Aesthetic and functional outcome of surgical and orthodontic correction of bilateral clefts of lip, palate, and alveolus.

OBJECTIVE: To assess the aesthetic and functional long-term results of surgical and orthodontic treatment of patients with bilateral cleft lip, palate, and alveolus. DESIGN: Long-term follow-up study. SETTING: Teaching hospital in Austria. PATIENTS: Twenty adult patients who had been operated on as children for bilateral cleft lip, palate, and alveolus. INTERVENTIONS: Lateral cephalometric and model analysis. The sum of all mesiodistal tooth diameters in the maxilla and mandible were compared with standard Bolton tracings. MAIN OUTCOME MEASURES: Aesthetic and functional results. RESULTS (MODEL ANALYSIS): The upper arch was too wide in 12 patients and the mandibular arch was too wide in 4 patients. In 11 patients, the lateral teeth were crowded, and all had a persistent transverse space deficit and a reduction in sagittal measurements. Fifteen patients had alveolar midline displacement of the maxilla as well as of the mandible. RESULTS (LATERAL CEPHALOMETRIC MEASUREMENTS): The lateral cephalograms showed a mean sella-nasion-A point angle of 77 degrees and a maxillary baseline-nasion-sella line angle of 9 degrees, indicating a tendency toward maxillary retrognathia. An anterior facial height index of 42% (compared with the standard 58%) indicated a slight reduction in midface height with consequent increase in the height of the lower face. CONCLUSION: There is specific growth impairment of the midface in adults who were treated as children for bilateral clefts of lip, palate, and alveolus. An optimal result can be achieved only by additional orthognathic surgery (Le Fort II osteotomy).     

Cephalometric findings in a normal Nigerian population sample and adult Nigerians with unrepaired clefts

Cephalometric values have been established for twenty adult Nigerians, three adults with unrepaired unilateral cleft lip and alveolus (UCLA) and two adults with unrepaired unilateral cleft lip and palate (UCLP). Normal values for SNA and SNB were 85.5 degrees +/- 3.5 and 82.7 degrees +/- 3.2 respectively, and the mean ANB values were 3.1 degrees +/- 0.8. The cephalometric data for unilateral cleft lip and alveolus (UCLA) subjects whose clefts were not repaired until adulthood did not differ significantly from normal controls. However, in two adults with unrepaired unilateral cleft lip and palate (UCLP), the SNA values were less than normal controls and the ANB values were reduced to negative levels. Bimaxillary protrusion of the incisors appears to be a normal feature in Nigerians. There appears to be inhibition of maxillary growth in UCLP patients but not in UCLA cases.     

Mandibular morphology and spatial position in patients with clefts: intrinsic or iatrogenic?

Lateral cephalometric films of operated (Op) and non-operated (Nop) patients with cleft lip and alveolus, cleft lip and palate or cleft palate only, were compared to determine whether the shape or position of the mandible is affected by lip and/or palate surgery. The sample included 204 adult cleft patients, Caucasians of both sexes with one of the following three cleft types: complete unilateral lip and alveolus (n = 50), complete unilateral lip and palate (n = 68), and isolated palate (n = 86). The comparison involved 113 cleft patients operated at the conventional timing and 91 cleft patients who had received no surgical or orthodontic treatment. Comparison was done in order to ascertain if the surgery performed had had any influence upon mandibular growth. The results indicated that, in all three cleft types, the surgery did not induce significant changes in the mandibular growth.     

Periodontal disease in patients with cleft palate and patients with unilateral and bilateral clefts of lip, palate, and alveolus

