Vol. 80 No.

2 August 1995

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ORAL AND MAXILLOFACIAL SURGERY Editor: Larry J. Peterson

Anthropometric profile evaluation of the midface in patients

with cleft lip and palate
Nipon Chaisrisookumporn, DDS, a John Paul Stella, DDS, b and
Bruce N. Epker, DDS, PhD, c Fort Worth, Tex.
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, CENTER FOR CORRECTION OF FACIAL
DEFORMITY, JOHN PETER SMITH HOSPITAL

This study was done to determine those profile anthropometric measurements that are abnormal in the
midface profile in patients with cleft lip and palate. The sample population consisted of 30 randomly selected skeletally
mature white patients with cleft lip and palate who had been treated by the same team who were accredited by the
American Cleft Palate-Craniofacial Association. Twenty patients had unilateral and 10 had bilateral complete clefts. None
of these patients had previously undergone orthognathic surgery or definitive rhinoplasty surgery. Fifteen facial
anthropometric features were measured on each person's face. The result from this study showed that in patients with
cleft lip and palate right versus left side differences did not exist and only four statistically significant differences existed
between the unilateral and bilateral cases. However, in all patients, four of these esthetic facial features were consistently
and significantly abnormal: obtuse nasofrontal angle: obtuse nasomental angle; a posteriorly positioned infraorbitale
relative to globe; and an obtuse general facial angle. Several other features were abnormal in a high percentage of
persons in this study. These were lack of supratip break, flat to concave paranasal contour, increased
subnasale-alargroove:subnasale-pronasale ratio, decreased nasal protrusion:nasal length ratio, decreased nasolabial angle
ratio, decreased maxillary length ratio, increased nasal bridge projection:nasal protrusion ratio, and deficient cheek
contour. This data indicates that the major deformity in persons with adult cleft lip and palate exist in the nose and
secondarily in other components of the midface. (ORALSuec OPALMED ORAl PATHOLORALRADIOLENDOD1995;80:127-36)

Cleft lip and palate (CLP) deformities comprise the
most common of all congenital facial deformities.
The incidence of CLP ranges from 1 in 2400 births
in African-Americans 1 to 1 in 500 in Asian-Ameri-
cans. 2 The most recent data from the American Cleft
Palate Educational Foundation reports about 1 in 700
live white births have a cleft lip or palate. The risk for
parents who have one child with a cleft lip or palate
to have a second child with a cleft lip or palate is about
1 in 20. The incidence rises to 1 in 10 for parents with
This study was supported by The Center for Correction of Facial
Deformities, John Peter Smith Hospital, Fort Worth, Tex. 76104.
aResearch Fellow.
bChairman.
cStaff
Received for publication Jan. 3, 1995; returned for revision Mar.
16, 1995; accepted for publication Mar. 31, 1995.
Copyright 9 1995 by Mosby-Year Book, Inc.
1079-2104/95/$3.00 + 0 7/12/65392
two children with cleft lip or palate who plan for a
third child. Accordingly, research in this area de-
serves high priority. 3, 4
Authors 5, 6 reported that early palatoplasty (at less
than 18 months of age) predispose patients to maxil-
lary retrusion, others reported that maxillary retrusion
or midface deficiency (MFD) is inherent in the CLP
population.7, 8 Clinically, it is commonly stated that
CLP patients have the appearance of MFD; described
in the literature under various terms. 9-14 The surgery
to correct the skeletal discrepancy in cleft patients
may involve a Le Fort I or mandibular setback. 9, 15-18
Currently, the state of the art in the correction of
skeletal facial or dentofacial deformities is to inte-
grate the findings from the clinical facial esthetic ex-
amination, cephalometric radiograph analysis, pan-
oramic radiograph, and dental study models to estab-
lish the specific diagnosis of the existing dentofacial
deformities. Esthetic information is believed by most

