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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 25-30

Comparison of craniodentofacial morphology of children with and without unilateral cleft lip and palate


1 Department of Orthodontics, Faculty of Dentistry, Ege University, Izmir, Turkey
2 Orthodontist, Private Cliniq, Izmir, Turkey

Date of Web Publication21-Nov-2017

Correspondence Address:
Servet Dogan
Department of Orthodontics, Faculty of Dentistry, Ege University, 35100 Bornova, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_88_17

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  Abstract 

Background: This retrospective case-control study was done to investigate the cranio-dento-facial morphology of Turkish children with unilateral complete cleft lip and palate from Ege University and compare them with a normal group to highlight the effect of surgical correction on craniofacial development. Methods: 60 patients with unilateral complete cleft lip and palate were compared with 55 control children without cleft at mean ages of 13 and 15 years. The cleft lip was operated with modified Millard technique at 3 months, cleft palate was operated with von Langenbeck technique at 12 months. The patients were not given any orthopaedic or orthodontic treatment also. Angular and linear measurements of cranio-dento-facial complex were measured by using Dolphin Imaging 11.5 software programme, and the resulting data were evaluated statistically. Results: The children with unilateral complete cleft lip and palate had considerable morphological deviations when compared with the matched children without clefts. The most striking findings in the unilateral complete cleft lip and palate group: Maxillary and mandibular complex and nasal projections were retruded when compared with normal (P<0.001). Also, nasal airway dimensions were higher in control group (P<0.001). Soft tissue structure, especially upper lip thickness, upper and lower lip lengths were decreased (P<0.001, P<0.001, P<0.05, respectively) in cleft group. Maxillar anterior height was decreased (P<0.001). Besides, nasolabial angle and upper incisor inclination according to the maxillary occlusal plane (P<0.001) were increased while overjet (Mx1-Md1) were decreased (P<0.001). Conclusion: The surgical technique and the number of operations seem to be the most effective factors for maxillary retrusion in patients with unilateral complete cleft lip and palate.

Keywords: Craniodentofacial morphology, dentofacial morphology, unilateral cleft lip and palate


How to cite this article:
Dogan S, Olmez S, Dogan E. Comparison of craniodentofacial morphology of children with and without unilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:25-30

How to cite this URL:
Dogan S, Olmez S, Dogan E. Comparison of craniodentofacial morphology of children with and without unilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:25-30. Available from: https://www.jclpca.org/text.asp?2017/4/3/25/218900


  Introduction Top


Cleft lip and palate (CLP) anomaly is a congenital malformation caused by morphologic changes, altered growth factors, and absolute tissue deficiency in the hard palate and abnormal tissues in the maxillary palatal region.[1],[2],[3] This anomaly has significant effects on the facial morphology, function, growth, and development of the individual, which requires a detailed study of the dental and craniofacial characteristics. The defects usually associated with CLP patients are those of growth in all three planes; vertical, sagittal, and transverse. The most striking feature in a cleft patient is the sagittal deficiency of the midface leading to a concave facial profile.[4],[5],[6]

The aim of this study is to investigate the craniodentofacial morphology of Turkish children with unilateral complete CLP (UCCLP), who were operated by surgeons using modified Millard and von Langenbeck technique and compare them with a normal group to highlight the effects of surgical corrections on craniofacial development.


  Materials and Methods Top


The study consisted of sixty children with UCCLP (35 females and 25 males) aged between 13 and 15 years (mean age: 14 years) which were compared to 55 children without clefts (32 females and 23 males) aged between 13 and 15 years (mean age: 14 years). The patients were not given any orthopedic or orthodontic treatment and alveolar bone grafting. None of the patients had an associated syndrome or mental retardation. Patients with UCCLP were operated in the Department of Plastic and Reconstructive Surgery, Medical Faculty, Ege University. The cleft lip was operated using the modified Millard technique at 3 months, and cleft palate was operated using the von Langenbeck technique at 12 months. Operations were done by three different surgeons.

Angular and linear measurements of craniodentofacial complex were measured using the Dolphin Imaging 11.5 software program, and the resulting data were evaluated statistically.

