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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 30-42

Comparison of maxillofacial growth characteristics in patients with and without cleft lip and palate


Department of Orthodontics, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India

Date of Submission28-Aug-2019
Date of Acceptance09-Dec-2019
Date of Web Publication20-Jan-2020

Correspondence Address:
Dr. Sneh Lata Verma
Department of Orthodontics, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_22_19

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  Abstract 


Introduction: The neurotropic growth precedes the somatic growth, in the craniofacial region, any lag or disturbance in the development of cervical vertebrae may attribute to the development of craniofacial cleft. Objective: The aim of this study is to evaluate the developmental relationship of cervical vertebrae and maxillofacial morphology in complete cleft lip and palate patients (untreated and surgically treated) and noncleft patients based on the parameters on lateral cephalograms. Materials and Methods: One hundred and sixty patients were first divided into two groups, Group I patients (6–12 years) and Group II patients (12–18 years). These groups were further subdivided into three subgroups, i.e., noncleft or normal patients, untreated cleft group, and surgically treated cleft group patients. Thirteen angular and 19 linear parameters taken on digital lateral cephalogram were analyzed and discussed to evaluate and compare the growth status and craniofacial morphology. Results: There was no significant delay in skeletal maturity noted in cleft patients when they were compared with their normal counterparts. Cranial base length and the cranial base angle were insignificantly reduced in cleft groups, whereas the maxilla in surgically treated patients was found to be significantly shorter along with retroposition and clockwise rotation with respect to cranial base. Mandible was shorter in length and posteriorly positioned with respect to cranial base with downward and backward rotation in surgically untreated and treated cleft patients, but the difference was statistically nonsignificant. Marked differences in maxillo-mandibular relationship were seen in surgically treated patients suggestive of the establishment of Class III jaw relation in those patients. Conclusion: The iatrogenic repercussion of surgery on cleft patients has a significant restraining effect on maxilla, mandible, and maxillo-mandibular relationship and morbidity do not play a significant role in delaying skeletal maturity.

Keywords: Cervical vertebrae maturity indicator, cleft lip and palate, hypoplastic maxilla


How to cite this article:
Khanna R, Tikku T, Verma SL, Verma G, Dwivedi S. Comparison of maxillofacial growth characteristics in patients with and without cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2020;7:30-42

How to cite this URL:
Khanna R, Tikku T, Verma SL, Verma G, Dwivedi S. Comparison of maxillofacial growth characteristics in patients with and without cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Aug 12];7:30-42. Available from: http://www.jclpca.org/text.asp?2020/7/1/30/276198




  Introduction Top


Cleft lip and palate (CLP) anomaly is one of the most frequently encountered congenital malformations which present with striking asymmetries of the soft and hard tissues of the naso-maxillary complex. The possible etiology of the craniofacial deformity has been attributed to intrinsic developmental defect (morbidity), secondary functional disturbances, and iatrogenic factors secondary to surgical treatment to correct morbid anatomy.[1]

Shprintzen[2]et al. have suggested that CLP is a part of “malformation spectrum” because of its frequent association with other abnormalities which may also include the cervical region. The cervical vertebrae develop from sclerotomes which surround the notochord and neural tube. Endochondral ossification of the upper cervical vertebrae commences by the 8th week of fetal life and is completed by about 3–6 years of postnatal life. Studies done by Ross and Lindsay,[3] and Smahĕl and Skvarilová,[4] and Uǧar Semb[5] indicated that anomalies of the cervical spine may influence the lifting of the head of the fetus and could be associated with the failure of the palatine shelves to fuse, precipitating orofacial clefts.

Since the neurotropic growth precedes the visceral growth, we are assessing the influence of the cervical vertebrae development on cleft formation through cervical vertebrae maturity indicators (CVMIs).

