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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 6-10

Evaluation and comparison between effects of early and late palatoplasty on the mandibular morphology and spatial position with respect to the cranial base and maxilla: A two-dimensional retrospective study


1 Department of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College and Hospital, Wardha, Maharashtra, India
2 Department Of Orthodontics and Dentofacial Orthopedics, Sharad Pawar Dental College, Wardha, Maharashtra, India
3 Department of Orthodontics and Dentofacial Orthopedics, Palika Health Complex Hospital, New Delhi, India

Date of Web Publication8-Feb-2018

Correspondence Address:
Dr. Khushboo Ratnani
17, Vainketesh Colony, Shankar Nagar, Amravati - 444 606, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_50_17

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  Abstract 


Background: This retrospective cephalometric study was designed to clarify the influence of the timing of surgical repair of cleft and its effect on mandibular growth and its position in the cleft patients which is questionable. Aim: The aim of the study was to assess the effect of timing of palate repair on the mandibular spatial position and morphology in relation to cranial base and maxilla in patients born with unilateral cleft lip and palate (UCLP) using Lateral Cephalograms. Material and Methods: This study was carried out on 20 surgically treated UCLP patients within the age group of 8–16 years. Twenty UCLP subjects were further divided into two groups (early palatal repair n = 10 and late palatal repair n = 10) according to their age at which initial hard palate repair was performed. Results: Stage of palatal repair had a significant effect on the Y-axis (P- 0.045) but there is no significant difference in the spatial position, size and morphology of mandible when compared in relation to anterior cranial base and in relation to maxilla. Conclusion: Timing of surgical repair of palate has no detrimental effects on the position and morphology of mandible in patients with unilateral cleft lip and palate.

Keywords: Mandible, morphology, palatoplasty, position


How to cite this article:
Ratnani K, Daigavane P, Shrivastav S, Kamble R, Babbar K, Deshmukh S. Evaluation and comparison between effects of early and late palatoplasty on the mandibular morphology and spatial position with respect to the cranial base and maxilla: A two-dimensional retrospective study. J Cleft Lip Palate Craniofac Anomal 2018;5:6-10

How to cite this URL:
Ratnani K, Daigavane P, Shrivastav S, Kamble R, Babbar K, Deshmukh S. Evaluation and comparison between effects of early and late palatoplasty on the mandibular morphology and spatial position with respect to the cranial base and maxilla: A two-dimensional retrospective study. J Cleft Lip Palate Craniofac Anomal [serial online] 2018 [cited 2018 Oct 22];5:6-10. Available from: http://www.jclpca.org/text.asp?2018/5/1/6/224904




  Introduction Top


Cleft lip with or without cleft palate (CL/P) comprises of 65% of all orofacial malformations and is one of the most frequent congenital anomalies.[1] The majority of CL/P cases are believed to have a multifactorial etiology, with several genetic and environmental factors interacting to shift the complex process of morphogenesis toward an abnormality where a cleft has taken place.[2],[3]

Adult facial morphology in cleft patients is the result of cleft itself and may be functional compensations required by endogenous anatomic deficiency and the influence of different surgical techniques. Furthermore, Krogman et al.[4] concluded that the clefting process has growth and/or development implications for the contiguous cranial base and facial structures as well as for the maxilla. Bishara and Iversen [5] have reported that the posterior positioning of the maxilla and mandible relative to the anterior cranial base may result from the cleft's influence on contiguous skeletal structures, and affects maxillary development and facial morphology. Few authors have also stated that the effect of surgery on facial growth in CLP has shown a severe maxillary deficiency in all dimensions in patients who have been operated at an early age.[6],[7],[8] The maxillary growth in CLP patients might also be negatively affected by the bony union in the midline of the maxilla seen after some cleft surgeries. This could be from a bone graft [9] or from a periosteal envelope promoting bone formation.[10],[11] Hence to evaluate the isolated influence of surgical repair of craniofacial complex of a growing cleft patient due to number and intricacy of factors linked to growth such as individual genetic pattern, cleft type and size, surgical techniques and timing and additional therapy (e.g., obturators) is not an easy task. The effect of surgery could be detected in the best way if the comparison is done separately for each cleft type. Therefore, only unilateral patients were chosen in this study.

