Journal of Cranio-Maxillo-Facial Surgery (1992"1 20, l I 1 118
Influence of surgery on maxillary growth in cleft lip and/or palate patients Antonio David CorrEa Normando, Omar Gabriel da Silva Filho, Leopoldino Capelozza Filho
Department of Orthodontics (Head: Prof. L. Capelozza Filho, DDS, MDS), Hospital de Pesquisa e Reabilitaf8o de Lesges Ldbio-Palatais, University of SSo Paulo, Bauru, Brazil
S U M M A R Y . Using a sample of 204 caucasian adults of both sexes, with complete unilateral cleft lip and alveolus, isolated cleft palate and complete unilateral cleft lip, alveolus and palate, the influence of surgery on maxillary morphology and spatial position for the three main types of cleft lip and/or palate were evaluated. 113 cleft patients operated on at conventional timings were compared to 91 cleft patients who had never been operated on. Findings permit the conclusion that cheiloplasty in cleft lip and alveolus patients is associated with osseous remodelling in the anterior alveolar region, without significant changes in anterior nasal spine or other areas of the maxilla. In isolated cleft palate subjects palate repair does not promote significant changes in maxillary morphology and spatial position. The most evident effects were seen in the cleft lip, alveolus and palate group: reconstructive surgery in these patients leads to a severe maxillary retroposition associated with a downward rotation.
KEY WORDS: Maxillary growth - Cephalometrics - Cleft lip and/or palate - Cheiloplasty - Palatoplasty
INTRODUCTION AND LITERATURE REVIEW
inherent to cleft type (Silva Filho et al., 1991). Regarding surgical effects on the maxillary pattern in cleft lip and alveolus patients, cheiloplasty induces some changes only in the anterior region of the maxilla, causing a repositioning of ANS and A points (Silva Filho et al., 1989a); while in isolated cleft palate, the effects of palatoplasty are considered insignificant (Bishara, 1973; Silva Filho et al., 1989b) or minimal (Dahl, 1970). The literature is very conflicting regarding maxillary surgical effects in cleft lip and palate patients. Although reports in the literature indicated a smaller and backward maxilla in cleft lip and palate in patients operated on conventionally, when compared to non-cleft individuals (Dahl, 1970; Ross, 1970; Krogman et al., 1975 ; Hayashi et al., 1976; Bishara et al., 1979; Smahel and Brejcha, 1983; Miyahara and Capelozza Filho, 1985; Capelozza Filho et al., 1987; Ross, 1987b), much has been discussed about the real surgical effects on the midfacial growth, especially on the isolated effects of each type of surgical intervention on the lip or palate. The divergence in the literature reports is mainly due to the difficulties in obtaining a homogeneous and large unoperated sample. Recently, Mars and Houston (1990) quantified the inhibiting effect that surgical repair has on maxillary antero-posterior growth in cleft lip and palate subjects. However, any evaluation had been done in respect of the vertical changes on maxillary growth produced by surgery. Comparison between adult cleft patients who had not undergone any surgical treatment with adult patients operated on at conventional timings, but without previous orthodontic treatment, allowed us to determine the isolated influence of lip and palate surgery on facial morphology in different cleft types during craniofacial development. In this study we attempted to evaluate the effect of lip and palate surgery on mid face growth.
Our daily work with cleft patients encourages us to clarify to what extent reconstructive surgery interferes with facial morphology during growth. One method to enable confident conclusions to be drawn on this issue would be a comparison between the facial patterns of a homogeneous adult cleft patient group that has never been operated on and the facial patterns of cleft patients operated on during infancy. Despite a great number of papers concerning facial growth in cleft patients, there are few studies that confront long term facial patterns of patients having been operated on compared with similar clefts not having been operated on. The studies available present some limitations related to the samples not having been operated on, such as: large range of age studied, including children and adults (Hagerty and Hill, 1963; Bishara, 1973); small sample size (Hagerty and Hill, 1963; Dahl, 1970; Bishara, 1973), different degrees of cleft severity (Dahl, 1970; Smahel and Mullerova, 1986); samples of different origins (Ross, 1987b); mixture of patients with and without operations (Hagerty and Hill, 1963; Dahl, 1970; Ross, 1987b) or with individuals only recently operated on (Silva Filho et al., 1989a), besides the association of other therapies with the surgical intervention, such as the u,;e of palatal obturators (Hagerty and Hill, 1963; Dahl, 1970; Bishara, 1973; Ross, 1987b) and the use of racial groups with facial patterns different from caucasians (Hagerty and Hill, 1963; Mars and Houston, 1!990). These limitations show the difficulties of research in this field. Concerning the surgical effects on facial growth, a previous paper (Silva Filho et al., 1990) showed an absence of significant mandibular changes as a consequence of surgical procedures, confirming that mandibular morphology and spatial position are 111
112
Journal of Cranio-Maxillo-Facial Surgery
Table 1 - Distribution of the sample according to the type of cleft, sex and previous surgical treatment
Type of cleft
Treatment received Operated on (Op) Not operated on (Nop) Total
Sex Male Female Total Male Female Total
Complete unilateral cleft lip and alveolus 17 13 30 11 9 20 50
MATERIAL AND METHODS Material
The sample is described in Table 1. Lateral cephalometric radiographs of 204 adult cleft lip and/or palate
Isolated cleft palate
Complete unilateral cleft lip, alveolus and palate
Total
12 31 43 19 24 43 86
17 23 40 11 17 28 68
46 67 113 41 50 91 204
patients (Figs 1, 2 and 3) with no other associated malformation were selected from case records. All individuals were patients regularly enrolled at the Hospital de Pesquisa e Reabilita~o des Les6es L~ibio-Palatais (HPRLLP), University of S~o Paulo
Fig. 1 - (A) Adult male patient not operated on, (B) complete cleft lip and alveolus, (C) adult male patient operated on, (D) complete cleft lip and alveolus.