Inhibition of the growth and development of the nasomaxillary complex in the treated CLP patients is an extensively debatable topic. Bishara,[6] Isiekwe and Sowemimo,[7] and Yoshida et al.[8] claimed that maxillary deficiency in cleft individuals is an intrinsic primary defect. Graber,[9] Ortiz-Monasterio[10]et al., Bishara[6]et al., Mars and Houston,[11] and Capelozza[12]et al. have written that maxillary deficiency is secondary to surgical repair due to altered functional matrices.

Investigations have also shown a close relationship between craniofacial growth, skeletal maturation, and general body growth. CVMI can be extremely useful to detect periods of reduced growth rate in CLP patients.

Evaluation of the individual craniofacial morphology and the identification of correct timing of accelerated and intense growth provide valuable information on orthodontic treatment planning and retention procedures. Hence, this study was designed to document the growth characteristics and craniofacial morphology of patients with CLP and to compare them with noncleft patients.

Aims and objectives

  1. The aim is to identify and compare the characteristics of craniofacial morphology and growth pattern in children with complete CLP and noncleft children at different age intervals
  2. To find out if any difference exists in skeletal maturation between complete CLP patients and noncleft patients.



  Materials and Methods Top


Lateral cephalograms of 160 patients of the Indian origin from Uttar Pradesh were included in the study. Surgically treated nonsyndromic CLP patients (no other surgical procedure or orthodontic treatment except CLP repair) and untreated CLP patients (6–18 years) were selected from different Smile Train Centers in Uttar Pradesh, India. The records for noncleft patients who had pleasing profiles with Angle's Class I molar relationship, ANB value of ≤4°, and no history of previous orthodontic treatment or orthognathic surgery were taken from the Orthodontics Department of BBDCODS, Lucknow. Participants were distributed according to chronological age [Table 1] and [Figure 1].
Table 1: The distribution of patients selected for the study

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Figure 1: Extra-oral and intra-oral photographs of (a) noncleft patient, (b) patient with nonrepaired cleft lip and palate, (c) patient with repaired cleft lip and palate

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Written consent was obtained from all the patients and approval was taken from the Ethical committee of BBD College of Dental Sciences, Lucknow. Digital lateral cephalograms obtained from cephalostat machine were transferred to a computer loaded with Planmeca software to save in a Compact Disc-read only memory (CD ROM) and then transferred to a computer loaded with Nemotech digital imaging software (version 6.0, Nemotech Company, USA). To eliminate magnification error 10-mm calibration was done on lateral cephalograms using image calibration tool. Two points 10 mm apart were marked on the scale attached to the head positioner on the lateral cephalograms using cursor, and this resulted in automatic correction of magnification error by the software itself. After performing all these procedures, tracings were performed [Figure 2]. All the lateral cephalograms were analyzed for 32 parameters (19 linear and 13 angular). Anatomical and constructed landmarks,[13],[14],[15] as well as reference planes used in the study, are shown in [Figure 3]a, [Figure 3]b, [Figure 3]c.
Figure 2: (a) Transfer and calibration of cephalogram using Nemotech software. (b) Tracing performed and analysis done by Nemotech software