127
128 Chaisrisookumporn, Stella, and Epker
Fig. 1. Facial anthropometric landmarks:
Ag (Alar groove), the most lateral part of the groove on the
curved baseline of each ala nasi
C1 (Columella), the most anterior point on the columella of
the nose
FH (Frankfort horizontal), the horizontal imaginary line be-
tween the porion and the orbitale. (In this study, FH was
transferred from lateral cephalometric radiograph onto
the drawn profile.)
G' (Glabella), the most prominent point in the midsagittal
plane of the forehead
Globe, the most anterior projection of the globe
Infraorbitale, the most inferior point of the orbit
Ls (Labiale superius), a point indicating the mucocutaneous
junction of the upper lip at midline
Me (Soft tissue menton), the most inferior point on the soft
tissue chin
N (Soft tissue nasion), the most concave point in the tissue
overlying the area of the frontonasal suture
Or (Orbitale),the lowest point on the inferior margin of the
orbit
Pg' (Soft tissue pogonion), the most anterior point on the soft
tissue chin
Pm (Pronasale),the most prominent or anterior point of the nose
Sn (Subnasale), the point at which the columella (nasal
septum) merges with the upper cutaneous lip in the
midsagittal plane
Sn:: (Subnasale parallel), the line passing through the subnasale
and running parallel to the FH
Sn: (Subnasale perpendicular), the line passing through the
subnasale and running perpendicular to the FH
Supratip break, a slight depression in the nasal dorsum just supe-
rior to the tip region
T (Tragion),the notch on the upper margin of the tragus
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 1995
to be paramount in establishing the most appropriate
surgical treatment option(s).
Anthropometry facial esthetic evaluation is an ob-
jective method that can be used to supplement
subjective visual judgment (anthroposcopy) with
quantitative measurement. 19 Recently, the details of
this method have been reported. 2~ Many authors 21-38
have labored to evaluate craniofacial growth and ob-
jectively describe morphology in CLP patients~ Fur-
thermore, some have emphasized the clinical appear-
ances of MFD. 9, 17 Others published cephalometric
guidelines to establish objective diagnoses. 15 Never-
theless, a search of the existing literatures has failed
to reveal objective anthropometric criteria to identify
or to diagnose the specific nature of the midface de-
formities in skeletally mature CLP patients.
The purpose of this study was to provide objective
criteria, specifically anthropometric analyses, for the
evaluation and diagnosis of midface abnormalities in
adult CLP patients.
MATERIAL AND METHODS
Patient selection
Data on 30 randomly selected CLP patients were
obtained from the Fort Worth Cleft Palate Program at
John Peter Smith Hospital in Fort Worth, Tex. Ten
had bilateral complete cleft lip and palates, and 20 had
unilateral complete CLP. Selection of patients was
based on the following criteria: (1) all were nonsyn-
dromic CLP patients; (2) all were white, the females
patients were 12, and male patients were 16 years of
age or older; (3) good quality, well-oriented, right or
left profile color slides were available for each
patient; (4) no orthognathic or facial cosmetic surgery
had been previously performed.
In addition, each patient had been surgically treated
with the standard protocol for CLP patients in the Fort
Worth Cleft Palate Program. The standard protocol
includes the following procedures. The lip is closed
with a Millard rotation advancement flap at age 10 for
all unilateral cleft lips. Rarely can a lip adhesion pro-
cedure be done. With bilateral cleft lip patients, most
are repaired with a Manchester or Mulliken proce-
dure. Palatoplasty is performed when the patient is
between 1 and 2 years of age, depending on the pa-
tient's overall development, most importantly speech
and language development. A Wardill palatoplasty is
usually performed. Velopharyngeal flaps are per-
formed if it is determined that surgery will be required
to establish velopharyngeal competence. If surgery is
required, it is usually performed before the patient
enters school, usually around the age of 4 to 5 years.
Alveolar cleft grafting is performed between the ages
of 9 and 11 years with autogenous cancellous bone
harvested from the ilium.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Chaisrisookumporn, Stella, and Epker 129
Volume 80, Number 2

Fig. 2. A, Right side view of bilateral cleft patient. B, Left side view of bilateral cleft patient.

