattern.[23] Further clinical research must also be conducted to identify treatment protocols that will interfere least with the normal growth and development of the maxilla in patients with cleft lip and palate which may permit normal growth to proceed.

In this study, an increased lower anterior facial height has contributed to the posterior position of the mandible. Bishara et al.[3] and Mars and Houston[26] have observed similar findings of an increased lower anterior facial height in their study. Ross[25] in his surgically treated patients with clefts found that mandible to be smaller in size and also positioned more posteriorly. Da Silva et al.[24] compared mandibular morphology in operated and unoperated samples concluding that there is no statistical difference found between the two groups. He further stated that the mandibular growth pattern has little influence on the surgical procedure done. The mandible may not be directly affected by the cleft, though it may have an altered growth pattern because of the affected maxilla and functional factors present.

All the variables assessed for the maxillary and mandibular dentition stated that the incisors were positioned more retroclined and retrusive when compared with the control values. Anterior crossbite is a common finding seen in patients with repaired clefts. In our operated cleft lip and palate group, the maxillary incisor position was found similar to that of the control group. Mars and Houston evaluated that a tight lip repair may result in retroclination of maxillary incisors but does not have a significant effect on the growth of the midface.[26] The mandibular dentition was more upright when compared with the control group which was possibly due to lower lip pressure exerted during swallowing as the patient makes an effort to achieve an oral seal.

The two groups showed a significant difference in the changes in the upper lip strain and thickness. In the cleft group, relationship of the upper lip was improved significantly. In the noncleft group, a significant increase occurred in the upper lip thickness, while in the unilateral cleft lip and palate group, the distance also changed significantly. Many studies have reported that especially in patients with cleft lip and palate, not only anterior teeth but also other variables, such as initial lip strain, muscle tonicity, and lip thickness, strongly influence the form and position of the lips.[20],[25],[26] Such factors may modify the soft-tissue response to treatment-induced changes in the underlying hard tissue structures. Hypertrophy of the lower lip musculature is seen as patients constantly strain to obtain bilabial closure. The typical deformity seen was a hypertrophied, superiorly displaced, and forwardly rotated lower lip.[27] Limitations of this study include small and heterogeneous sample size and difficulty in taking accurate cephalometric X-rays of the 5-year-old patients (the accuracy of head position and occlusion, the problems of deciduous and erupting permanent teeth, and crossbite of the cleft side incisors). The drawback of this study is that it does not allow differentiation to be made as etiology could not be identified as the control patients are noncleft cases. For this purpose, a control group including unoperated cleft cases will be required.


  Conclusions Top


The maxillary and mandibular lengths were less than the control group as seen in patients with unilateral cleft lip and palate. Maxilla and mandible both were retrognathic. Upper lip thickness and strain were also seen less than the control group. Retroclination of the maxillary and mandibular anterior teeth was also seen. This indicates that the surgical repair of cleft lip and palate has an effect on the growth of maxilla and mandible and it also affects the dentition as well. There is a restraining effect seen on lip repair. The basal part of the premaxilla was influenced by cleft palate lip repair.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Graber TM. A study of craniofacial growth and development in the cleft palate child from birth to six years of age. In: Early Treatment of Cleft Lip and Palate. Bern: Hans Huber; 1964. p. 30-43.  Back to cited text no. 1
    
2.
Johnson N, Williams A, Singer S. Initial cleft size does not correlate with outcome in unilateral cleft lip and palate. Eur J Orthod 2000;22:93-100.  Back to cited text no. 2
    
3.
Bishara SE, Krause CJ, Olin WH, Weston D, Ness JV, Felling C. Facial and dental relationships of individuals with unoperated clefts of the lip and/or palate. Cleft Palate J 1976;13:238-52.  Back to cited text no. 3
    
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Smahel Z, Betincová L, Müllerová Z, Skvarilová B. Facial growth and development in unilateral complete cleft lip and palate from palate surgery up to adulthood. J Craniofac Genet Dev Biol 1993;13:57-71.  Back to cited text no. 4
    
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Liao YF, Mars M. Long-term effects of palate repair on craniofacial morphology in patients with unilateral cleft lip and palate. Cleft Palate Craniofac J 2005;42:594-600.  Back to cited text no. 5
    
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Shi B, Losee JE. The impact of cleft lip and palate repair on maxillofacial growth. Int J Oral Sci 2015;7:14-7.  Back to cited text no. 6
    
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Richard B, Russell J, McMahon S, Pigott R. Results of randomized controlled trial of soft palate first versus hard palate first repair in unilateral complete cleft lip and palate. Cleft Palate Craniofac J 2006;43:329-38.  Back to cited text no. 7
    
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Shao Q, Chen Z, Yang Y, Chen Z. Effects of lip repair on maxillofacial morphology in patients with unilateral cleft lip with or without cleft palate. Cleft Palate Craniofac J 2014;51:658-64.  Back to cited text no. 8
    