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Figure 3: (a) Anatomical landmarks on lateral cephalogram. 1. Nasion. 2. Sella. 3. Sellion (Se) Porion (Po). 4. Basion. 5. Pterygomaxillary fissure. 6. Orbitale. 7. Anterior nasal spine. 8. Point A (Subspinale). 9. Posterior nasal spine. 10. Articulare. 11. Condylion (Co). 12. Gonion (Go). 13. Point B (Supramentale). 14. Suprapogonion (PM). 15. Pogonion (Pog). 16. Gnathion (Gn). 17. Menton (Me). 18. C2d: the deepest point on the lower border of the body of C2. 19. C2p: the most posterior point on the lower border of the body of C2. 20. C2a: the most anterior point on the lower border of the body of C2. 21. C3up: the most superior points of the posterior border of the body of C3. 22. C3um: the deepest point of the superior borders of the body of C3. 23. C3ua: the most superior points of the anterior border of the body of C3. 24. C3m: the deepest point on the lower border of the body of C3. 25. C3lp: the most posterior point on the lower border of the body of C3. 26. C3la: the most anterior points on the lower border of the body of C3. 27. C4up: the most superior points of the posterior border of the body of C4. 28. C4um: the deepest point of the superior borders of the body of C4. 29. C4ua: the most superior points of the anterior border of the body of C4. 30. C4m: the deepest point on the lower border of the body of C4. 31. C4lp: the most posterior point on the lower border of the body of C4. 32. C4la: the most anterior points on the lower border of the body of C4. (b) Constructed landmarks on Lateral cephalogram. 1. Xi point-It is the geometric center of the Ramus of the mandible (Ricketts62). 2. S' point: It is constructed by dropping a perpendicular from Sellion (Se) to Palatal Plane (Schwartz58). 3. CC point: It is the point where the basion nasion plane and the facial axis intersect. 4. DC point: A point selected in the center of the neck of condyle where the basion nasion plane crosses it. (c) Reference planes used in the study. 1. Horizontal plane – Surrogate Frankfort horizontal plane constructed by drawing a line 7° to the line sella to nasion. 2. Sella–nasion plane (S-N plane). 3. Frankfort horizontal plane (FH plane). 4. Palatal plane. 5. Mandibular plane

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Following parameters were analyzed for the study

(A). To assess the growth status [Figure 4]
Figure 4: Growth status parameters analyzed in the study

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Cervical vertebrae parameters analyzed (Baccetti[13]et al.)

  1. C2Conc, C3Conc, and C4Conc
  2. C3BAR: Ratio between the length of the base (distance C3lp-C3la) and the anterior height (distance C3ua-C3la) of the body of C3
  3. C3PAR: Ratio between the posterior (distance C3up-C3lp) and anterior (distance C3ua-C3la) heights of the body of C3
  4. C4BAR: Ratio between the length of the base (distance C4lp-C4la) and the anterior height (distance C4ua-C4la) of the body of C4
  5. C4PAR: Ratio between the posterior (distance C4up-C4lp) and anterior (distance C4ua-C4la) heights of the body of C4

    Based on the length of the anterior and posterior border and depth of the concavity at the lower border of the cervical vertebrae measured on lateral cephalograms, the six stages of cervical vertebrae maturation were given as per the modified version of Baccetti[13]et al.


  6. Other parameters used to assess the growth status included[14],[15]:-

  7. S-N plane length-length of anterior cranial base drawn from sella to nasion. This distance is used to assess the proportional lengths of maxillary and mandibular bases
  8. B-N plane length (cranial plane length) length of cranial base drawn from basion to nasion. Basion–nasion line is used to define the border between the face and cranium
  9. Facial axis – An angle formed between the basion-nasion plane and the plane form CC point and gnathion
  10. Cranial base angle – Angle formed by sella nasion line and sella basion line.


(B)To assess maxillo-mandibular morphologic characteristics [Figure 5], [Figure 6], [Figure 7]
Figure 5: (a) Parameters to access maxillary size and position. (1) ANS- PNS, (2) Condylion to point A, (3) SNA, (4) N ┴ A ┴ (FH), (5) Posterior maxillary position (S' ┴ [on PP] – PNS), (6) N-A (II HP). (b) Parameters to access maxillary Orientation. (1) Inclination angle, (2) Palatal plane angle

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Figure 6: (a) Parameters to access mandibular size and position. (1) Mandibular arch (DC-Xi-Pm), (2) Corpus length, (3) Mandibular length (Co-Gn), (4) N–B (II HP), (5) Facial depth angle, (6) SNB. (b) Parameters to access mandibular orientation. (1) Mandibular plane angle, (2) Occlusal plane angle. (c) Parameters to access maxillomandibular relation. (1) ANB, (2) Convexity of point A, (3) Basal plane angle, (4) Lower facial height, (5) Maxillomandibular difference

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Figure 7: (a and b) Intragroup comparison of mean values of cervical vertebrae maturity indicator growth status parameters for Groups I and II. (c and d) Intragroup comparison of mean values of other growth status parameters for Groups I and II

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(I). Maxillary measurement

(A). Maxillary size and position

  1. ANS-PNS
  2. Condylion to point A-describes effective midface length
  3. SNA
  4. N ┴ A ┴ (FH)-
  5. Posterior maxillary position {S' ┴ (on PP)– PNS} N-A (II HP).