Table I. F a c i a l a n t h r o p o m e t r i c e v a l u a t i o n a d a p t e d for this study

Variables Evaluations Normal values

Ratios
V1 Subnasale-alar groove:subnasale-nasal tip (Sn-Ag:Sn-Prn) 1:2
V2 Nasolabial angle ratio (Sn-C1/FH:FH/Sn-Ls) 1:4
V3 Infraorbiale:Globe (positive, 0, negative) Positive
V4 Nasal protrusion: Nasal length (Sn-Pm:N'-Prn) 1:2.5
V5 Nasal bridge projection:nasal protrusion (Globe-N':Sn-Pm) 1:1.33
V6 Maxillary length ratio (T-Sn:T-N') 1:1
V7 Mandibular length ratio (T-Me':T-N') 1:0.87
Angles
V8 General facial angle (G-Pg'/Vertical) -5 deg+/-2
V9 Midface angle (G-Sn/Vertical) - I deg +/-1
V10 Nasofrontal angle (N'-G tangent/N'-Pm) 130deg+/-5
Vll Nasolabial angle (Sn-CI/Sn-Ls) 100 deg+/-5
V12 Nasomental angle (N'-Prn/Pm-Pg') 125 deg+/-5
Surface contours
V13 Paranasal (convex, flat, concave) Convex
V14 Cheek (convex, flat, concave) Convex
V15 Supratip break (present, absent) Present

Morphometric esthetic evaluation of the face
The 35 m m 2 x 2 c o l o r slides o f the p a t i e n t s ' pro-
files w e r e p r o j e c t e d on a sketch p a d so that the dis-
tance f r o m soft tissue nasion (N) to soft tissue p o g o -
nion (Pg) was s t a n d a r d i z e d at 100 m m . W i t h the
sketch p a p e r u s e d as the screen, the p a t i e n t s ' p r o f i l e s
were drawn. B o t h the right and left p r o f i l e s w e r e
evaluated. T h e s a m e i n v e s t i g a t o r (N.C.) s k e t c h e d and
collected the d a t a on all patients.
Quantitative surface contour, angular, and inclina-
130 Chaisrisookumporn, Stella, and Epker
Fig. 3. A, Right side view of patient with right side cleft; B, left side view of patient with right side cleft.
Table II. Age, sex, and cleft side distribution in
study group
Age (years) Sex
Total Right Left Bilateral
Range Mean Male Female (number) cleft cleft cleft
12-42 20.8 15 15 30 9 11
tion measurements were obtained from a facial pro-
jection of the patients in the study group with the an-
atomic landmarks, reference points, planes, and an-
gles used as illustrated in Fig. 1. Figs. 2, 3, and 4
illustrate the profiles with the anthropometric land-
marks and major referant lines drawn as was done in
this study of three patients who had bilateral, right,
and left complete CLP, respectively.
Fifteen selected anthropometric norms reported by
Farkas 34 and Koury and Epker 2~ were applied and
adapted to the study population. Table I summarizes
the norms used for each variable studied. The selected
anthropometric norms were as follows:
V1 is the linear ratio between subnaSale-alar groove
to subnasale-nasal tip (Sn-Ag:Sn-Prn). The
normal value is 1:2 or 0.5.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 1995
V2 (nasolabial angle ratio) is the ratio between the
two angles formed by dividing the nasolabial
angle by subnasale parallel. 36 The numerator is
the angle formed by the subnasale-columella
(Sn-C 1) and subnasale parallel, and the denom-
inator is the angle formed by subnasale parallel
10
and subnasale-labiale superius (Sn-Ls) (Sn-C1/
Frankfert Horizontal (FH):FH/Sn-Ls). The nor-
mal value is 1:4 or 0.25.
V3 is the position of orbitale relative to a line drawn
from the most anterior projection of globe per-
pendicular to Frankfort horizontal. The normal
position is positive, that is orbitale is anterior to
the cornea. For statistic calculation, positive
position was coded as 1, zero position as 2 and
negative position as 3, respectively.
V4 is the linear ratio between nasal protrusion and
nasal length (Sn-Prn:N-Prn). The normal value
is 1:2.5 or 0.40.
V5 is the linear ratio between nasal bridge projec-
tion and nasal protrusion (Globe-N:Sn-Prn).
The normal value is 1:1.33 or 0.75.
V6 (maxillary length ratio) is the linear ratio be-
tween tragion-subnasale to tragion-soft tissue
nasion (T-Sn:T-N). The normal value is 1:1.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Chaisrisookumporn, Stella, and Epker 131
Volume 80, Number 2