Cephalometric analysis

The children were evaluated by cephalometric radiographs. Landmarks and cephalometric analyses were those of Arnett et al.[7] Before taking cephalometric radiograph, metallic markers were placed on the right side of the face on orbital rim, subpupil, and alar base contours to indicate the anteroposterior position of the maxilla. With the midface structures marked, a lateral head film was obtained in natural head position, seated condyle, and with passive lips. The true vertical line (TVL) was established. The line was placed through subnasale and was perpendicular to the natural horizontal head position. The vertical or horizontal position of soft tissue and hard tissue landmarks was then measured relative to the patient's natural horizontal head position or TVL.

The landmarks and linear and angular measurements identified on the cephalometric films are shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Dentoskeletal measurements. True vertical line placed through subnasale, maxillary occlusal plane to true vertical line, overjet and overbite, upper incisor to maxillary occlusal plane, lower incisor to mandibular occlusal plane[7]

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Figure 2: True vertical line projections: True vertical line is placed through subnasale except when maxillary retrusion exists. Maxillary retrusion is based on clinical nasal projection (short, normal, and long), clinical orbital rim, cheek bone, subpupil, and alar base contours (depressed, flat, normal, and prominent), clinical upper lip support (by incisor, gingiva, and no support [air]), cephalometric upper lip angle, and cephalometric upper lip thickness. When midface retrusion is diagnosed the true vertical line is moved 1 to 3 mm anterior. Midface retrusion is defined by clinical factors (long nose, deficient midface structures, and poor incisor upper lip support) and cephalometric factors (upright upper lip and/or thick upper lip). Profile points measured to true vertical line: Glabella (G'), nasal tip (NT), soft tissue A point (A'), upper lip anterior, lower lip anterior, soft tissue B point (B'), and soft tissue Pogonion (Pog'). Midface points measured with metallic beads to true vertical line: soft tissue orbital rim (OR'), cheekbone height of contour (CB'), subpupil (SP'), alar base (AB'). Hard tissue measured to true vertical line: upper incisor tip and lower incisor tip[7]

Click here to view
Figure 3: Soft tissue lengths include facial height (Na' to Me'), lower one-third height (Sn to Me'), upper lip length (Sn to upper lip inferior), lower lip length (lower lip superior to Me'), and interlabial gap (upper lip inferior to lower lip superior). Soft tissue to hard tissue measurements include maxillary incisor exposure (upper lip inferior to maxillary incisor tip), maxillary height (Sn to maxillary incisor tip), and mandibular height (mandibular incisor tip to Me'). The only hard tissue to hard tissue measurements is the overbite[7]

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Figure 4: Soft tissue structures: tissue thickness at upper lip, lower lip, Pogonion', and Menton' are depicted. Soft tissue thickness and dentoskeletal factors determine the profile. Upper lip angle and nasolabial angle are depicted. These soft tissue structures are altered by movement of the incisor teeth. These angles should be studied before orthodontic overjet correction to assess the potential for changes out of normal range[7]

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The authors declare the principles outlined in the Declaration of Helsinki have been respected while conducting the current investigation.

Statistical analysis

A total of 34 linear and angular measurements were analyzed statistically by Student's t-tests, 95% confidence intervals were also calculated. All calculations were made using the Statistical Package for the Social Sciences (SPSS 10.0 for Windows).


  Results Top


The mean values, standard deviations, minimum and maximum values, and Student's t-tests of all the variables used in this study are shown in [Table 1]. The level of significance adopted for statistical test was P < 0.05.
Table 1: The mean values, standard deviations and P value for unilateral complete cleft lip and palate and control groups

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No significant differences were observed between the cleft and control groups in terms of gender, but there were significant differences between the craniodentofacial dimensions in control and cleft groups. The children with UCCLP had considerable morphological deviations when compared with the matched children without clefts.

Relative to the control group without cleft, the UCCLP patients had retruded maxillary, mandibular complex, and nasal projections according to the TVL (P < 0.001). Furthermore, nasal airway dimensions were higher in control group (P < 0.001).

Soft tissue structure, especially upper lip thickness, and upper and lower lip lengths were decreased (P < 0.001, P < 0.001, and P < 0.05, respectively) in the cleft group. At the same time, maxillary anterior height was decreased (P < 0.001). Besides, nasolabial angle was increased (P < 0.001) whereas overjet (Mx1-Md1) was decreased (P < 0.001).