(B). Maxillary orientation

  1. Inclination angle – Angle formed between perpendicular drown from Se-N' line through N' to palatal plane
  2. Palatal plane angle – Angle formed between the palatal plane (ANS-PNS) and Frankfort horizontal (FH) plane.


(II). Mandibular measurement

(A). Mandibular size and position

  1. Mandibular arch (DC-Xi-Pm) – Angle formed by the line joining the DC (center on Condyle on Ba-N plane) to Xi and Suprapogonion (Pm) and Xi
  2. Corpus length – Linear measurement from Xi point to Suprapogonion (Pm) that describes the morphology of mandible
  3. Mandibular length (Co-Gn) – Linear distance between condylion and gnathion that describes the mandibular length
  4. N–B (II HP) – Linear distance between perpendicular line dropped from nasion on HP and point B which is measured on a plane parallel to HP
  5. Facial depth angle – Internal angle between FH plane and nasion to pogonion
  6. SNB angle.


(B). Mandibular orientation

  1. Mandibular plane angle – Angle formed between the mandibular plane (Go-Me) and true horizontal plane
  2. Occlusal plane angle – Angle formed between the occlusal plane and corpus axis (Xi-Pm).


(III). Maxillo-mandibular relation

  1. ANB angle
  2. Convexity of point A
  3. Basal plane angle – The angle formed between palatal plane to mandibular plane
  4. Lower facial height – Angular measurement between Xi-to ANS and Xi to suprapogonion (PM)
  5. Maxillo-mandibular difference – Difference between mandibular length (Co-Gn) and maxillary length (Co-Point A).


Statistical tests used

The statistical analysis was performed using the Statistical Package for the Social Sciences version 15.0 statistical analysis software (SPSS). The values were represented in number (%) and mean ± standard deviation. The ANOVA test was used to compare within the group and between-group variances among the study groups. To test the significance of two means, the Student “t” test was used. Post-hoc tests (Tukey-honest significant difference) was done to check if Tukey's score is statistically significant with Tukey's probability/critical value table taking into account appropriate dfwithin and number of treatments.


  Results Top


No significant delay was noted in skeletal maturity of cleft patients as compared to normal patients, but the cranial base length and cranial base angle were insignificantly reduced in cleft groups. In both the age groups, maxilla in surgically treated cleft patients was found to be significantly short, retropositioned and clockwise rotated with respect to cranial base when compared to surgically untreated and noncleft patients. Mandible was insignificantly shorter, posteriorly positioned with downward and backward rotated for both the cleft groups as compared to normals [Table 2], [Table 3], [Table 4], [Table 5].
Table 2: Intra-group comparison of various growth status parameters for Group I

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Table 3: Intra-group comparison of various parameters for Group II

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Table 4: Intra-group comparison of various craniofacial morphology parameters for Group I

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Table 5: Intra-group comparison of various craniofacial morphology parameters for Group II

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  Discussion Top


CLP affects craniofacial growth through many factors, including intrinsic developmental deficiencies, functional distortions, and iatrogenic consequences.

Cephalometric studies have shown differences in maxillo-mandibular spatial relationships in children with and without CLP. There is a tendency for relative retrusion of the anterior portion of the maxilla, steeper mandibular plane, larger mandibular length, and increased face height in CLP. These differences in facial morphology may be attributed to the surgical repair of the lip and palate, functional changes resulting from the mechanical presence of the cleft, inherited trait such as genetic influences on size and form, or a combination of these factors.[6]