Fig. 4. A, Right side view o f patient with left side cleft; B, left side view o f patient with left side cleft.

Table III. Differences between the right and left profiles in unilateral complete CLCP
Right side cleft Left side cleft
Statistical
Variables Mean R Mean L Mean R Mean R significance

V1 0.67 0.72 0.83 0.68 NS

V2 0.18 0.21 0.16 0.15 NS
V3 2.17 2.83 2.43 2.17 NS
V4 0.34 0.33 0.33 0.36 NS
V5 0.86 0.80 1.00 0.90 NS
V6 1.02 1.03 0.99 0.98 NS
V7 1.22 1.24 1.20 1.20 NS
V8 -1.00 -1.17 0.93 0.36 NS
V9 -0.83 -0.92 0.79 -0.29 NS
V10 151.33 150.17 149.57 150.14 NS
V11 85.42 93.00 92.14 87.86 NS
V12 144.58 142.92 144.57 144.14 NS
V13 2.50 2.33 2.29 2.29 NS
V14 2.00 1.83 1.86 2.00 NS
V15 1.50 1.55 1.86 1.86 NS
NS, Not significant.

V7 (mandibular length ratio) is the linear measure-
ment between tragion-soft tissue menton to tra-
gion-soft tissue nasion (T-Me:T-N). The normal
value is 1:0.87 or 1.15.
V8 (general facial angle) is the angle formed by a line
form glabella-soft tissue pogonion and true verti-
cal line (G-Pg/Vert). The normal value is -5 de-
grees.
V9 (midface angle) is the angle formed by the line
glabella-subnasale and the true vertical line (G-
Sn/Vert). The normal value is -1 degree.
V10 (nasofrontal angle) is the angle formed by a line
132 Chaisrisookumporn, Stella, and Epker ORAL SURGERY ,ORAL MEDICINE ORAL PATHOLOGY
August 1995

Table IV. Differences between the right and left Table V. Differences between the right and left
profiles in bilateral complete CLCP profiles in unilateral and bilateral cleft patients
Statistical Bilateral Unilateral Statistical
Variables Mean R Mean L significance Variables Mean R Mean R significance

V1 0.46 0.44 NS V1 0.46 0.67 NS

V2 0.21 0.24 NS V2 0.21 0.18 NS
V3 2.17 2.67 NS V3 2.17 2.17 NS
V4 0.44 0.34 NS V4 0.44 0.34 NS
V5 0.80 0.86 NS V5 0.80 0.86 NS
V6 0.94 1.02 NS V6 0.94 1.02 NS
V7 1.17 1.18 NS V7 1.17 1.22 NS
V8 -2.08 -2.00 NS V8 -2.08 -1.00 NS
V9 -4.42 -5.50 NS V9 -4.42 -0.83 S
V10 151.50 152.58 NS V10 151.50 151.33 NS
V11 110.58 109.50 NS V11 110.58 85.42 S
V12 144.00 147.00 NS VI2 144.00 144.58 NS
V13 1.33 2.00 NS V13 1.33 2.50 S
V14 1.17 1.17 NS V14 1.17 2.00 S
V 15 2.00 2.00 NS V15 2.00 1.50 NS
NS, Not significant. S, Significant.
NS, Not significant.