Upper incisor inclination to maxillary occlusal plane was greater in children with UCCLP indicating retroinclination of the upper incisors (P < 0.001). Anteroposterior position of the incisors was significantly less in those with clefts than in controls.


  Discussion Top


The defects usually associated with CLP patients are those of growth in all three planes; vertical, sagittal, and transverse. These patients are generally characterized as possessing abnormalities of the dental arch form, malocclusion, facial deformity, and masticatory. Differences in craniofacial characteristics were noted between the cleft and noncleft individuals. These differences were more pronounced in sagittal plane and less in transverse plane.[1],[8],[9],[10],[11] Studies comparing the craniofacial features among cleft individuals have demonstrated significant differences in various parameters when compared to noncleft individuals.

According to the results of our study, the maxillofacial growth of children with UCCLP was severely inhibited. The anterior maxillary height was significantly reduced. Increased nasolabial angle also pointed out the severe maxillary hypoplasia. This is in agreement with the results of Liu et al. and Liu et al.,[4],[5] Gaukroger et al.,[10] and Johnston et al.[12]

Chen et al.[2] concluded that patients with operated CLP showed maxillary retrusion as well as reduced anterior-posterior maxilla length.

Horswell[13] evaluated craniofacial growth in unilateral CLP (UCLP) patients and reported reduced maxillary arch length in cleft individuals. Camargo[14] in their study on the influence of cleft on maxillary arch morphology, concluded that maxillary arch is distorted in the presence of cleft.

Our data showed that facial angle (G'-Sn'-Pog'), which represents the relationship of maxilla and mandible, was decreased relative to the control group in the UCCLP group, which indicates serious maxillary retrognathism in relation to mandible.

Fudalej et al.[6] claimed that patients with UCCLP almost feature concave facial profile, increased facial height, shortened upper lip, and flattening of the nose. The mandible also compensates for the maxillary hypoplasia and is also retrusive. Similar to their results in this study, both maxillary and mandibular projections showed reduction. Nasal projection also decreased compared to the control group.

Treutlein et al.[15] evaluated the craniofacial morphology of children with UCLP by cephalometry. These children showed a significant retrusion of maxilla and clockwise rotation of the mandible as well as a reduced vertical development of the midface.

Dogan et al.[11] found that the children with UCCLP had considerable morphological deviations compared with the matched children without clefts. They had significantly shorter and more posteriorly positioned maxilla (P < 0.01). There was also an increase in cranial base angle (P < 0.05), mandibular plane, and gonial angle (P < 0.01). There was a reduction in the posterior facial height (P < 0.05) and an increase in the anterior facial height (P < 0.01). The profile of the soft tissue was less convex (P < 0.001) and the upper lip was thinner than in the children in the control group (P < 0.01), and their noses were relatively further backward and downward (P < 0.01).

Reduction in arch perimeter of the maxilla after operation may be as a result of the scar. The soft tissue profile of the children with clefts was less convex, and the soft tissue of the upper lip was thinner compared to the noncleft group. The configuration of the nasal outline in terms of both hard and soft tissue suggests that the nose is positioned relatively backward and downward in children with clefts.

The present study indicated that the cleft individuals had considerable morphological deviations when compared with the matched children without clefts. The most striking findings in the UCCLP group: Projections to TVL of the structures of maxillary, mandibular complex, and nasal projections were retruded when compared with normal (P < 0.001). Furthermore, nasal airway dimensions were higher in control group (P < 0.001). Soft tissue structure, especially upper lip thickness, and upper and lower lip lengths were decreased (P < 0.001, P < 0.001, and P < 0.05, respectively) in cleft group. At the same time, maxillary anterior height was decreased (P < 0.001). Besides, nasolabial angle and upper incisor inclination according to the maxillary occlusal plane (P < 0.001) were increased while overjet (Mx1-Md1) was decreased (P < 0.001).

We found a significant increase in the interincisal angle and retroinclination of the upper incisors which shows that the dentoalveolar region could not compensate for the impairment of sagittal relations between maxilla and mandible.