BACKGROUND: Long-term health of the stomatognathic system, as well as esthetics, is the therapeutic goal in patients with facial clefts. The aim of this study was to analyze the periodontal situation of patients with cleft palate (CP) and cleft lip, palate, and alveolus (CLPA) to elicit the differing degrees and localization of periodontal disease. METHODS: In 30 patients with unilateral cleft lip, palate, and alveolus (UCLPA), 30 patients with cleft palate (CP), and 20 patients with bilateral cleft lip, palate, and alveolus (BCLPA), the gingival situation was identified and classified according to the sulcus bleeding index (SBI). Periodontal attachment loss and pathological loosening of teeth were noted for identification of periodontal lesions. The state of oral hygiene was recorded by the approximal plaque index (API). RESULTS: In general, poor oral hygiene was found in all patients. The SBI showed a high incidence of gingivitis in patients with cleft lip, palate, and alveolus. Patients with cleft palate had a minor extent of sulcus bleeding. Periodontal disease was found to a similar extent to that in the general population in patients with cleft palate, whereas patients with cleft lip, palate, and alveolus had a predisposition to deep periodontal destruction of teeth adjacent to the cleft. The registration of pathological loosening of teeth, a result of attachment loss, corresponded to the degree of periodontal disease shown by the attachment loss. CONCLUSIONS: A critical periodontal situation was found in patients with unilateral and bilateral cleft lip, palate, and alveolus, ultimately leading to tooth loss in the front tooth region. In contrast, patients with cleft palate exhibited periodontal situations similar to that found in the general population with additional damage, which may be attributed to orthodontic treatment.     

Comparison of periodontal disease in patients with clefts of palate and patients with unilateral clefts of lip, palate, and alveolus.

OBJECTIVE: Long-term health of the stomatognathic system as well as esthetic aspects are the therapeutic goals in patients with orofacial clefts. The aim of this study was to analyze the periodontal condition of patients with cleft palate (CP) and cleft lip, palate, and alveolus (CLP) and to determine the differing degrees and localization of periodontal disease. DESIGN: In 30 patients with unilateral cleft lip, palate, and alveolus and 30 patients with cleft palate (CP), periodontal lesions were identified and classified according to the Community Periodontal Index of Treatment Needs (CPITN) and pathological mobility of teeth was noted. The state of oral hygiene was recorded by the Approximal Plaque Index. RESULTS: In general, poor oral hygiene was found in all patients. Patients with CLP were classified as CPITN code 0 in 0%, codes 1 and 2 in 7%, code 3 in 43%, and code 4 in 50% of cases. Patients with cleft palate showed code 0 in 0%, codes 1 and 2 in 30%, code 3 in 45%, and code 4 in 25% of cases. In this study, periodontal disease was found in patients with cleft palate to a similar extent to that in the general population, whereas patients with cleft lip, palate, and alveolus had a predisposition to deep periodontal destruction of teeth adjacent to the cleft. The registration of pathological mobility of teeth and resulting loss of attachment corresponded to the periodontal disease classification according to the CPITN. CONCLUSION: A critical periodontal situation was found in patients with unilateral cleft lip, palate, and alveolus. In contrast, patients with cleft palate exhibited a similar periodontal situation to that found in the general population, with additional damage that may be attributed to orthodontic treatment.     

Cephalometric and occlusal outcome in adults with unilateral cleft lip, palate, and alveolus after two different surgical techniques.

OBJECTIVE: To assess differences in the aesthetic and functional long-term results of one-stage and two-stage surgical and orthodontic treatment in patients with cleft lip, palate, and alveolus. DESIGN: Sixty adult patients who were operated on as children for unilateral cleft lip, palate, and alveolus were examined. In every patient the lip was closed using Tennison's technique. Thirty patients had soft and hard palate closure in two stages and 30 patients in a single stage. Lateral cephalometric and model analyses were conducted at a mean age of 18.4 years. RESULTS: In the model analysis, transverse narrowing was seen in all patients after two-stage operations and in three patients after one-stage operations. The deficit was more severe in the molar region in the two-stage group and nearly similar in the premolar and molar region in the one-stage group. A sagittal deficiency in the anterior maxilla was found in 26 patients after two-stage operations and in 16 patients after one-stage operations. In the lateral cephalometric analysis, the mean sella-nasion-point A angle in the one- and two-stage group was 78.2 degrees and 76.8 degrees, respectively. The ANB angle was normal in both groups. In both groups the inclination of the midface was low. There was a low posterior facial height. Minor scarring was seen in the single-stage group. CONCLUSION: A more severe impairment of growth of the maxilla in the sagittal and frontal plane was observed after two-stage operations on the cleft palate.     