The influence of multiple surgical procedures on mandibular growth in the cleft patients remains questionable and controversial as there has been much disagreement about whether there is an accompanying underdevelopment of the mandible and a malpositioning of the mandible in relation to other cranial and facial structures.[12],[13],[14] Furthermore, the altered mandibular growth can affect the treatment strategy for the cleft cases, and therefore, its evaluation is important. This is the question that led us to perform the present study. Therefore, the aim is to evaluate and compare the effect of early and late palatoplasty on the mandibular growth (morphology and spatial position) in UCLP cases with respect to the cranial base.


  Materials and Methods Top


Materials

A retrospective study was performed. This study was approved by the Institutional Research Ethics Committee, and informed consent was signed by all the parents of cleft patients. The study was carried out on 20 surgically treated unilateral CLP patients within the age group of 10–18 years irrespective of gender who are registered under Smile train were selected from the archival patient data of the Department of Orthodontics and Dentofacial Orthopedics of our institution. The exclusion criteria included cleft associated with diagnosed syndromes and prior adenoidectomy and/or tonsillectomy and prior orthodontic treatment or surgical treatment which includes alveolar bone grafting, etc. None of the patients underwent two-stage palatal closure. Palatal mucoperiosteal flap procedure was carried out for hard palate repair, and the von Langenbeck procedure was carried out for soft palate repair.

These samples were further divided into two groups consisting of 10 patients in each group based on the age at which their surgically treated for the palatal repair.

  • Group 1: Unilateral cleft patients who had undergone palatal repair before 18 months (early)
  • Group 2: Unilateral cleft patients who had undergone palatal repair after 18 months (late).


In this study, the control group was not evaluated as the effect of palatoplasty is seen in unilateral cleft lip and palate patients. Hence, there were only two groups for comparison that is early and late palatoplasty group. The timing of repair of cleft palate depends on the individual circumstances of each child. In general, it is performed when the child is around 9–18 months of age. The cleft palate should be closed this early for several reasons, mainly to improve speech and to separate the oral and nasal cavity.[15],[16]

[Table 1] shows the mean age of patients was 12.50 ± 1.35 years in early palatoplasty patients and 10.80 ± 2.10 years in late palatoplasty patients. Similarly, the lip surgery was done at mean 5.35 ± 2.87 months and at 10.90 ± 8.01 months in early and late palatoplasty patients, respectively. Whereas, palate surgery was done at 15.60 ± 1.78 months in early palatoplasty patients and at 44.60 ± 32.01 months in late palatoplasty patients.
Table 1: Age-wise Distribution of both the groups

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Method

The manual cephalometric tracing was done on digital lateral cephalograms using an 8 × 10 inches acetate matte tracing paper (0.003 inches thick) and 3H mechanical pencil on the view box. The measurements were performed using a protractor for angular measurements and a millimeter ruler for linear measurement of selected parameters [Figure 1]. All the landmarks located in the tracing were re-evaluated by a senior faculty member to be more precise and accurate to avoid any error.
Figure 1: Tracings with dimensions and angles used: 1 = S-N, 2 = S-Go, 3 = N-Me, 4 = Go-Gn, 5 = Co-Gn, 7 = P-NB, 8 = SNB, 9 = SN.GoGn, 10 = SN.Ga, 11 = CoGoMe. Mandibular Morphology and Spatial Position in patients with Clefts: Intrinsic or Iatrogenic? Cleft Palate Craniofacial Journal, July 1992, Vol. 29 No. 4

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All the parameters were evaluated and analyzed by three examiners, and a mean value was taken for each parameter and for each patient. These examiners were trained and calibrated, and the results of Kappa statistics were 0.85 and 0.88 for inter- and intra-examiner reliability, respectively. [Table 2] shows the parameters evaluated for the present study.
Table 2: Parameters evaluated for the present study

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  Results Top


Statistical analysis was performed with SPSS software (version 15.0J for Windows; SPSS Inc., Chicago, IL, USA). Comparison of skeletal parameters in early and late palatoplasty patients was done using unpaired t-test. [Table 3] shows the parameters evaluating mandible, the relation of the mandible to cranial base and relation of the mandible to maxilla in both the groups. All the various parameters show the comparison among early and late palatoplasty patients. The mean of Y-axis was 64.30 ± 5.25 in early palatoplasty patients which were less as compared to late palatoplasty patients (68.30 ± 2.79) and this difference was statistically significant (P< 0.05). No other parameters were found to be statistically significant among both the groups.
Table 3: Evaluation of parameters in both groups