Influence of surgery on maxillarygrowth in cleft lip and/or palate patients 113
Fig. 2 - (A) Adult male patient not operated on, (B) isolated cleft palate, (C) adult male patient operated on, (D) isolated cleft palate.
(USP), Bauru, Brazil. Only a few cases have had primary surgery at H P R L L P - U S P . Caucasian patients with a permanent dentition were carefully selected. The minimum age used was 15 years for males and 14 years for females, with means of 19.5 years for males and 19.2 years for females. This sample is the same as that described in a previous paper (Silva Filho et al., 1990) where surgical effects on mandibular morphology and spatial position were evaluated. The evaluation of surgical effects on the maxillary pattern was analyzed separately for each cleft type according to treatment, divided into two groups: operated on (Op) and not operated on (Nop) individuals. The group not operated on comprised those adult patients who sought treatment at H P R L L P - U S P and have never been subjected to any therapy. The group operated on consisted of patients with cleft lip repair at no more than 3 years of age and palate repair up to 5 years of age. Those cases having had multiple operations and orthodontic treatment were not included. Surgical technique, functional
results and the place where the surgery was performed were not taken into consideration. Studies have shown that the surgical technique employed is not an important variable (Ross, 1987a, 1987b). Table 2 shows mean ages at operation and radiography for the different cleft types. Comparisons between groups operated on and not operated on were done separately for each cleft type by Student's t-test. Thus, the complete unilateral cleft lip and alveolus group had 50 patients: 20 not operated on (Fig. 1A) and 30 operated on (Fig. 1B). In the isolated cleft palate group, 43 patients were operated on (Fig. 2A) and 43 were not operated on (Fig. 2B). Clefts involving only the uvula were not included and only a few cases of soft palate clefts were evaluated. The sample of complete unilateral cleft lip and palate patients included 68, of whom 28 were not operated on (Fig. 3). In all cleft types the number of male and female patients were similar in each group. Methods Cephalometry was the method used to define maxil-
114 Journal of Cranio-Maxillo-Facial Surgery
Fig. 3 - (A) Adult female patient not operated on, (B) complete unilateral cleft lip, alveolus and palate, (C) adult female patient operated on, (D) complete unilateral cleft lip, alveolus and palate. Table 2 - Average age at surgery (months) and cephalometric radiograph (years -both groups) Type of cleft Complete unilateral cleft lip and alveolus Age at surgery (months) Range Age at cephalometry radiograph X (years) Range
Isolated cleft plate 21 (6-58)
7 (1-23) Op 19.6 (14.7-35.9)
Nop 18.8 (14.1-34.4)
Op Nop 19.3 19.9 (14.6--27.7) (14.6-36.2)
lary morphology and spatial position, using lateral head films obtained by conventional methods. Using the cephalometrics points: S (sella); N (nasion); ANS (anterior nasal spine); A (A point); P t m ' (posterior nasal spine) and Co (condylion), angular and linear measurements were obtained, permitting a morphological evaluation of maxilla (Co-A, A N S - P t m ' ) and its spatial position in relation
Complete unilateral cleft lip, alveolus and palate (lip) 7 (1-22)
(palate) 20 (5-55)
Op 19.8 (14.1-35.4)
Nop 19.9 (14.2-36.1)
to the anterior cranial base (SNA, S N . A N S , SN. P t m ' A N S , S N - A N S , S N - P t m ' , N - A N S ) (Fig. 4).
RESULTS Means, standard-deviation, and Student's t-test values among cephalometric measurements analyzed for the
Influence of surgery o n maxillary growth in cleft lip and/or palate patients
115
d i f f e r e n t cleft t y p e e x a m i n e d a r e s h o w n i n T a b l e 3 a n d F i g u r e 5 f o r u n i l a t e r a l c l e f t lip a n d a l v e o l u s , T a b l e 4 and Figure 6 for isolated cleft palate, and Table 5 and F i g u r e 7 f o r u n i l a t e r a l c l e f t lip, a l v e o l u s a n d p a l a t e .
~.. 4~ 9 ~ ....-.8 tm
DISCUSSION
5
~'N " " ' - - .
~
Ans
/ Fig. 4 - Tracing with cephalometric points, angles and dimensions used: (1) S-N, (2) N-ANS, (3) SN-ANS, (4) SN-Ptm', (5) Ptm'-ANS, (6) Co-A, (7) SN. ANS, (8) SNA, (9) SN. Ptm'ANS.