不同的早期治疗模式对单侧完全性唇腭裂患者颌面形态的影响

目的 探讨不同的早期治疗模式对非综合征性单侧完全性唇腭裂患者(UCCLPAs)颌面形态的影响.方法 纳入47位6~7岁的非综合征性单侧完全性唇腭裂患者为病例组,将其按不同的早期治疗模式分为4组,纳入13位性别及年龄与之相当的单侧不完全性唇裂患者为对照组.通过比较反映颌面形态的8个指标来评价病例组和对照组颌面部骨性形态差异.统计采用t检验、单因素方差分析及秩和检验方法.结果 与对照组相比,12月龄前修复唇裂的UCCLPAs的骨性咽腔深度(Ba-PMP) 减小(P<0.05).与未修复腭裂的UCCLPAs相比, 12月龄前修复唇裂,24月龄前修复腭裂的UCCLPAs的面突度(SNA)减小(P<0.05),上颌骨后面高(R-PMP)减小(P<0.05).病例组间相比,3月龄前行唇粘连术,12月龄前行硬腭犁骨瓣整复术的 UCCLPAs 的上颌骨位置(S-Ptm)偏后(P<0.05).结论 当UCCLPAs 6~7岁时,3月龄前行唇粘连术,且12月龄前行硬腭犁骨瓣整复术者的患者上颌骨生长受抑制最严重.24月龄内行硬腭裂整复术者上颌骨向前的生长及后面高的生长均会受抑制.     

Prognosis of facial growth in patients with unilateral complete clefts of the lip, alveolus and palate.

AIM: Unfavourable facial growth in patients with cleft lip, alveolus, and palate may occur during puberty. Usually this development is not predictable in a young patient. The aim of the present study was to find an individual growth prediction at an early age that would allow us to decide whether later orthognathic surgery should be included in the treatment plan. MATERIAL AND METHODS: Lateral cephalograms of 41 patients with unilateral clefts of lip, alveolus and palate (uCLAP) with observation intervals of 4 years were computerized, correlations between the variables of the first and second radiograph were calculated and regression equations were established. RESULTS: The skeletal change of the intermaxillary relationship can be explained purely by the lack of midfacial growth. An individual prediction of the angle SNA over a period of 4 years is possible with a correlation coefficient of 0.95. Additional predictions for SNB, Holdaway angle and the index of anterior facial height proportions are demonstrated. CONCLUSION: The prediction procedure elaborated in this paper facilitates the decision at the age of 12 years already, whether or not orthodontic occlusal treatment has been successfully completed at an early age. The alternative is to limit orthodontic treatment to the simple alignment of the two dental arches independently of their intermaxillary relation, and then to correct the facial skeleton and the dental occlusion simultaneously by combining surgical and orthodontic treatment after the completion of growth.     

Cleft size at the time of palate repair in complete unilateral cleft lip and palate as an indicator of maxillary growth

Cleft size at the time of palate repair might affect the difficulty of surgical repair and, thus, indirectly postoperative maxillary growth. This retrospective study aimed to determine whether a correlation existed between the cleft size at the time of palate repair and the growth of the maxilla. Maxillary dental casts of 39 infants with non-syndromic complete unilateral cleft lip and palate, taken at the time of palate repair, were used to measure cleft size. Cleft size was defined as the percentage of the total palatal area. The later growth of the maxilla was determined using lateral and postero-anterior cephalometric radiographs taken at 9 years of age. The Pearson correlation analysis was used for statistical analysis. The results showed negative correlations between cleft size and the maxillary length (PMP–ANS, PMP–A) and the maxillary protrusion (S–N–ANS, SNA). These data suggest that in patients with complete unilateral cleft lip and palate there is a significant correlation between the cleft size at the time of palate repair and the maxillary length and protrusion. Patients with a large cleft at the time of palate repair have a shorter and more retrusive maxilla than those with a small cleft by the age of 9 years.     

Skeletal stability in patients with clefts after large maxillary advancements using intraoral distraction

Maxillary hypoplasia is a common outcome in patients with cleft lip and palate after surgical and orthodontic interventions, and maxillary distraction osteogenesis has become a useful procedure for patients with extensive maxillary deformities. The aim of this study was to evaluate long term (two years) stability after maxillary advancement of more than 10 mm by distraction osteogenesis in cleft patients using internal devices. We organised a retrospective study on 42 patients with cleft lip and palate using cephalometric analysis before and after maxillary distraction osteogenesis and evaluated them for 24 months. Postoperative measurements showed a marked advancement with an increase of 13.3 mm and 10.8° in the length of the maxilla (Co-A) and SNA, respectively, including a shift from Angle class III to class I in dental relations. Follow-up observations showed preservation of maxillary length with a relapse of only 6.0 % (mean (SD) 0.8 (0.7) mm) and 10% relapse in SNA angle (mean (SD)1.1 (1.4) °) one year postoperatively and a negligible regression at the two years’ follow up. This large-scale study shows stable results of skeletal advancement using distraction osteogenesis, indicating safe and reliable outcomes among patients with cleft lip and palate.     