Several studies reported an association between unilateral CLP (UCLP) and cervical vertebrae shortening,[4] forward position and decrease in the curvature of the cervical spine.[16] Chen,[17] Lamparski,[18] Silveira et al.[19] suggested that the growth of the cervical vertebrae width was almost completed during early cervical growth, and cervical vertebrae were increased in height later in growth. Children with CLP were generally smaller in stature than controls; this effect could be attributed to the difference in the maturity of cervical vertebrae. Various explanations have been used to explain the growth lag reported in children with clefts. These include slow growth during embryogenesis, slow postnatal growth of children with clefts,[20] feeding difficulties after birth, and an increased frequency of airway and middle ear infections.[21] A possible explanation may lie in the embryological process by focusing on the primitive embryonic cellular origins of the upper cervical vertebrae from the parachordal cartilage that arises from the cranial end of the notochord and incorporates the sclerotomes of the four occipital and upper cervical somites.[22] The present study evaluates growth status through skeletal maturation in patients with CLP using the cervical vertebra maturation method by Baccetti et al.[13]

To modify the previous shortcomings due to the small sample size, this retrospective cephalometric study was conducted with a sufficiently large sample size to determine the effect of morbidity versus iatrogenicity in all three planes, i.e., sagittal, transverse, and vertical plane. The size, position, and orientation of maxilla and its consequential effects on mandible and maxillo-mandibular relationship on digital lateral cephalogram of normal versus treated and untreated patients with nonsyndromic complete CLP were evaluated.

This study attempted to match, as closely as possible, the cleft patients with normal, noncleft patients based on age and ethnicity from the same geographical area, who were their contemporaries.

Growth status

On comparing the growth status conflicting results exist regarding the effect of clefting on skeletal maturation (assessed by CVMI) [Table 4]. Taking into account the depth of the concavity of the cervical vertebrae (C2, C3, C4) and the ratios (C3 BAR, C3 PAR, C4 BAR) no significant changes were seen in either the depth of the concavity of cervical vertebrae or the ratios in Group I (a-c), except for the C4 PAR which shows significant difference between normal patient to both treated cleft and untreated cleft patients (P < 0.05), but there was no significant difference between untreated and treated cleft patients. While in Group II (a-c), the statistically significant difference was observed only between Group II a and II c (P < 0.05) [Table 5]. The probable explanation for this could be that the somatic growth in later life makes up for the neurotropic growth deficit. Some studies have suggested that there is a catch-up of skeletal maturity during early adolescence in CLP patients. Our findings agree with those of Bowers[20]et al. who reported that children with UCLP did not show skeletal age delay. On the contrary, Jensen[23]et al. reported that skeletal maturity was slower in children with clefts from 6 to 20 years of age. This skeletal delay should be considered when planning treatment and timing of surgeries.

It is possible that part of these conflicting results may be attributed to the fact that their age estimates were made using hand-wrist radiograph, selection of the sample (which included different types of clefts), and patients from the different ethnic backgrounds. Moreover, the inclusion criteria of previous studies vary significantly from study to study, thus making comparison difficult.

Cranial base

Total cranial base length (B-N) and anterior cranial base length (S-N) [Table 4] and [Figure 7] showed progressive decrease among the intragroup measurements, though the difference was statistically insignificant (P > 0.05) for all comparisons except for the subgroups Ia–Ic and II a–II c where the difference was statistically significant (P < 0.05).

The above findings were supported by Ross,[1] Bishara et al.[24] who also observed a decrease of cranial base length in cleft patients as compared to noncleft normal patients. The reason for the condition was hypothesized by Moss[25] as that “Early embryonic stages of fetal development may be responsible for this difference.” Mølsted and Dahl[26] also favors our findings and suggested this due to the general tendency of the cranial base toward flattening. Contrary to our findings, Oztürk and Cura[27] found linear measurements of the cranial base of cleft patients similar to that of noncleft patients while Krogman et al.[28] reported that anterior cranial base length was greater in cleft patients than normals. Cranial base angle showed insignificant reduction (P > 0.05) in both the cleft groups (treated and untreated) as compared to normal noncleft group. Cranial base angle in untreated cleft patients as compared to normal patients has been found smaller by Moss,[25] Bishara et al.,[24] larger by Mølsted and Dahl,[26] and normal by Ross[1] [Table 4] and [Table 5], also the flexural angle establishes much before the surgical intervention so the probable cause for change in cranial base angle is ascertained. The facial axis showed greater values in cleft patients as compared to normal patients in both the groups, but difference was statistically not significant (P > 0.05).