from soft tissue nasion-glabella and a line from
soft tissue nasion-pronasale (N-G tangent/N-Prn).
The normal value is 130 degrees.
V11 (nasolabial angle) is the angle formed by a line
from subnasale-columella and a line from subna-
sale-labiale superius (Sn-CI/Sn-Ls). The normal
value is 100 degrees.
V12 (nasomental angle) is the angle formed by a line
from soft tissue nasion-pronasale and pronasale-
soft tissue pogonion (N-Prn/Prn-Pg). The normal
value is 125 degrees.
V I 3 (paranasal) is the surface contour ofparanasal area
lateral to the alar of the nose. The normal appear-
ance is convex. For statistical calculation, convex
contour was coded as 1, fiat contour as 2, and
concave contour as 3, respectively.
V14 (cheek) is the surface contours of cheek superior
to the paranasal area. The normal appearance is
convex. For statistical calculation, convex contour
was coded as 1, flat contour as 2, and concave
contour as 3, respectively.
V I 5 (supratip break) is a slight depression in the nasal
dorsum just superior to the tip r e g i o n . 36 T h e nor-
mal appearance is present. For statistic calcula-
tion, present was coded as 1, and absent was coded
as 2.
We distinguished between the ratio and the angu-
lar measurements notationally by using a colon (:) to
denote the ratio and a slash (/) to denote an angular
measurement (measured in degrees).
Patient grouping
The unilateral complete cleft lip and palate patients
were compared with the bilateral cleft lip and palate
patients for each variable. In addition, in the unilat-
eral CLP patients the right and left sides were com-
pared.
STATISTICAL ANALYSIS
The confidence interval analysis was conducted
to test the statistical difference at a 95% confidence
level between (1) the right and left profiles in the
unilateral group; (2) right and left profiles in the bi-
lateral group; (3) the bilateral and unilateral cleft
groups; and (4) the total cleft group right profiles and
norms.
Also, the frequency of those anthropometric vari-
ables that were at variance with normal control val-
ues were calculated. We devised and used the
following grading of anthropometric abnormalities in
the midface. Those abnormal variables that were
consistently identified (found in more than 25 of 30
patients) were noted as the strongest characteristics or
major criteria of abnormalities in the midface of per-
sons with repaired clefts. The variables found in 16
to 24 patients were noted as the intermediate Charac-
teristics or minor criteria. The variables found in less
than 15 patients (one half of the test group) were noted
as the weakest characteristics.
RESULTS
Table II summarizes the age, sex, and cleft side
distribution in this study group of patients. The mean
age of the patients at the time of taking facial photo-
graphs was 20.8 years (range, 12 to 42 years). The 30
randomly selected CLP patients were composed of 15
males and 15 females. Ten of the patients had bilat-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Chaisrisookumporn, SteIla, and Epker 133
Volume 80, Number 2

Table VI. Differences between the right profiles versus n o r m s

Normal value Right profile

Standard Standard Statistical

Variables Mean deviation Mean deviation significance

V1 0.50 0.25 0.672 0.261 S

V2 0.25 0.50 0.192 0.126 NS
V3 1.00 0.00 2.267 0.640 S
V4 0.40 0.25 0.362 0.059 NS
V5 0.75 0.3 0.860 0.241 NS
V6 1.00 0.2 0.978 0.050 NS
V7 1.15 0.2 1.177 0.093 NS
V8 -5 2 -0.067 3.471 S
V9 -1 1 -0.067 4.985 NS
V10 130 5 150.867 6.553 S
V11 100 5 94.550 20.791 NS
V12 125 5 142.483 7.419 S
V 13 1 0.00 2.133 0.900 S
V14 1 0.00 1.633 0.669 S
V15 1 0.00 1.800 0.407 S
S, Significant.
NS, Not significant.

fable VII, F r e q u e n c y of each variable (N = 30)