上颌骨前牵引器与正畸联合治疗单侧唇腭裂的评价

目的:对单侧完全性唇腭裂伴上颌骨发育不足的患者,进行面罩式上颌骨前牵引加正畸治疗,探讨其对颌骨发育的影响。方法:14例患者在治疗前、上颌前牵引后及正畸治疗后分别摄X线头颅侧位定位片,通过9个测量指标数据进行治疗前后的比较分析。数据资料用SPSS10.0软件作统计学处理,治疗前后比较用t检验,以确定上颌前牵引及正畸联合治疗对上下颌骨的影响。结果:本组患者经上颌骨前牵引器牵引加后期正畸治疗,获得满意的效果。切牙覆盖达2mm,咬合关系较稳定;侧面呈直面型。SNA角增加,有高度显著性差异,P<0.001。SNB及下颌平面角SN-MP无变化,P>0.05;颌凸角的差值有显著改变(P<0.001)。结论:单侧完全性唇腭裂伴上颌骨发育不足的患者进行整形加正畸治疗,能促进上颌骨的发育,下颌骨未见显著的变化;通过上颌前牙轴倾度增大,下颌前牙轴倾度变小以及舌代偿,上颌前牙前移,覆牙合覆盖改善。这些改变反应在侧貌上,表现为上颌突度增加,上唇变丰满,凹面形变直面形,上下颌协调。     

唇裂修复术对上颌骨生长发育影响的初步探讨

目的：进一步了解唇裂修复手术对唇裂伴牙槽突裂和唇腭裂患者上颌骨生长发育影响方面的差异及其机制,方法：将84例唇裂修复术后患者分为唇裂伴牙槽突裂、唇腭裂唇裂修复组和唇腭裂均修复组,并设健康对照组,摄定位头颅线片并测量分析。结果：唇裂修复术对唇腭裂组上凳骨生长发育的影响明显大于唇裂伴牙槽突裂组,结论：唇腭裂的裂与组织缺损是导致唇裂修复影响上颌骨生长的重要原因。     

Hard palate repair timing and facial growth in unilateral cleft lip and palate: a longitudinal study.

OBJECTIVE: To investigate whether timing of hard palate repair had a significant effect on facial growth in patients with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective longitudinal study. SETTING: Sri Lankan Cleft Lip and Palate Project. PATIENTS: A total of 104 patients with nonsyndromic UCLP who had hard palate repair by age 13 years, with their 290 cephalometric radiographs taken after lip and palate repair. MAIN OUTCOME MEASURES: Clinical notes were used to record surgical treatment histories. Cephalometry was used to determine facial morphology and growth rate. RESULTS: Timing of hard palate repair had a significant effect on the length and protrusion of the alveolar maxilla (PMP-A and SNA, respectively) and the anteroposterior alveolar jaw relation (ANB) at age 20 years but not on their growth rates. CONCLUSION: Timing of hard palate repair significantly affects the growth of the maxilla in patients with UCLP. Late hard palate repair has a smaller adverse effect than does early hard palate repair on the growth of the maxilla. This timing effect primarily affects the anteroposterior development of the maxillary dentoalveolus and is attributed to the development being undisturbed before closure of the hard palate.     

Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients: Supraperiosteal flap technique versus mucoperiosteal flap technique.

