PREOPERATIVE CLEFT LIP

MEASUREMENTS AND
MAXILLARY GROWTH IN
PATIENTS WITH
UNILATERAL CLEFT LIP AND
PALATE
Gregory S. Antonarakis, D.D.S., M.Sc., Ph.D., Bryan D. Tompson, D.D.S., D. Paedo., D.
Ortho., David M. Fisher, M.B. B.Ch., F.R.C.S.C., F.A.C.S
 INTRODUCTION
 Craniofacial growth deficiencies in individuals with complete unilateral cleft
lip and palate (cUCLP) are widely recognized and have been reported for more
than half a century

 Different etiological factors have been suggested to be responsible for these

growth deficiencies

 A certain percentage of cUCLP patients will go on to require orthognathic

surgery at the end of their active growth to correct their midface deficiency.
 Midface growth deficiency is multifactorial

 The severity at birth may reflect differing contributions of tissue

deficiency and/or tissue displacement.

 We hypothesize that the dimensions of the cleft lateral lip element are
associated with subsequent maxillary growth

 The aim of the current study was to investigate the presence of

associations between the severity of the unilateral cleft lip deficiency and
maxillary growth using cephalometry
 MATERIALS AND METHODS
 Retrospective cross-sectional study.

 Patients: Children with cUCLP.

 Methods: Preoperative cleft lip measurements were made at the time of

primary cheiloplasty and available for each patient.

 Maxillary growth was evaluated on lateral cephalometric radiographs

taken prior to any orthodontic treatment and alveolar bone grafting (8.5 6
0.7 years).

 The presence of associations between preoperative cleft lip

measurements and cephalometric measures of maxillary growth was
determined using regression analyses
 Determination of Cleft Phenotype :cUCLP phenotype was based on
clinical diagnosis. All diagnoses were made by the senior author at or soon
after birth and confirmed at the time of primary cheiloplasty. Laterality of
the cleft (left or right sided) was also recorded

 Preoperative Lip Measurements : The senior author performed all

preoperative lip measurements, with calipers, at the time of primary
cheiloplasty with the patient under general anesthesia. Height and transverse
width measurements of both the cleft and the noncleft lateral lip element
were recorded to the nearest 0.5 mm. The landmarks used for measurements
are shown in Figure 1
LATERAL CEPHALOMETRIC
A NA LY S I S
All lateral cephalometric radiographs had been taken on the
same cephalostat according to standardized cephalometric
guidelines with natural head position, the teeth in occlusion, and
the lips at rest.

A total of six cephalometric landmarks were located on each

radiograph, and a resulting seven variables were measured (four
linear and three angular; Fig. 2).
 STATISTICAL ANALY SIS
All data were analyzed using the Statistical Package for Social
Sciences Version 21.0 for Windows (SPSS Inc., Chicago, IL).
Statistical significance was set at the P , .05 level.

Preoperative lip measurements and all lateral cephalometric

measurements were initially tested for normality visually based
on plots (histograms and normal Q-Q plots) as well as
statistically using the Shapiro-Wilks test.
Selected variables were measured representing the maxilla (Table 1), based on recent published
studies investigating cleft severity and maxillary growth. Variables were divided into length,
height, protrusion, and inclination.
The presence of associations between preoperative lip
measurements and lateral cephalometric measurements
was subsequently examined using linear regression
analysis.

When a significant association was found, the variables

were then incorporated in the final linear regression
model as covariates.
E R RO R O F TH E M E TH O D
A NA LY S I S

 The error of the method was calculated by performing duplicate tracings on 20

lateral cephalometric radiographs 2 to 4 weeks later by the same investigator.

 Systematic error was assessed by using one-sample t tests comparing the

duplicate lateral cephalometric tracings.

 Random error was assessed using Dahlberg’s (1940) formula (SE¼=Rd2/2n),

where n ¼ the number of patients undergoing repeated measurements and d ¼ the
difference in measurements.
Sample
RESULTS
Fifty-eight cUCLP children fit the predefined
inclusion and exclusion criteria.

The sample comprised 44 males (30 left- and 14

right-sided clefts) and 14 females (11 left- and 3
right-sided clefts).

 The overall left:right ratio was 41:17.

 PREOPERATIVE LIP MEASUREMENTS

 A total of 52 of 58 (90%) patients had a cleft lateral lip height deficiency, while 47
of 58 (81%) had a cleft lateral lip transverse width deficiency.

 Severe cleft lateral lip height deficiency (defined as .1 standard deviation

 from the mean) was seen in 11 patients.

 Severe cleft lateral lip transverse width deficiency was observed in four patients.