Indicative
Frequency Variables ofabnormalcy

Strongest characteristics
30 V10 Nasofrontal angle (N'-G/N'-Prn) >Normal
30 V12 Nasomental angle (N'-Prn/Prn-Pg'_) >Normal
27 V3 Infrorbitale:Globe 0 or Negative
26 V8 General facial angle (G-Pg'/Vertical) >Normal
Intermediate characteristics
24 V15 Supratip break Absent
23 V13 Paranasal Flat or concave
22 V1 Sn-Ag:Sn-Pm >Normal
22 V4 Nasal protrusion:Nasallength (Sn-Pru:N'-Prn) >Normal
20 V2 Nasolabial angle ratio (Sn-C1.FH:FH/Sn-Ls) >Normal
18 V6 Maxillary length ratio (T-Sn:T-N') >Normal
17 V5 Nasal bridge projection:nasalprotrusion(Globe-N':Sn-Pru) >Normal
17 VI4 Cheek Flat or concave
Weakest characteristics
12 V11 Nasolabial angle (Sn-CI/Sn-Ls) > Normal
12 V7 Mandibularlength ratio (T-Me,:T-N') >Normal
11 V9 Midface angle (G-Sn/Vertical) >Normal

eral clefts, 9 had right clefts, and 11 had left complete
CLP.
Table III lists the comparison b e t w e e n right and left
profiles of all variables measured in the unilateral
C L P patients. No statistically significant differences
were noted in any group.
Table IV reports the c o m p a r i s o n b e t w e e n right and
left profiles in the bilateral C L P patients. Again, no
statistically significant differences were noted be-
tween right and left profiles.
Table V tabulates the differences b e t w e e n the right
profiles in the unilateral C L P a n d in the bilateral C L P
patients. The differences i n four variables were
statistically significant: the m i d f a c e angle ( G - S n / v e r -
tical), nasolabial angle (Sn-C1/Sn-Ls), paranasal con-
tour (V13), and cheek c o n t o u r (V14).
T a b l e VI reports the statistical differences b e t w e e n
the right profiles versus n o r m s previously reported
for the anthropometric characters studied. 19-22 Sta-
tistically significant differences were n o t e d i n the
f o l l o w i n g variables: V1 subnasale-alar groove: sub-
nasale-nasal tip, V3 (the position of infraorbitale
134 Chaisrisookumporn, &ella, and Epker
Variables
(v)
5 10
Patients (n=30)
Fig. 5. Frequency of abnormality in each variable in the study population.
relative to globe), V8 (general facial angle), V10 (na-
sofrontal angle), V12 (nasomental angle), V13 (para-
nasal contours), V14 (cheek contours), and V15 (su-
pratip break).
Table VII and Fig. 5 showed the frequency of each
variable in the study population. The most prevalent
abnormal characteristics were nasofrontal angle, 1~
nasomental angle (V12)--the position of infraorbi-
tal relative to globe (V3), and general facial angle (V8).
The former two variables occurred in every patients in
our study group. The latter two variables occurred in 27
and 26 of 30 patients examined, respectively.
The intermediate abnormal characteristics were
supratip break (V15), paranasal contour (V13), Sn-
Ag:Sn-Prn ratio (V1), nasal protrusion:nasal length
ratio (Sn-Prn:N-Pru) (V4), nasolabial angle ratio
(Sn-CI/Fh:Fh/Sn-Ls) (V2), maxillary length ratio (T-
Sn:T-N) (V6), nasal bridge projection:nasal protru-
sion ratio (globe-N:Sn-Prn) (V5), and cheek contour
(V14).
The least prevalent abnormal characteristics in the
cleft patient population were midfacial angle (G-Sn/
vertical) (V9), nasolabial angle ratio (Sn-CI/Sn-Ls)
(V11), and mandibular length ratio (T-Me:T-N) (V7).
In addition, by looking at each of the strongest
characteristics in every patients, it was noted that ev-
ery patient in the study had at least 3 of 4 of the
strongest characteristics and 2 of 8 of the intermedi-
ate characteristics.
DISCUSSION
The soft tissues of the face are the outside layer
through which we can judge skeletal morphology.
Appraisal of patients with middle-third facial defor-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 1995
15 20 25 30
mities required special attention in an objective sys-
temic clinical examination of the facial features. Im-
portantly, these same anthropometric measurements
can be used postoperatively to analyze treatment re-
sults quantitatively.
To more objectively define the specific nature of
the midfacial deformities in both unilateral and bilat-
eral CLP patients, clinical anthropometric measure-