BACKGROUND: The aim of this study was to evaluate and compare the maxillary dental arch shape and speech of cleft palate patients following pushback palatoplasty using either the supraperiosteal flap technique or the mucoperiosteal flap technique. PATIENTS: Sixty-two patients (29, cleft palate only; 33, unilateral cleft lip, alveolus and palate) operated on by the supraperiosteal technique and 47 patients (23, cleft palate only; 24 unilateral cleft lip, alveolus and palate) by the mucoperiosteal technique were reviewed in this study. Study design: Dental arch shape and speech proficiency at preschool and school age were evaluated in all patients. RESULTS: Dental arch shapes were classified as U type (good dental arch shape) and V type (narrow dental arch shape). In cleft palate only patients, U type was observed in 90% of the supraperiosteal group and 83% of the mucoperiosteal group. In unilateral cleft lip, alveolus and palate patients, U type was observed in 85% of the supraperiosteal group, while only in 33% of the mucoperiosteal group. In cleft palate only patients, normal speech at school age was observed 100% of the supraperiosteal group and 83% of the mucoperiosteal group. In unilateral cleft lip, alveolus and palate patients, normal speech at school age was observed in 97% of the supraperiosteal group and 75% of the mucoperiosteal group. Misarticulation was frequently found in patients with the V type of dental arch shape. CONCLUSION: It is suggested that pushback palatoplasty using the supraperiosteal technique is more advantageous for speech development compared with the mucoperiosteal technique.     

Long-term effects of palate repair on craniofacial morphology in patients with unilateral cleft lip and palate.

OBJECTIVE: To identify the long-term effects of palate repair on craniofacial growth in patients with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective cross-sectional study. SETTING: Sri Lankan Cleft Lip and Palate Project. SUBJECTS: Forty-eight adults with nonsyndromic unilateral cleft lip and palate, 29 men and 19 women, had lip repair only (LRO group). Fifty-eight adults with nonsyndromic unilateral cleft lip and palate, 35 men and 23 women, had lip and palate repairs by the age of 9 (LPR group). MAIN OUTCOME MEASURES: Clinical notes were used to record surgical treatment histories. Cephalometry was used to determine craniofacial morphology. RESULTS: In the lip and palate repair group, the depth of the bony pharynx (Ba-PMP), the maxillary length at the alveolar level (PMP-A), the effective length of the maxilla (Ar-IZ, Ar-ANS, Ar-A), the maxillary protrusion (S-N-ANS, SNA), the anteroposterior jaw relation (ANS-N-Pog, ANB), and the overjet were smaller than in the lip repair only group. There were no significant differences in the maxillary length at the basal level (PMP-IZ, PMP-ANS) and the anterior and posterior maxillary heights (N-ANS and R-PMP, respectively) in the two groups. CONCLUSION: Palate repair inhibits the forward displacement of the basal maxilla and anteroposterior development of the maxillary dentoalveolus in patients with unilateral cleft lip and palate. Palate repair has no detrimental effects on the downward displacement of the basal maxilla or on palatal remodeling in patients with unilateral cleft lip and palate.     

Hard palate repair timing and facial morphology in unilateral cleft lip and palate: Before versus after pubertal peak velocity age.

OBJECTIVE: To investigate whether timing of hard palate repair, before versus after pubertal peak velocity age, had a significant effect on facial growth in patients with unilateral cleft lip and palate. DESIGN: Retrospective cross-sectional study. Setting: Sri Lankan Cleft Lip and Palate Project. PATIENTS: A total of 125 adult patients with nonsyndromic unilateral cleft lip and palate were recruited and their last cephalometric radiographs were used. MAIN OUTCOME MEASURES: Clinical notes were used to record surgical treatment histories. Cephalometry was used to determine facial morphology. RESULTS: The patients who had hard palate repair after pubertal peak velocity age had a deeper bony pharynx (Ba-PMP), a longer alveolar maxilla (PMP-A), a longer effective length of the maxilla (Ar-ANS, Ar-A), and as a result had a more favorable anteroposterior jaw relation (ANS-N-Pog, ANB, NAPog) and larger overjet, compared with those who had hard palate repair before pubertal peak velocity age. CONCLUSION: Timing of hard palate repair significantly affects the growth of the maxilla in patients with unilateral cleft lip and palate. Hard palate repair after (versus before) pubertal peak velocity age has a smaller adverse effect on the forward growth of the maxilla. This timing affects the forward displacement of the basal maxilla and the anteroposterior development of the maxillary dentoalveolus.     