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  Discussion Top


Several authors express the view that if one part of the body is malformed, there is a tendency for other parts also to be malformed. The degree and extent of the malformation result basically from the difference in the modifying cause, the intensity of the modifying cause, and also the time of its action. Hence, the modifying cause is different in the two types of the defect, then a difference might be expected in the types of associated malformations.[17],[18] For the ideal timing of palatal repair, two contrasting factors should be considered, late hard palate repair should result in better growth because possible interference with maxillary growth is postponed to a delayed age when less growth remains.[19] Some studies have reported that delayed palatal repair may lead to better craniofacial morphology,[20],[21],[22],[23] whereas others reported that early palate repair may give better craniofacial morphology.[24]

Gilley reported a definite increase in the mandibular-Frankfort plane angle in the cleft individuals which he thought might be due to short ramus. The angular measurements that he used to evaluate the mandible when compared with normal values, showed the difference which was not significant.[25] Friede et al. advocated two-stage protocol for repair of the palatal cleft which resulted in very satisfactory growth outcome. A palatal scar, which might impair maxillary development, was created only by the velar surgery. If this scar is located close to the posterior border of the hard palate, it might result in less maxillary growth restriction than if it is positioned further anteriorly. His study reported a significant difference in mandibular plane angle, SNB and ANB angle. Mandibular plane angle and ANB reduced with increasing age, while SNB angle increased.[26]

Swanson statistically evaluated the growth of the face in cleft lip and palate subjects that had undergone surgical repairs of the palate. The lateral cephalograms were evaluated by employing Down's analysis where the most significant findings were related to the mandible. The chin point was retruded with the mean facial angle 7° less than Down's 88° normal, the Frankfort mandibular plane angle were 10° greater than Down's mean, and the Y-axis was found to have a mean of 6° greater than the standard. Swanson ends the report of his study by pointing out that the cleft group differed only in minor detail.[27] Rohrich et al. found no difference in maxillary growth between repair of hard palate at 11 months and 4 years.[28]

The study demonstrated that there was no significant difference in the spatial position and morphology of mandible in relation to cranial base and maxilla between both the groups of early palatal surgery and late palatal surgery except Y-axis (P = 0.047). There is no significant difference found in the ramal length between both the groups but Y-axis is significantly higher in the late palatal group which can be due to short ramal length considerably.


  Conclusion Top


Using lateral cephalograms (two-dimensional [2D] images), this study found that there was no significant difference in the position and morphology of mandible except the Y-axis which shows a significant difference (P = 0.047). Further, well-designed studies for long-term results with a larger sample size of patients with CLP are required.

Limitation of the study

  1. It is a 2D retrospective study
  2. The measurements were evaluated only in anteroposterior directions
  3. The sample size was considerably small
  4. The operator for all the surgical procedures in all the samples of early and late palatoplasty was not the same
  5. Institutes where the palatoplasty had undergone were not considered.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Calzolari E, Bianchi F, Rubini M, Ritvanen A, Neville AJ; EUROCAT Working Group. Epidemiology of cleft palate in Europe: Implications for genetic research. Cleft Palate Craniofac J 2004;41:244-9.  Back to cited text no. 1
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Amaratunga NA. A study of etiologic factors for cleft lip and palate in Sri Lanka. J Oral Maxillofac Surg 1989;47:7-10.  Back to cited text no. 2
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Kohli SS, Kohli VS. A comprehensive review of the genetic basis of cleft lip and palate. J Oral Maxillofac Pathol 2012;16:64-72.  Back to cited text no. 3
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4.
Krogman WM, Mazaheri M, Harding RL, Ishiguro K, Bariana G, Meier J, et al. Alongitudinal study of the craniofacial growth pattern in children with clefts as compared to normal, birth to six years. Cleft Palate J 1975;12:59-84.  Back to cited text no. 4
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5.
Bishara SE, Iversen WW. Cephalometric comparisons on the cranial base and face in individuals with isolated clefts of the palate. Cleft Palate J 1974;11:162-75.  Back to cited text no. 5
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6.
Graber TM. Craniofacial morphology in cleft palate and cleft lip deformities. Surg Gynecol Obstet 1949;88:359-69.  Back to cited text no. 6
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Ross RB. The clinical implications of facial growth in cleft lip and palate. Cleft Palate J 1970;7:37-47.  Back to cited text no. 7
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Friede H. Abnormal craniofacial growth. Acta Odontol Scand 1995;53:203-9.  Back to cited text no. 8
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Friede H, Johanson B. A follow-up study of cleft children treated with primary bone grafting 1. Orthodontic aspects. Scand J Plast Reconstr Surg 1974;8:88-103.  Back to cited text no. 9
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Prydso U, Holm PC, Dahl E, Fogh-Andersen P. Bone formation in palatal clefts subsequent to palato-vomer plasty. Influence on transverse maxillary growth. Scand J Plast Reconstr Surg 1974;8:73-8.  Back to cited text no. 10
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Mølsted K, Palmberg A, Dahl E, Fogh-Andersen P. Malocclusion in complete unilateral and bilateral cleft lip and palate. The results of a change in the surgical procedure. Scand J Plast Reconstr Surg Hand Surg 1987;21:81-5.  Back to cited text no. 11
    