Several studies have attempted to define the isolated i n f l u e n c e o f s u r g e r y o n c r a n i o f a c i a l g r o w t h i n c l e f t lip a n d / o r p a l a t e p a t i e n t s . A scientific m e t h o d t o s o l v e this problem would be the direct comparison between cleft s u b j e c t s o p e r a t e d o n a n d n o t o p e r a t e d o n . H o w e v e r , s e v e r a l difficulties i n o b t a i n i n g a h o m o g e n e o u s l a r g e s a m p l e o f a d u l t cleft i n d i v i d u a l s n o t operated on have made confident conclusions im-
Table 3 Mean, standard-deviation (S.D.), difference of means, and Student's t-test for measurements of complete unilateral deft lip and alveolus group
S-N Co--A Ptm'-ANS N-ANS SN-ANS SN-Ptm' SNA SN.ANS SN.Ptm'ANS
No operation (n = 20) Mean S.D.
Operation (n = 30) Mean S.D.
Difference No-Op
t-Values D.F. = 48 t = 2.01
71.63 94.29 56.34 51.16 51.13 45.04 87.85 90.17 6.16
72.05 92.64 59.64 52.62 52.50 45.84 83.68 88.41 6.28
-0.42 1.65 0.60 1.46 --1.37 -0.80 4.17 1.76 -0.12
0.35 0.94 0.48 1.05 0.98 0.69 3.60* 1.49 0.88
4.03 5.63 3.88 4.87 4.88 4.02 3.11 3.29 4.14
4.18 6.32 4.49 4.74 4.80 3.91 4.50 4.53 5.04
* P < 0.05
Table 4
Mean, standard-deviation (S.D.), difference of means, and Student's t-test for measurements of isolated cleft palate group
SN Co-A Ptm'-ANS N-ANS SN-ANS SN-Ptm' SNA SN.ANS SN.Ptm'ANS
No operation (n = 43) Mean S.D.
Operation (n = 43) Mean S.D.
Difference No-Op
t-Values D.F. = 84 t = 1.99
70.30 86.16 53.24 53.87 53.72 43.68 80.00 86.97 10.88
70.98 85.81 53.04 53.57 53.31 43.56 78.80 85.51 10.68
-0.68 0.35 0.20 0.30 0.41 0.12 1.20 1.46 0.20
0.86 0.25 0.21 0.34 0.47 0.14 1.48 1.62 0.23
3.54 6.44 3.99 3.92 3.96 3.67 3.98 3.87 4.13
3.72 6.11 4.74 4.03 4.08 3.86 3.52 4.42 3.65
* P < 0.05 Table 5 - Mean, standard-deviation (S.D.), difference of means, and Student's t-test for measurements of complete unilateral cleft lip, alveolus and palate group
S-N Co-A Ptm'-ANS N-ANS SN ANS SN Ptm' SNA SN.ANS SN.Ptm'ANS * P < 0.05
No operation (n = 28) Mean S.D.
Operation (n = 40) Mean S.D.
Difference No-Op
t-Values D.F. = 66 t = 2.00
70.02 88.71 56.31 49.63 49.25 43.09 85.06 90.86 6.27
71.75 84.99 55.05 53.43 53.02 43.40 76.94 84.55 10.15
- 1.73 3.72 1.26 - 3.80 -3.77 -0.31 8.12 6.31 3.88
1.76 1.84 0.87 3.74* 3.88* 0.31 6.38* 4.14" 3.81"
3.81 7.63 7.11 3.89 3.59 4.14 6.19 7.40 3.97
4.09 8.57 4.75 4.27 4.17 3.88 4.30 5.16 4.24
116 Journalof Cranio-Maxillo-FacialSurgery
J
A/
k
L
Fig. 5 - Superimposition on SN with the average values of the
maxillarymorphologyand spatial position of the groups operated on (----) and not operated on ( ), for complete unilateral cleft lip and alveolus.
) L
L
Fig. 6 - Superimposition on SN with the average values of the
maxillarymorphologyand spatial position of the groups operated on (----) and not operated on ( ), for isolated cleft palate.
Fig. 7 - Superimpositionon SN with the average values of the maxillarymorphologyand spatial position of the operation (----) and no operation groups ( ), for complete unilateral cleft lip, alveolus and palate.
changes in the alveolar region, caused by labial pressure created by surgical closure of the lip (Bardach and Eisbach, 1977). The findings obtained in this study show that lip pressur e is able to change only the alveolar region, because the ANS point did not change significantly in relation to the cranial base (Fig. 5). These findings confirm those of a previous paper (Silva Filho et al., 1989a) and allow us to conclude that, in unilateral complete cleft lip and alveolus, cheiloplasty performed in the early months of age induces some favourable clinical changes in the anterior alveolar region of maxilla, but does not change other areas of the craniofacial complex (Fig. 1B). The findings of the present study do not corroborate the results obtained from experimental research (Eisbach et al., 1978; Bardach and Mooney, 1984) that reported great changes in facial growth as a conseqdence of lip repair in animals where cleft lip and palate were surgically produced. However the differences concerning cleft type should be examined. Isolated Cleft P a l a t e
possible (see Introduction). The sample used in the present study was selected carefully and produces significant and confident data regarding surgical influence upon mid face growth in the three main cleft types. C o m p l e t e U n i l a t e r a l Cleft Lip and Alveolus
Comparing means between groups operated on and not operated on, only the SNA angle was different between the two groups, with this angle significantly smaller in the group operated on. This may prove
According to Dahl (1970), comparing 16 patients with isolated cleft palate not operated on who used palatal obturators versus 41 patients operated on, palatoplasty remodelled the facial pattern, reducing the mandibular downward rotation with a consequent decrease in anterior facial height. Nevertheless, previous study data (Silva Filho et al., 1990) do not support this optimism related to vertical changes induced by palatoplasty. One can verify in Table 4 and Figure 6 that surgical intervention did not result in any maxillary dimensional or spatial changes. None of the cephalometric values (dimensions or angles) showed a statistically significant difference between
Influence of surgery on maxillary growth in cleft lip and/or palate patients 117 groups with and without operation, repeating for the maxilla, the previous findings obtained for the mandible (Silva Filho et al., 1990). Bishara (1973) and Silva Filho et al. (1989b) also show the absence of significant differences in the cephalometric pattern of patients operated on early compared with those not operated on, confirming that the changes observed in comparison with non cleft subjects are part of the craniofacial morphological characteristics of cleft palate patients. Therefore, with regard to facial growth, palatoplasty, at least in the isolated cleft palate, can be done as early as the age of 2 years and may benefit the patient functionally, without causing significant disturbance of craniofacial morphology.