ment were used in this evaluation.
Table III compares the unilateral complete CLP
patients who had both right and left profile photo-
graphs available in their records. They had six right
clefts and seven left clefts. No statistically significant
differences in the variables measured existed between
the fight and left profiles.
Therefore, in studying the middle face deformities
in nonsyndromic CLP patients, the evaluator can
choose to use either fight or left profile in any CLP type.
These findings were similar to former reports. 22, 23
Table IV compares the differences between right
and left profiles in bilateral complete CLP patients.
Again, no statistically significant differences between
right and left profiles were found for the variables
studied.
Table V compares the reported differences between
the right profile in unilateral and bilateral cleft
patients. In this comparison four statistically signifi-
cant (<0.05) differences existed. The midface angle
indicated a greater degree of retrusion of the midface
in bilateral CLP when compared with unilateral CLP
patients. Similarly, the nasolabial angle was increased
in bilateral CLP patients, indicative of more midface
deficiency. Finally, although somewhat paradoxical,
the deficiency in the cheeks and paranasal areas was
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 80, Number 2
greater or more evident in the unilateral CLP patients
than in the bilateral CLP patients.
Table VI and Fig. 5 summarize the frequency of
each anthropometric measurement that was abnormal
in the study population. Importantly, nasofrontal an-
gle (N-G/N-Prn) and nasomental angle (N-Prn/Prn-
Pg) were abnormal in every CLP patients studied.
The position of infraorbital relative to globe (V3)
was found in a more posterior position than normal
in a very high frequency; this was also reported in a
study by Leonard and Walker.11 and Ortiz-Monaste-
rio and Musolas. 36
The increase in general facial angle (V8) in 26 of
30 patients may be caused from the counterclockwise
rotation of the mandible, as a result of deficient ver-
tical maxillary growth.
Those abnormal characteristics (variables) that oc-
curred with what we considered intermediate fre-
quency were also highly related to abnormalities in
the nose or skeletal nasal base.
In general, the presence and frequency of these
strong and intermediate variables indicate that a great
deal of the deformity in this patient population is na-
sal in origin. Specifically, the nose is very vertical
(flat), the tip is poorly projected, the skeletal nasal
base is deficient, and the dorsum and supratip area are
abnormal.
CONCLUSIONS
From the data presented, it can be concluded
that there was no statistically significant difference
in the variables studied between right and left pro-
file in any cleft type (bilateral cleft, right cleft, or
left cleft). Therefore, in evaluating nonsyndromic
CLP patients, either the cleft or noncleft profile
may be used. Furthermore, we suggest that the
midface deformity in CLP patients is highly related
to the nasal deformity. This information may assist
surgeons to more precisely and definitely diagn-
ose the specific deformities in CLP patients that
eventually will lead to better treatment planning and
results.
W e thank Dr. Tabiri H. Tabasuri, Bit-Statistician o f John
Peter Smith Hospital for his untiring assistance in this
study's statistical analysis.
REFERENCES
1. Chung CS, Myrianthopoulos NC. Racial and prenatal factors
in major congential malformations. Am J Hum Genet 1968;
20:44.
2. Tan KL. Incidence and epidemiology of cleft lip/palate in
Singapore. Ann Acad Med Singapore 1988;17:311.
3. Stavkin HC: Incidence of cleft lips, palates rising. J Am Dent
Assoc 1992;123:61.
4. Shaw WC, Asher-McDade C, BrattstromV, et al. A six cen-
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August 1995

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Reprint requests:
Bruce N. Epker, DDS, PhD
John Peter Smith Hospital
1625 St. Louis Ave.
Fort Worth, TX 76104

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