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Pruzansky S. The foundation of the cleft palate centre & training program at the university of Illinois. Angle Orthod 1957;27:69-82.  Back to cited text no. 12
    
13.
Ricketts RM. Present status of knowledge concerning the cleft palate child. Angle Orthod 1956;26:10-21.  Back to cited text no. 13
    
14.
Slaughter WB, Brodie AG. Facial clefts and their surgical management in view of recent research. Plast Reconstr Surg (1946) 1949;4:311-32.  Back to cited text no. 14
    
15.
Buchman SR, Kasten SJ, Waalborn C. Repair of Cleft Lip & Palate, University of Michigan Medical Centre; A Parent's guide. 2011.  Back to cited text no. 15
    
16.
Agrawal K. Cleft palate repair & variations. Indian J Plast Surg 2009;42:3 Suppl:102.  Back to cited text no. 16
    
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Fogh-Andersen P. Inheritance of Harelip & Cleft Palate. Copenhagen, Denmark: Nyt Nordisk Forlag Arnold Busck; 1942.  Back to cited text no. 17
    
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Wang MK, Macomber WB. Congenital lip sinuses. Plast Reconstr Surg 1956;18:319-28.  Back to cited text no. 18
    
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Yang IY, Liao YF. The effect of 1-stage versus 2-stage palate repair on facial growth in patients with cleft lip and palate: A review. Int J Oral Maxillofac Surg 2010;39:945-50.  Back to cited text no. 19
    
20.
Hotz M, Gnoinski W. Comprehensive care of cleft lip and palate children at Zürich University: A preliminary report. Am J Orthod 1976;70:481-504.  Back to cited text no. 20
    
21.
Hotz MM, Gnoinski WM. Effects of early maxillary orthopaedics in coordination with delayed surgery for cleft lip and palate. J Maxillofac Surg 1979;7:201-10.  Back to cited text no. 21
    
22.
Friede H, Enemark H. Long-term evidence for favorable midfacial growth after delayed hard palate repair in UCLP patients. Cleft Palate Craniofac J 2001;38:323-9.  Back to cited text no. 22
    
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Nollet PJ, Katsaros C, Van't Hof MA, Kuijpers-Jagtman AM. Treatment outcome in unilateral cleft lip and palate evaluated with the GOSLON yardstick: A meta-analysis of 1236 patients. Plast Reconstr Surg 2005;116:1255-62.  Back to cited text no. 23
    
24.
Gaggl A, Schultes G, Feichtinger M, Santler G, Mossböck R, Kärcher H, et al. Differences in cephalometric and occlusal outcome of cleft palate patients regarding different surgical techniques. J Craniomaxillofac Surg 2003;31:20-6.  Back to cited text no. 24
    
25.
Gilley FM. A Cephalometric Analysis of the Developmental Pattern and Facial Morphology in Cleft Palate. M. S. D. Thesis, Northwestern University; 1947.  Back to cited text no. 25
    
26.
Friede H, Lilja J, Lohmander A. Long-term, longitudinal follow-up of individuals with UCLP after the gothenburg primary early veloplasty and delayed hard palate closure protocol: Maxillofacial growth outcome. Cleft Palate Craniofac J 2012;49:649-56.  Back to cited text no. 26
    
27.
Swanson LT. A cephalometric evaluation of one hundred patients who have had cleft plate repairs. Cleft Palate Bull 1955;5:8-10.  Back to cited text no. 27
    
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Rohrich RJ, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, et al. Timing of hard palatal closure: A critical long-term analysis. Plast Reconstr Surg 1996;98:236-46.  Back to cited text no. 28
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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