is associated with a remodelling in the maxillary anterior alveolar region causing a significant retrusion of point A, without changes in other areas of the maxilla. Palate repair in isolated cleft palate patients is not associated with significant changes in maxillary dimensions and spatial position. The most evident surgical sequels occurred in the cleft lip, alveolus and palate patients verifying an accentuated maxillary retrusion associated with a downward rotation with the centre of rotation near the posterior nasal spine.
References Bardach, J., K. J. Eisbach : The influence of primary unilateral cleft lip repair on facial growth: 1. Lip pressure. Cleft Palate J.
Unilateral Complete Cleft Lip, Alveolus and Palate
14 (1977) 88 Bardach, J., M. P. Mooney ." The relationship between lip
At variance with previous maxillary superimpositions, Figure 7 shows a severe retrusion of the maxilla associated with a significant clockwise rotation. These changes are confirmed by statistical analysis between groups operated and not operated on (Table 5). Antero-posteriorly the findings show a significant reduction of 8.12 ° in SNA angle, confirmed by the decrease of 6.31 ° in SN. ANS angle, as a consequence of the surgical effects. Severe reduction in these angles reveals the disturbance that the surgical procedures cause in the anterior midface displacement. Thus, it confirms the clinical aspect seen regularly in cleft lip and palate patients operated on at conventional timings (Fig. 3B) and according to the current concepts in the literature, that show a retrusion of the maxilla in relation to the cranial base in patients operated on when compared to non-cleft subjects (Dahl, 1970; Ross, 1970; K r o g m a n et al., 1975; H a y a s h i et al., 1976; Bishara et al., 1979; S m a h e l and Brejcha, 1983 ; M i y a h a r a and C a p e l o z z a Filho, 1985; C a p e l o z z a Filho et al., 1987; Ross, 1987b) and compared with clefts not operated on ( M a r s and H o u s t o n , 1990). Regarding vertical relationships, surgery caused a maxillary downward inclination of 3.88 ° , with the centre of rotation near the posterior nasal spine (Ptm'). Maxillary rotation caused an increase in anterior midface height ( N - A N S , S N - A N S ) of almost 4 r a m , without changing the posterior maxillary height (SN-Ptm'). This rotating effect, associated with surgery, improved the vertical facial growth, however, it has an influence on maxillary anterior displacement because of the backward spatial repositioning.
pressure following lip repair and craniofacial growth: an experimental study in Beagles. Plast. Reconstr. Surg. 73 (1984) 554 Bishara, S. E. : Cephalometric evaluation of facial growth in operated and non-operated individuals with isolated clefts of the palate. Cleft Palate J. 10 (1973) 239 Bishara, S. E., D. L. Sierk, K. S. Huang : A longitudinal study on unilateral cleft lip and palate subjects. Cleft Palate J. 16 (1979) 59
CONCLUSIONS
Silva Filho, O. G. da, A. de O. Cavassan, .4. D. C. Normando : Influ~ncia da palatoplastia no padr~o facial de pacientes
This comparative study of facial pattern between adults having clefts operated and not operated on involving the three main cleft types, lead us to the conclusion that reconstructive surgery, performed during infancy, produces different maxillary changes for each cleft type. Lip repair in unilateral cleft lip and alveolus patients
Capelozza Filho, L., A. de O. Cavassan, O. G. da Silva Filho :
Avaliaq~o do crescimento craniofacial em portadores de fissuras transforame incisivo unilateral: estudo transversal. Rev. Bras. Cirurg. 77 (1987) 97 Dahl, E. : Craniofacial morphology in congenital clefts of the lip and palate. Acta Odont. Scand. 28 (Suppl. 57) (1970) 1 Eisbach, K. J., J. Bardach, E. C. Klausner : The influence of primary cleft lip repair on facial growth: Part II. Direct cephalometric of the skull. Cleft Palate J. 15 (1978) 109 Hagerty, R. F., M. J. Hill: Facial growth and dentition in the unoperated cleft palate. J. Dent. Res. 42 (1963) 412 Hayashi, L, M. Sakuda, K. Takirnoto, T. Miyazaki : Craniofacial growth in complete unilateral cleft lip and palate: a roentgenocephalometric study. Cleft Palate J. 13 (1976) 215 Krogman, IV. M., M. Mazaheri, R. L. Harding et al. : A
longitudinal study of the craniofacial growth pattern in children with clefts as compared to normal, birth to six years. Cleft Palate J. 12 (1975) 59 Mars, M., W. J. B. Houston: A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J. 27 (1990) 7 Miyahara, M., L. Capelozza Filho : Caracterx'sticascefalom&ricas da face no flssurado unilateral adulto. Ortodontia 18 (I985) 5 Ross, R. B. : The clinical implications of facial growth in cleft lip and palate. Cleft Palate J. 7 (1970) 37 Ross, R. B. : Treatment variables affecting facial growth in cleft lip and palate: Part 4. Repair of the cleft lip. Cleft Palate J. 24 (1987a) 45 Ross, R. B. : Treatment variables affecting facial growth in unilateral cleft lip and palate: Part 6. Techniques of palate repair. Cleft Palate J. 24 (1987b) 64 Silva Filho, O. G. da, R. Rocha, L. Capelozza Filho : Padr~o facial do pacien te portador de fissura pr~-forame incisivo unilateral completa. Rev. Bras. Cirurg. 79 (1989a) 197 portadores de fissura prs-forame incisivo. Rev. Bras. Cirurg. 79 (1989b) 315 Silva Filho, O. G. da, A. D. C. Normando, L. Capelozza Filho :
Mandibular morphology and spatial position in cleft lip and/or palate patients: intrinsic pattern or influenced by surgical procedures? Cleft Palate J. (1992) (Accepted for publication) Silva Filho, O. G. da, A. D. C. Normando, L. Capelozza Filho."