 A combined cleft lateral lip element deficiency (both height and transverse width)
was found in 41 of 58 (71%) patients, but a combined severe cleft lateral lip element
(.1 standard deviation for both height and width) was not found in any of the
patients
Mean height and transverse width measurements, as well as differences between
the cleft and noncleft sides, for the total study sample are shown in Table 2.
 L A TE R A L C E P H A L O M E TR I C
A NA LY S I S

The lateral cephalometric variables measured are presented in Table 3. No significant

differences were found when comparing males to females or left- to rightsided clefts.
 ASSOCIATIONS
 Bivariate analyses investigating the possible confounding determinants of facial
growth showed significant associations between the age at which the lateral cephalometric
radiograph was taken and the basal maxillary length (b coefficient¼0.282; P¼.032) as well
as alveolar maxillary length (b coefficient ¼ 0.298; P ¼ .023).

 No other significant covariates (sex, laterality, age at primary repair, surgeon’s

experience) were found.

 Correlations were observed as shown in Table 4. Children with a more deficient

preoperative cleft lateral lip height showed a shorter maxillary length, a less protruded
maxilla, and a shorter anterior maxillary height than those with a less deficient cleft lateral
lip height.
 DISCUSSION
 Children with a more deficient cleft lateral lip height and a less
deficient cleft lateral lip transverse width are more likely to
demonstrate a shorter maxillary length, a less protruded maxilla,
and a shorter anterior maxillary height.

 Seckel et al. (1995) illustrated the difficulties in measuring initial

cleft severity in this way and stated that reproducible landmark
positioning on the infant maxilla can be a reality only with optimal
cast quality and an experienced investigator
 In the present study, maxillary length was found to be partly
dependent on cleft severity as defined by preoperative cleft lip
measurements.

 From the other studies that examined maxillary length in relation

to initial cleft severity (Table 5), four were in line with our results
(Peltoma¨ ki et al., 2001; Honda et al., 2002; Liao and Mars, 2005;
Liao et al.,2010), while five did not find significant associations
(Suzuki et al., 1993; Nakamura et al., 2005; Chiu et al., 2011; Tomita
et al., 2012; Wiggman et al., 2013).
Maxillary protrusion was also found to be partly
dependent on cleft severity as defined by preoperative
cleft lip measurements in this study

With regard tomaxillary height, our study found

positive associations with cleft severity

Three studies found significant associations between

cleft severity and anterior maxillary height
 One must be aware that the different maxillary measurements that
were undertaken on the lateral cephalometric radiographs are
inherently correlated to some extent.

 Different cephalometric measurements with at least one similar

cephalometric landmark can be influenced by differences in that
specific landmark in any direction.

 The associations between initial cleft severity and maxillofacial

growth are usually attributed to an intrinsic growth potential.
 The extent of the cleft lip may affect the difficulty of surgical
repair, thereby ultimately influencing outcome via greater generation
of scar tissue or amount of surgical tissue movement.

 Tension from scar tissue arising from lip and palate repair may show
adverse effects on maxillary growth. Delestan et al. (2014) advocate
that a more detailedanalysis of the different cleft subtypes within a
cUCLP population is necessary to distinguish between the role of
treatment and the inherent growth potential
 The heterogeneity of cUCLP and its characterization by subtype or
initial cleft severity can have important clinical implications.

 Individual treatment planning based on presenting morphology could

be adopted for every cUCLP-affected child rather than conforming to
predetermined surgical treatment protocols (Reiser et al., 2010).

 Maxillary growth disturbances in cUCLP patients may be expressed in

three dimensions, and no data were available in the current study that
allowed an assessment of maxillary growth in the transverse dimension
 The choice of using Noordhoff ’s point as the proposed peak of
Cupid’s bow on the cleft lateral lip element are one could have also
used a true anatomical point instead in the hope that this may provide
a better basis for correlations.

 The finding that the cleft lateral lip height was inversely correlated
to the transverse width may have been related to the use of this point.

 All lip measurements in the present patient sample were done after
nasoalveolarmolding, which included lip taping.
The present data, however, suggest that within the spectrum
of the deformity for patients with cUCLP, the degree of lateral
lip element hypoplasia is one of the factors associatedwith the
resultingmaxillary growth potential

Children with cUCLP could be ranked by severity before

correlating specific treatment variables and outcomes, moving
away from the traditional pooling of patients (Peltoma¨ ki et al.,
2001)
 CONCLUSIONS
In patients with cUCLP, there is wide variability in the
degree of deficiency of the cleft lateral lip element in
both height and width.We have demonstrated that the
extent of lateral lip hypoplasia is one of the factors that
may be predictive of later maxillary growth deficiencies
as determined by maxillary sagittal and vertica
dimensions and maxillary position.
Thank You