Craniofacial morphology

Maxillary size

The structure, relative positions, and effect of growth on the maxilla in individuals with CLP had been exhaustively studied. In the present study, the maxillary length and total midface length showed reduction in sagittal plane which could be attributed to the hypoplastic maxilla due to morbidity, but the difference was not statistically significant between noncleft to untreated cleft patients for both Group I and Group II [Table 4], [Table 5] and [Figure 8], whereas highly significant reduction (P ≤ 0.001) was noted in surgically treated cleft patients as compared to normal and untreated cleft patient. Findings suggested that the inhibition of linear sagittal maxillary growth is attributed to the iatrogenic effect of surgical act to correct the morbid anatomy and favored by Ross,[1] Mølsted and Dahl,[26] Smahel and Mullerova,[29] and Hayashi et al.[30] Our observation of insignificant reduction (P > 0.05) in maxillary length and total midface length in unoperated cleft patients as compared to noncleft patients was also supported by Liao and Mars,[31] and Yoshida et al.[8] Shetye and Evans[32] and Hermann et al.[33] found normal growth potential of maxilla in cleft individuals and shortening of maxilla develops due to scar formation which is a consequence of surgery. However, contrary to our findings, Bishara and Iversen[34] found nonsignificant difference between untreated and treated cleft patients.
Figure 8: (a and b) Intragroup comparisons of mean values of maxillary size, position and orientation for Groups I and II. (c and d) Intragroup comparisons of mean values of mandibular size, position and orientation for Groups I and II

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Maxillary position

When the maxillary position in the sagittal and vertical plane with respect to cranial base was compared, [Table 4] and [Table 5] [Figure 8] observations reflect the posterior positioning of premaxilla with respect to cranial base in operated CLP in both noncleft and unoperated cleft patients. The maxilla was found posteriorly positioned with respect to cranial base in surgically operated cases (P ≤ 0.001), which again attributed to altered functional matrices and pull effect occurring due to fibrosis caused by the surgical repair of soft palate. Results are in accordance with the studies done by Bishara et al.,[6] who showed maxillary retrognathism in relation to the cranial base. Filho et al.[35] found that in the absence of surgery, cleft maxilla appears to have near-normal anteroposterior maxillary growth and if the surgery is performed, maxillary retrusion will be ensued. They also stated that the major disturbance in maxillary positioning is attributable to lip and not palatal surgery as opposed to the findings of Mars and Houston[11] who reported that lip surgery without palatal surgery does not significantly interfere with anteroposterior maxillary growth. Some other studies reported that both the maxilla and the mandible were positioned more posteriorly in the cleft patients.[26] The conflicting results might be due to the variations among these studies in patient's age, the design of control groups, and the methods of evaluation adopted. Law FE, Fulton JT[36] found that there was no significant reduction in SNA; rather, few authors[12] found an increased SNA in unoperated cleft patients when compared to noncleft controls.

Maxillary orientation

Palatal plane angle describing the orientation of maxilla to cranial base was significantly increased in Group Ic and II c, whereas the inclination angle showed statistically significant reduction (P ≤ 0.001) [Table 4], [Table 5] and [Figure 8] in operated cleft patients as compared to normal and unoperated cleft patients reflecting the rotation of palatal plane in a clockwise direction (caudally) contrary to normal patients which could be due to altered functional matrices present due to the fibrosis created by scar tissue secondary to surgical act for the correction of altered morbid anatomy. The findings were in accordance with Xu et al.[37] Lisson and Weyrich.[38] These conclusions were contrary to Mars and Houston[11] that lip surgery without palatal surgery did not significantly interfere with anteroposterior positioning of the maxillary arch.