Mandibular growth in clef~lip and/or palate patients: the
118
Journal of Cranio-Maxillo-Facial Surgery
influence of cleft type. Amer. J. Orthodont. Dentofacial Orthop. (1992) (Accepted for publication) Smahel, Z., M. Brejcha: Differences in craniofacial morphology between complete and incomplete unilateral cleft lip and palate in adults. Cleft Palate J. 20 (1983) 113 Smahel, Z., Z. Mullerova : Craniofacial morphology in unilateral cleft lip and palate prior to palatoplasty. Cleft Palate J. 23 (1986) 225
Professor L. Capelozza Filho, DDS, MDS Rua Silvio Marchione 3-20-Cx. Postal 620 CEP: 17.043-Bauru/SP Brazil Paper received 19 June 1991 Accepted 8 November 1991
Influence of surgery on maxillary growth in cleft lip and/or palate patients Antonio David CorrEa Normando, Omar Gabriel da Silva Filho, Leopoldino Capelozza Filho
Department of Orthodontics (Head: Prof. L. Capelozza Filho, DDS, MDS), Hospital de Pesquisa e Reabilitaf8o de Lesges Ldbio-Palatais, University of SSo Paulo, Bauru, Brazil
S U M M A R Y . Using a sample of 204 caucasian adults of both sexes, with complete unilateral cleft lip and alveolus, isolated cleft palate and complete unilateral cleft lip, alveolus and palate, the influence of surgery on maxillary morphology and spatial position for the three main types of cleft lip and/or palate were evaluated. 113 cleft patients operated on at conventional timings were compared to 91 cleft patients who had never been operated on. Findings permit the conclusion that cheiloplasty in cleft lip and alveolus patients is associated with osseous remodelling in the anterior alveolar region, without significant changes in anterior nasal spine or other areas of the maxilla. In isolated cleft palate subjects palate repair does not promote significant changes in maxillary morphology and spatial position. The most evident effects were seen in the cleft lip, alveolus and palate group: reconstructive surgery in these patients leads to a severe maxillary retroposition associated with a downward rotation.
KEY WORDS: Maxillary growth - Cephalometrics - Cleft lip and/or palate - Cheiloplasty - Palatoplasty
INTRODUCTION AND LITERATURE REVIEW
inherent to cleft type (Silva Filho et al., 1991). Regarding surgical effects on the maxillary pattern in cleft lip and alveolus patients, cheiloplasty induces some changes only in the anterior region of the maxilla, causing a repositioning of ANS and A points (Silva Filho et al., 1989a); while in isolated cleft palate, the effects of palatoplasty are considered insignificant (Bishara, 1973; Silva Filho et al., 1989b) or minimal (Dahl, 1970). The literature is very conflicting regarding maxillary surgical effects in cleft lip and palate patients. Although reports in the literature indicated a smaller and backward maxilla in cleft lip and palate in patients operated on conventionally, when compared to non-cleft individuals (Dahl, 1970; Ross, 1970; Krogman et al., 1975 ; Hayashi et al., 1976; Bishara et al., 1979; Smahel and Brejcha, 1983; Miyahara and Capelozza Filho, 1985; Capelozza Filho et al., 1987; Ross, 1987b), much has been discussed about the real surgical effects on the midfacial growth, especially on the isolated effects of each type of surgical intervention on the lip or palate. The divergence in the literature reports is mainly due to the difficulties in obtaining a homogeneous and large unoperated sample. Recently, Mars and Houston (1990) quantified the inhibiting effect that surgical repair has on maxillary antero-posterior growth in cleft lip and palate subjects. However, any evaluation had been done in respect of the vertical changes on maxillary growth produced by surgery. Comparison between adult cleft patients who had not undergone any surgical treatment with adult patients operated on at conventional timings, but without previous orthodontic treatment, allowed us to determine the isolated influence of lip and palate surgery on facial morphology in different cleft types during craniofacial development. In this study we attempted to evaluate the effect of lip and palate surgery on mid face growth.