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Capelozza Filho L, Normando AD, da Silva Filho OG. Isolated influences of lip and palate surgery on facial growth: Comparison of operated and unoperated male adults with UCLP. Cleft Palate Craniofac J 1996;33:51-6.  Back to cited text no. 9
    
10.
Chierici G, Harvold EP, Vargervik K. Morphogenetic experiments in cleft palate: Mandibular response. Cleft Palate J 1973;10:51-61.  Back to cited text no. 10
    
11.
Ye Z, Xu X, Ahmatjian A, Bing S. The craniofacial morphology in adult patients with unoperated isolated cleft palate. Bone Res 2013;1:195-200.  Back to cited text no. 11
    
12.
Pai BC, Ko EW, Huang CS, Liou EJ. Symmetry of the nose after presurgical nasoalveolar molding in infants with unilateral cleft lip and palate: A preliminary study. Cleft Palate Craniofac J 2005;42:658-63.  Back to cited text no. 12
    
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14.
Li Y, Shi B, Song QG, Zuo H, Zheng Q. Effects of lip repair on maxillary growth and facial soft tissue development in patients with a complete unilateral cleft of lip, alveolus and palate. J Craniomaxillofac Surg 2006;34:355-61.  Back to cited text no. 14
    
15.
Swennen G, Berten JL, Schliephake H, Treutlein C, Dempf R, Malevez C, et al. Midfacial morphology in children with unilateral cleft lip and palate treated by different surgical protocols. Int J Oral Maxillofac Surg 2002;31:13-22.  Back to cited text no. 15
    
16.
Rohrich RJ, Love EJ, Byrd HS, Johns DF. Optimal timing of cleft palate closure. Plast Reconstr Surg 2000;106:413-21.  Back to cited text no. 16
    
17.
Gaggl A, Feichtinger M, Schultes G, Santler G, Pichlmaier M, Mossböck R, et al. Cephalometric and occlusal outcome in adults with unilateral cleft lip, palate, and alveolus after two different surgical techniques. Cleft Palate Craniofac J 2003;40:249-55.  Back to cited text no. 17
    
18.
Lilja J, Mars M, Elander A, Enocson L, Hagberg C, Worrell E, et al. Analysis of dental arch relationships in Swedish unilateral cleft lip and palate subjects: 20-year longitudinal consecutive series treated with delayed hard palate closure. Cleft Palate Craniofac J 2006;43:606-11.  Back to cited text no. 18
    
19.
Peltomäki T, Vendittelli BL, Grayson BH, Cutting CB, Brecht LE. Associations between severity of clefting and maxillary growth in patients with unilateral cleft lip and palate treated with infant orthopedics. Cleft Palate Craniofac J 2001;38:582-6.  Back to cited text no. 19
    
20.
Schultes G, Gaggl A, Kärcher H. A comparison of growth impairment and orthodontic results in adult patients with clefts of palate and unilateral clefts of lip, palate and alveolus. Br J Oral Maxillofac Surg 2000;38:26-32.  Back to cited text no. 20
    
21.
Lisson JA, Hanke I, Tränkmann J. Changes of vertical skeletal morphology in patients with complete unilateral and bilateral cleft lip and palate. Cleft Palate Craniofac J 2005;42:490-4.  Back to cited text no. 21
    
22.
Stein S, Dunsche A, Gellrich NC, Härle F, Jonas I. One- or two-stage palate closure in patients with unilateral cleft lip and palate: Comparing cephalometric and occlusal outcomes. Cleft Palate Craniofac J 2007;44:13-22.  Back to cited text no. 22
    
23.
DiBiase AT, DiBiase DD, Hay NJ, Sommerlad BC. The relationship between arch dimensions and the 5-year index in the primary dentition of patients with complete UCLP. Cleft Palate Craniofac J 2002;39:635-40.  Back to cited text no. 23
    
24.
da Silva Filho OG, Valladares Neto J, Capelloza Filho L, de Souza Freitas JA. Influence of lip repair on craniofacial morphology of patients with complete bilateral cleft lip and palate. Cleft Palate Craniofac J 2003;40:144-53.  Back to cited text no. 24
    
25.
Ross RB. Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Cleft Palate J 1987;24:5-77.  Back to cited text no. 25
    
26.
Mars M, Houston WJ. A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J 1990;27:7-10.  Back to cited text no. 26
    
27.
Hayashi I, Sakuda M, Takimoto K, Miyazaki T. Craniofacial growth in complete unilateral cleft lip and palate: A roentgeno-cephalometric study. Cleft Palate J 1976;13:215-37.  Back to cited text no. 27
    
28.
Fudalej P, Obloj B, Dudkiewicz Z, Hortis-Dzierzbicka M. Mandibular morphology and spatial position following one-stage simultaneous repair of complete unilateral cleft lip and palate. Cleft Palate Craniofac J 2008;45:272-7.  Back to cited text no. 28
    
29.
Ortiz-Monasterio F, Serrano A, Barrera G, Rodriguez-Hoffman H, Vinageras E. A study of untreated adult cleft palate patients. Plast Reconstr Surg 1966;38:36-41.  Back to cited text no. 29
    


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