Mandibular size

Mandibular size, position, and orientation were also analyzed in the present study. While comparing the parameters for mandibular size, the value of total mandibular length and corpus length were found to be insignificantly reduced (P > 0.05) in untreated cleft patients as compared to normal patients [Table 4], [Table 5] and [Figure 8], [Figure 9]. Contrary to our findings Nakamura[8]et al. in their longitudinal study observed significantly smaller mandibular length in untreated isolated cleft patients as compared to the normal control group. A comparison of normal patients to treated cleft group showed highly significant reduction for total mandibular length and corpus length (P < 0.01). This probably could be explained due to scaring of orbicularis oris, a circular ring of muscles around the upper and lower lip that results in restraining effect on the underlying skeletal maxilla as well as on the mandible to a lesser extent. Studies done by Swennen and Berten,[39] Filho et al.[35] also revealed significant decrease in corpus length and total mandibular body length in their cleft groups.
Figure 9: (a and b) Intragroup comparison of the mean values of maxillomandibular relation in Groups I and II

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Mandibular position

While comparing the parameters for sagittal mandibular position from nasion perpendicular to point B, facial depth angle, and SNB showed reduction in the cleft subgroups (Ib, IIb and Ic, IIc) as compared to subgroup Ia and IIa; although, the findings were nonsignificant (P > 0.05) [Table 4], [Table 5] and [Figure 8], [Figure 9]. Similar observations were reported by McCance et al.,[40] Bishara et al.[24] suggesting smaller and retruded mandibles in cleft patients due to morbidity and not a consequence of palatal surgery.

Mandibular orientation

To assess the orientation of mandible, parameters such as mandibular plane angle and occlusal plane angle were included in the present study. Although the mandibular plane angle and occlusal plane angle increased in the unoperated and operated CLP subjects showed clockwise rotation, the mean difference was statistically nonsignificant (P > 0.05) [Table 4], [Table 5] and [Figure 8], [Figure 9]. The above findings indicate the vertical growth pattern of the mandible in treated cases. This finding is similar to the studies done by Bishara and Iversen[34] and also suggests that cleft patients have a clockwise rotation of the mandible. Hermann et al.,[33] Vora and Joshi[41] observed shorter and more clockwise rotated mandible in cleft patients and showed increase in vertical height as well as increased Gonial angle and Frankfort mandibular angle in treated cleft group when matched to controls. This was postulated as a functional response of the mandible to the altered maxilla. Some authors also cited functional position of the tongue as a factor for downward and backward rotation of mandible. Filho et al.[35] proved that the different surgical protocols had no influence on mandibular structure and direction of mandibular growth and confirmed their hypothesis that mandibular morphology and growth direction are inherent to the cleft and are not vulnerable to surgical procedures.

Maxillo-mandibular relationship

To assess the maxillomandibular relationship in sagittal and vertical planes, the parameters such as basal plane angle, anterior lower facial height (Ricketts), ANB, convexity of point A and maxillo-mandibular difference, were compared [Bar diagram X and XI]. The unoperated cleft patient appears to have a relatively normal anteroposterior jaw relation as indicated by the ANB angle. Isiekwe and Sowemimo[7] reported negative ANB values (P ≤ 0.001) in the two patients with unrepaired UCLP as compared to normals. When Group Ia to Ic and Ib to Ic and IIa to IIc and IIb to IIc were compared statistically significant reduction (P ≤ 0.001) in ANB angle was observed. This may be because in cleft patients, lack of continuity of both the primary and secondary palates allows the effects of the lip and palate surgery to influence the growth of maxilla significantly. As a result treated cleft patients have an increased incidence of maxillo-mandibular discrepancy as evidenced by the significant reduction in the ANB angle. Capelozza et al.[12] found larger ANB angle in unoperated cleft patients then in normal patients which resulted from maxillary protrusion and normal position of the mandible. On the other hand, Bishara et al.[24] reported that the difference in maxillomandibular relationships is mainly due to mandibular retrusion in UCLP group, while Yoshida et al.[8] found that in the cleft palate group with mixed dentition, the maxillo-mandibular relationship measurements were comparable to those with mixed dentition in the normal population. Hayasi N[30] mentioned a decrease of angle ANB and a more severe skeletal Class III relationship with age in both cleft and normal control groups.