Our daily work with cleft patients encourages us to clarify to what extent reconstructive surgery interferes with facial morphology during growth. One method to enable confident conclusions to be drawn on this issue would be a comparison between the facial patterns of a homogeneous adult cleft patient group that has never been operated on and the facial patterns of cleft patients operated on during infancy. Despite a great number of papers concerning facial growth in cleft patients, there are few studies that confront long term facial patterns of patients having been operated on compared with similar clefts not having been operated on. The studies available present some limitations related to the samples not having been operated on, such as: large range of age studied, including children and adults (Hagerty and Hill, 1963; Bishara, 1973); small sample size (Hagerty and Hill, 1963; Dahl, 1970; Bishara, 1973), different degrees of cleft severity (Dahl, 1970; Smahel and Mullerova, 1986); samples of different origins (Ross, 1987b); mixture of patients with and without operations (Hagerty and Hill, 1963; Dahl, 1970; Ross, 1987b) or with individuals only recently operated on (Silva Filho et al., 1989a), besides the association of other therapies with the surgical intervention, such as the u,;e of palatal obturators (Hagerty and Hill, 1963; Dahl, 1970; Bishara, 1973; Ross, 1987b) and the use of racial groups with facial patterns different from caucasians (Hagerty and Hill, 1963; Mars and Houston, 1!990). These limitations show the difficulties of research in this field. Concerning the surgical effects on facial growth, a previous paper (Silva Filho et al., 1990) showed an absence of significant mandibular changes as a consequence of surgical procedures, confirming that mandibular morphology and spatial position are 111
112
Journal of Cranio-Maxillo-Facial Surgery
Table 1 - Distribution of the sample according to the type of cleft, sex and previous surgical treatment
Type of cleft
Treatment received Operated on (Op) Not operated on (Nop) Total
Sex Male Female Total Male Female Total
Complete unilateral cleft lip and alveolus 17 13 30 11 9 20 50
MATERIAL AND METHODS Material
The sample is described in Table 1. Lateral cephalometric radiographs of 204 adult cleft lip and/or palate
Isolated cleft palate
Complete unilateral cleft lip, alveolus and palate
Total
12 31 43 19 24 43 86
17 23 40 11 17 28 68
46 67 113 41 50 91 204
patients (Figs 1, 2 and 3) with no other associated malformation were selected from case records. All individuals were patients regularly enrolled at the Hospital de Pesquisa e Reabilita~o des Les6es L~ibio-Palatais (HPRLLP), University of S~o Paulo
Fig. 1 - (A) Adult male patient not operated on, (B) complete cleft lip and alveolus, (C) adult male patient operated on, (D) complete cleft lip and alveolus.
Influence of surgery on maxillarygrowth in cleft lip and/or palate patients 113
Fig. 2 - (A) Adult male patient not operated on, (B) isolated cleft palate, (C) adult male patient operated on, (D) isolated cleft palate.
(USP), Bauru, Brazil. Only a few cases have had primary surgery at H P R L L P - U S P . Caucasian patients with a permanent dentition were carefully selected. The minimum age used was 15 years for males and 14 years for females, with means of 19.5 years for males and 19.2 years for females. This sample is the same as that described in a previous paper (Silva Filho et al., 1990) where surgical effects on mandibular morphology and spatial position were evaluated. The evaluation of surgical effects on the maxillary pattern was analyzed separately for each cleft type according to treatment, divided into two groups: operated on (Op) and not operated on (Nop) individuals. The group not operated on comprised those adult patients who sought treatment at H P R L L P - U S P and have never been subjected to any therapy. The group operated on consisted of patients with cleft lip repair at no more than 3 years of age and palate repair up to 5 years of age. Those cases having had multiple operations and orthodontic treatment were not included. Surgical technique, functional
results and the place where the surgery was performed were not taken into consideration. Studies have shown that the surgical technique employed is not an important variable (Ross, 1987a, 1987b). Table 2 shows mean ages at operation and radiography for the different cleft types. Comparisons between groups operated on and not operated on were done separately for each cleft type by Student's t-test. Thus, the complete unilateral cleft lip and alveolus group had 50 patients: 20 not operated on (Fig. 1A) and 30 operated on (Fig. 1B). In the isolated cleft palate group, 43 patients were operated on (Fig. 2A) and 43 were not operated on (Fig. 2B). Clefts involving only the uvula were not included and only a few cases of soft palate clefts were evaluated. The sample of complete unilateral cleft lip and palate patients included 68, of whom 28 were not operated on (Fig. 3). In all cleft types the number of male and female patients were similar in each group. Methods Cephalometry was the method used to define maxil-
114 Journal of Cranio-Maxillo-Facial Surgery
Fig. 3 - (A) Adult female patient not operated on, (B) complete unilateral cleft lip, alveolus and palate, (C) adult female patient operated on, (D) complete unilateral cleft lip, alveolus and palate. Table 2 - Average age at surgery (months) and cephalometric radiograph (years -both groups) Type of cleft Complete unilateral cleft lip and alveolus Age at surgery (months) Range Age at cephalometry radiograph X (years) Range
Isolated cleft plate 21 (6-58)
7 (1-23) Op 19.6 (14.7-35.9)
Nop 18.8 (14.1-34.4)
Op Nop 19.3 19.9 (14.6--27.7) (14.6-36.2)
lary morphology and spatial position, using lateral head films obtained by conventional methods. Using the cephalometrics points: S (sella); N (nasion); ANS (anterior nasal spine); A (A point); P t m ' (posterior nasal spine) and Co (condylion), angular and linear measurements were obtained, permitting a morphological evaluation of maxilla (Co-A, A N S - P t m ' ) and its spatial position in relation
Complete unilateral cleft lip, alveolus and palate (lip) 7 (1-22)
(palate) 20 (5-55)
Op 19.8 (14.1-35.4)
Nop 19.9 (14.2-36.1)
to the anterior cranial base (SNA, S N . A N S , SN. P t m ' A N S , S N - A N S , S N - P t m ' , N - A N S ) (Fig. 4).