This is in agreement with previous studies, which concluded that this failure of compensation could be the result of dysplastic influences from increased labial pressure after closure of the lip and from scar tissue left by palatal repair.[13],[14]


  Conclusion Top


The management of CLP cases requires a team effort, consisting of various specialists. The problems associated with the patients include growth defects, dental arch abnormalities, morphological defects, and esthetic and psychological trauma that the patients undergo.

The study is done to evaluate the facial morphology of UCLP individuals and to compare them with noncleft individuals. Significant differences exist in the craniofacial morphology between the untreated UCLP individuals and noncleft individuals.

The data obtained from the facial morphology of untreated adult CLP patients can be used as an aid in diagnosis and treatment planning. Further studies need to be done on different types of orofacial clefts including age and ethnicity of the individuals. Such investigations need to be conducted on a longitudinal basis to study the effects of cleft on the growth and development of the individual.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Smahel Z, Müllerova Z, Nejedly A, Horak I. Changes in craniofacial development due to modifications of the treatment of unilateral cleft lip and palate. Cleft Palate Craniofac J 1998;35:240-7.  Back to cited text no. 1
    
2.
Chen ZQ, Wu J, Chen RJ. Sagittal maxillary growth pattern in unilateral cleft lip and palate patients with unrepaired cleft palate. J Craniofac Surg 2012;23:491-3.  Back to cited text no. 2
[PUBMED]    
3.
Seo YJ, Park JW, Kim YH, Baek SH. Initial growth pattern of children with cleft before alveolar bone graft stage according to cleft type. Angle Orthod 2011;81:1103-10.  Back to cited text no. 3
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4.
Liu R, Lu D, Wamalwa P, Li C, Hu H, Zou S, et al. Craniofacial morphology characteristics of operated unilateral complete cleft lip and palate patients in mixed dentition. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e16-25.  Back to cited text no. 4
    
5.
Liu RK, Wamalwa P, Lu DW, Li CH, Hu HK, Zou S, et al. Soft-tissue characteristics of operated unilateral complete cleft lip and palate patients in mixed dentition. J Craniofac Surg 2011;22:1275-9.  Back to cited text no. 5
    
6.
Fudalej P, Surowiec Z, Offert B, Dudkiewicz Z, Katsaros C. Craniofacial morphology in complete unilateral cleft lip and palate patients consecutively treated with 1-stage repair of the cleft. J Craniofac Surg 2010;21:1468-73.  Back to cited text no. 6
    
7.
Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr., et al. Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop 1999;116:239-53.  Back to cited text no. 7
    
8.
da Silva Filho OG, Ramos AL, Abdo RC. The influence of unilateral cleft lip and palate on maxillary dental arch morphology. Angle Orthod 1992;62:283-90.  Back to cited text no. 8
    
9.
Semb G, Shaw WC. Facial growth after different methods of surgical intervention in patients with cleft lip and palate. Acta Odontol Scand 1998;56:352-5.  Back to cited text no. 9
    
10.
Gaukroger MJ, Noar JH, Sanders R, Semb G. A cephalometric inter-centre comparison of growth in children with cleft lip and palate. J Orthod 2002;29:113-7.  Back to cited text no. 10
    
11.
Doǧan S, Onçaǧ G, Akin Y. Craniofacial development in children with unilateral cleft lip and palate. Br J Oral Maxillofac Surg 2006;44:28-33.  Back to cited text no. 11
    
12.
Johnston CD, Leonard AG, Burden DJ, McSherry PF. A comparison of craniofacial form in Northern Irish children with unilateral cleft lip and palate treated with different primary surgical techniques. Cleft Palate Craniofac J 2004;41:42-6.  Back to cited text no. 12
    
13.
Horswell L. Craniofacial growth in UCLP, from 8 to 18 yrs. Cleft Palate J 1997;24:114.  Back to cited text no. 13
    
14.
Camargo OG. Influence of unilateral cleft lip and palate on maxillary dental arch morphology. Angle Orthod 1992;62:283-90.  Back to cited text no. 14
    
15.
Treutlein C, Berten JL, Swennen G, Brachvogel P. Comparative cephalometric study of 10-year-old patients with complete unilateral cleft lip and palate. A cross-sectional study of the Hanover concept. J Orofac Orthop 2003;64:27-39.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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