Basal plane angle and lower anterior facial height (LAFH) showed insignificant increase (P > 0.05) in Group II, but LAFH increased significantly (P < 0.05) in subgroup I c as compared to subgroup I a which could be due to downward and backward rotation of maxilla as well as mandible Bishara.[24] The findings of the present study were supported by Capelozza et al.,[12] Chen[17] who also observed larger LAFH in cleft group as compared to normals, but the difference was insignificant. However, McNamara[42] stated that the increase LAFH in cleft patients relative to normal patients has clinical significance when the correlation between effective maxillary length and LAFH is considered.

The convexity of point A for untreated cleft patients was comparable to normal patients, but it again showed statistically significant reduction (P ≤ 0.001) in treated patients for both Groups I and II. The maxillomandibular difference (McNamara[42]) was significantly higher in both treated and untreated cleft patients in Group I, while in Group II significant increase was seen only in treated cleft patients as compared to both normal and untreated cleft groups. All this may be due to decrease in maxillary length as well posterior positioning of entire maxilla due to scarring of orbicularis oris muscle fibers as a result of surgical intervention and consequential restraining effect on mandible along with maxilla. Filho et al.[35] had also demonstrated there is the likelihood of Class III jaw relationship in treated patients.

To summarize the findings of this study, we can state that on comparing the growth status through cervical vertebrae maturity indicators in the two cleft groups (Ib, Ic and IIa, IIc) there was no significant delay in skeletal maturity reported in cleft patients as compared to normal noncleft patients; while on evaluating the craniofacial morphology there was a tendency toward retrusion and retroposition of maxilla, significant reduction in mandibular length in the treated group with clockwise rotation of mandible and tendency toward Class III relation. The findings in the present study suggest that the term “hypoplastic” maxilla in CLP patients as used by Bishara,[6] Yoshida et al.[8] who have attributed this to intrinsic genetic defects is debatable. The findings of the present study showed that the restraining effect on maxillary growth is solely due to altered environmental factors, i.e., an iatrogenic consequence of the surgical act; hence, maxillary growth was found to be normal in subgroups Ib and IIb and retarded in subgroups Ic and IIc.

The maxillary dimensions such as maxillary length (ANS-PNS), N to A II HP, N┴A┴FH, posterior maxillary position, SNA in surgically untreated CLP patients was in the normal range; hence, it could well assumed that intrinsic genetic growth factor was normal despite morbidity. The morbidity was only due to the sequence of events occurring during the 7th week of intrauterine life in nonsyndromic patients, as considered in the present study.


  Conclusion Top


  1. A mild lag was found in growth as per CVMI status in CLP subjects as compared to normal noncleft patients in 6–12 year age group that later on was observed to catch-up in 12–18 years age group
  2. The iatrogenicity played a highly significant role in posterior maxillary positioning than the hypoplasia due to morbid anatomy in CLP. Maxilla was also clockwise rotated in CLP patients. This difference was more pronounced in the treated cleft group
  3. Reduction in mandibular size and inferoposterior rotation with increased lower facial height was found in CLP patients in both the groups
  4. Maxillomandibular relationship was less convex in both untreated and surgically treated CLP patients in both the age groups.


To conclude, the findings of this study suggested that the maxillofacial growth and development of the untreated CLP patients was almost similar to noncleft patients, the differences in maxillofacial growth exist in individuals with CLP who have undergone surgery in childhood when compared to noncleft and untreated cleft patients. Thus, it can be stated that morbidity plays a significant role in delaying skeletal maturity. On the other hand, the iatrogenic repercussion of surgery has significant restraining effect on maxilla primarily and on the mandible and maxillomandibular relationship to some extent. This could be because of altered functional matrix resulting due to the formation of scar tissue in the lip and palate region as a consequence of surgical intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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