RESULTS Means, standard-deviation, and Student's t-test values among cephalometric measurements analyzed for the
Influence of surgery o n maxillary growth in cleft lip and/or palate patients
115
d i f f e r e n t cleft t y p e e x a m i n e d a r e s h o w n i n T a b l e 3 a n d F i g u r e 5 f o r u n i l a t e r a l c l e f t lip a n d a l v e o l u s , T a b l e 4 and Figure 6 for isolated cleft palate, and Table 5 and F i g u r e 7 f o r u n i l a t e r a l c l e f t lip, a l v e o l u s a n d p a l a t e .
~.. 4~ 9 ~ ....-.8 tm
DISCUSSION
5
~'N " " ' - - .
~
Ans
/ Fig. 4 - Tracing with cephalometric points, angles and dimensions used: (1) S-N, (2) N-ANS, (3) SN-ANS, (4) SN-Ptm', (5) Ptm'-ANS, (6) Co-A, (7) SN. ANS, (8) SNA, (9) SN. Ptm'ANS.
Several studies have attempted to define the isolated i n f l u e n c e o f s u r g e r y o n c r a n i o f a c i a l g r o w t h i n c l e f t lip a n d / o r p a l a t e p a t i e n t s . A scientific m e t h o d t o s o l v e this problem would be the direct comparison between cleft s u b j e c t s o p e r a t e d o n a n d n o t o p e r a t e d o n . H o w e v e r , s e v e r a l difficulties i n o b t a i n i n g a h o m o g e n e o u s l a r g e s a m p l e o f a d u l t cleft i n d i v i d u a l s n o t operated on have made confident conclusions im-
Table 3 Mean, standard-deviation (S.D.), difference of means, and Student's t-test for measurements of complete unilateral deft lip and alveolus group
S-N Co--A Ptm'-ANS N-ANS SN-ANS SN-Ptm' SNA SN.ANS SN.Ptm'ANS
No operation (n = 20) Mean S.D.
Operation (n = 30) Mean S.D.
Difference No-Op
t-Values D.F. = 48 t = 2.01
71.63 94.29 56.34 51.16 51.13 45.04 87.85 90.17 6.16
72.05 92.64 59.64 52.62 52.50 45.84 83.68 88.41 6.28
-0.42 1.65 0.60 1.46 --1.37 -0.80 4.17 1.76 -0.12
0.35 0.94 0.48 1.05 0.98 0.69 3.60* 1.49 0.88
4.03 5.63 3.88 4.87 4.88 4.02 3.11 3.29 4.14
4.18 6.32 4.49 4.74 4.80 3.91 4.50 4.53 5.04
* P < 0.05
Table 4
Mean, standard-deviation (S.D.), difference of means, and Student's t-test for measurements of isolated cleft palate group
SN Co-A Ptm'-ANS N-ANS SN-ANS SN-Ptm' SNA SN.ANS SN.Ptm'ANS
No operation (n = 43) Mean S.D.
Operation (n = 43) Mean S.D.
Difference No-Op
t-Values D.F. = 84 t = 1.99
70.30 86.16 53.24 53.87 53.72 43.68 80.00 86.97 10.88
70.98 85.81 53.04 53.57 53.31 43.56 78.80 85.51 10.68
-0.68 0.35 0.20 0.30 0.41 0.12 1.20 1.46 0.20
0.86 0.25 0.21 0.34 0.47 0.14 1.48 1.62 0.23
3.54 6.44 3.99 3.92 3.96 3.67 3.98 3.87 4.13
3.72 6.11 4.74 4.03 4.08 3.86 3.52 4.42 3.65
* P < 0.05 Table 5 - Mean, standard-deviation (S.D.), difference of means, and Student's t-test for measurements of complete unilateral cleft lip, alveolus and palate group
S-N Co-A Ptm'-ANS N-ANS SN ANS SN Ptm' SNA SN.ANS SN.Ptm'ANS * P < 0.05
No operation (n = 28) Mean S.D.
Operation (n = 40) Mean S.D.
Difference No-Op
t-Values D.F. = 66 t = 2.00
70.02 88.71 56.31 49.63 49.25 43.09 85.06 90.86 6.27
71.75 84.99 55.05 53.43 53.02 43.40 76.94 84.55 10.15
- 1.73 3.72 1.26 - 3.80 -3.77 -0.31 8.12 6.31 3.88
1.76 1.84 0.87 3.74* 3.88* 0.31 6.38* 4.14" 3.81"
3.81 7.63 7.11 3.89 3.59 4.14 6.19 7.40 3.97
4.09 8.57 4.75 4.27 4.17 3.88 4.30 5.16 4.24
116 Journalof Cranio-Maxillo-FacialSurgery
J
A/
k
L
Fig. 5 - Superimposition on SN with the average values of the
maxillarymorphologyand spatial position of the groups operated on (----) and not operated on ( ), for complete unilateral cleft lip and alveolus.