唇腭裂患者牙槽突裂植骨术前使用半固定式四眼圈簧扩大上牙弓的正畸治疗

目的探讨半固定式四眼圈簧矫治器对伴有上牙弓狭窄的唇腭裂患者的扩弓效果。方法选择15例需行牙槽突裂植骨术的唇腭裂患者,术前正畸治疗先采用半固定式四眼圈簧矫治器扩大上牙弓,测量扩弓前、中、后的上颌左右尖牙、第一前磨牙、第一磨牙间宽度的变化。结果经过半固定式四眼圈簧矫治器扩弓治疗的患者,均在5个月左右的时间内有效地扩大了上牙弓。正畸治疗后上牙弓扩大,牙齿排列基本整齐,为牙槽突裂植骨术提供了良好的条件。结论半固定式四眼圈簧矫治器可有效扩大唇腭裂患者的上牙弓,同时配合固定正畸治疗,疗效确切,使用方便。     

Oral rehabilitation of an orthodontic patient with cleft lip and palate and hypodontia using secondary bone grafting, osseo-integrated implants, and prosthetic treatment.

OBJECTIVE: Complete skeletal and dental reconstruction of the anterior maxilla is of great importance to patients with cleft lip and palate. Accordingly, osseo-integrated implants have been utilized for dental reconstruction after secondary bone grafting. In this report, the orthodontic management of a patient with unilateral cleft lip and plate with associated hypodontia is described. The patient was treated with comprehensive orthodontic treatment in addition to secondary bone grafting, and dental reconstruction was achieved with a combination of osseo-integrated implants and fixed prosthodontic treatment.     

Effects of lip repair on maxillary growth and facial soft tissue development in patients with a complete unilateral cleft of lip, alveolus and palate.

PURPOSE: To examine the relationship between lip repair and inhibition of maxillary growth, and to investigate the characteristics of upper lip in patients with complete unilateral clefts of lip, alveolus and palate. MATERIAL AND METHODS: Lateral cephalometric radiographs and photographs (anterior-posterior and profile) were taken for 3 groups of patients: (1) 35 complete unilateral cleft lip, alveolus and palate cases in whom only a labioplasty was performed as infants; (2) 47 cases who had both lip and palate repaired; and (3) 37 non-cleft peers as controls. RESULTS: There was maxillary retrusion in groups (1) and (2). Surface area and height of the upper lip was reduced in both these groups when compared with the normal controls. CONCLUSION: Lip repair is a most important factor in the restraint of maxillary growth in patients with complete unilateral clefts of lip, alveolus and palate. And height and projection of the upper lip are reduced following lip repair.     

Vomer flap for hard palate repair is related to favorable maxillary growth in unilateral cleft lip and palate

Objective

Vomer flap repair is assumed to improve maxillary growth because of reduced scarring in growth-sensitive areas of the palate. Our aim was to evaluate whether facial growth in patients with unilateral cleft lip and palate was significantly affected by the technique of hard palate repair (vomer flap versus two-flap).

Materials and methods

For this retrospective longitudinal study, we analyzed 334 cephalometric radiographs from 95 patients with nonsyndromic complete unilateral cleft lip and palate who underwent hard palate repair by two different techniques (vomer flap versus two-flap). Clinical notes were reviewed to record treatment histories. Cephalometry was used to determine facial morphology and growth rate. The associations among facial morphology at age 20, facial growth rate, and technique of hard palate repair were assessed using generalized estimating equation analysis.

Results

The hard palate repair technique significantly influenced protrusion of the maxilla (SNA: β?=??3.5°, 95 % CI?=??5.2-1.7; p?=?0.001) and the anteroposterior jaw relation (ANB: β?=??4.2°, 95 % CI?=??6.4-1.9; p?=?0.001; Wits: β?=??5.7 mm, 95 % CI?=??9.6-1.2; p?=?0.01) at age 20, and their growth rates (SNA p?=?0.001, ANB p?<?0.01, and Wits p?=?0.02).

Conclusions

The results suggest that in patients with unilateral cleft lip and palate, vomer flap repair has a smaller adverse effect than two-flap on growth of the maxilla. This effect on maxillary growth is on the anteroposterior development of the alveolar maxilla and is progressive with age. We now perform hard palate closure with vomer flap followed by soft palate closure using Furlow palatoplasty.

Clinical relevance

These findings may improve treatment outcome by modifying the treatment protocol for patients with unilateral cleft lip and palate.