) L
L
Fig. 6 - Superimposition on SN with the average values of the
maxillarymorphologyand spatial position of the groups operated on (----) and not operated on ( ), for isolated cleft palate.
Fig. 7 - Superimpositionon SN with the average values of the maxillarymorphologyand spatial position of the operation (----) and no operation groups ( ), for complete unilateral cleft lip, alveolus and palate.
changes in the alveolar region, caused by labial pressure created by surgical closure of the lip (Bardach and Eisbach, 1977). The findings obtained in this study show that lip pressur e is able to change only the alveolar region, because the ANS point did not change significantly in relation to the cranial base (Fig. 5). These findings confirm those of a previous paper (Silva Filho et al., 1989a) and allow us to conclude that, in unilateral complete cleft lip and alveolus, cheiloplasty performed in the early months of age induces some favourable clinical changes in the anterior alveolar region of maxilla, but does not change other areas of the craniofacial complex (Fig. 1B). The findings of the present study do not corroborate the results obtained from experimental research (Eisbach et al., 1978; Bardach and Mooney, 1984) that reported great changes in facial growth as a conseqdence of lip repair in animals where cleft lip and palate were surgically produced. However the differences concerning cleft type should be examined. Isolated Cleft P a l a t e
possible (see Introduction). The sample used in the present study was selected carefully and produces significant and confident data regarding surgical influence upon mid face growth in the three main cleft types. C o m p l e t e U n i l a t e r a l Cleft Lip and Alveolus
Comparing means between groups operated on and not operated on, only the SNA angle was different between the two groups, with this angle significantly smaller in the group operated on. This may prove
According to Dahl (1970), comparing 16 patients with isolated cleft palate not operated on who used palatal obturators versus 41 patients operated on, palatoplasty remodelled the facial pattern, reducing the mandibular downward rotation with a consequent decrease in anterior facial height. Nevertheless, previous study data (Silva Filho et al., 1990) do not support this optimism related to vertical changes induced by palatoplasty. One can verify in Table 4 and Figure 6 that surgical intervention did not result in any maxillary dimensional or spatial changes. None of the cephalometric values (dimensions or angles) showed a statistically significant difference between
Influence of surgery on maxillary growth in cleft lip and/or palate patients 117 groups with and without operation, repeating for the maxilla, the previous findings obtained for the mandible (Silva Filho et al., 1990). Bishara (1973) and Silva Filho et al. (1989b) also show the absence of significant differences in the cephalometric pattern of patients operated on early compared with those not operated on, confirming that the changes observed in comparison with non cleft subjects are part of the craniofacial morphological characteristics of cleft palate patients. Therefore, with regard to facial growth, palatoplasty, at least in the isolated cleft palate, can be done as early as the age of 2 years and may benefit the patient functionally, without causing significant disturbance of craniofacial morphology.
is associated with a remodelling in the maxillary anterior alveolar region causing a significant retrusion of point A, without changes in other areas of the maxilla. Palate repair in isolated cleft palate patients is not associated with significant changes in maxillary dimensions and spatial position. The most evident surgical sequels occurred in the cleft lip, alveolus and palate patients verifying an accentuated maxillary retrusion associated with a downward rotation with the centre of rotation near the posterior nasal spine.
References Bardach, J., K. J. Eisbach : The influence of primary unilateral cleft lip repair on facial growth: 1. Lip pressure. Cleft Palate J.
Unilateral Complete Cleft Lip, Alveolus and Palate
14 (1977) 88 Bardach, J., M. P. Mooney ." The relationship between lip
At variance with previous maxillary superimpositions, Figure 7 shows a severe retrusion of the maxilla associated with a significant clockwise rotation. These changes are confirmed by statistical analysis between groups operated and not operated on (Table 5). Antero-posteriorly the findings show a significant reduction of 8.12 ° in SNA angle, confirmed by the decrease of 6.31 ° in SN. ANS angle, as a consequence of the surgical effects. Severe reduction in these angles reveals the disturbance that the surgical procedures cause in the anterior midface displacement. Thus, it confirms the clinical aspect seen regularly in cleft lip and palate patients operated on at conventional timings (Fig. 3B) and according to the current concepts in the literature, that show a retrusion of the maxilla in relation to the cranial base in patients operated on when compared to non-cleft subjects (Dahl, 1970; Ross, 1970; K r o g m a n et al., 1975; H a y a s h i et al., 1976; Bishara et al., 1979; S m a h e l and Brejcha, 1983 ; M i y a h a r a and C a p e l o z z a Filho, 1985; C a p e l o z z a Filho et al., 1987; Ross, 1987b) and compared with clefts not operated on ( M a r s and H o u s t o n , 1990). Regarding vertical relationships, surgery caused a maxillary downward inclination of 3.88 ° , with the centre of rotation near the posterior nasal spine (Ptm'). Maxillary rotation caused an increase in anterior midface height ( N - A N S , S N - A N S ) of almost 4 r a m , without changing the posterior maxillary height (SN-Ptm'). This rotating effect, associated with surgery, improved the vertical facial growth, however, it has an influence on maxillary anterior displacement because of the backward spatial repositioning.
pressure following lip repair and craniofacial growth: an experimental study in Beagles. Plast. Reconstr. Surg. 73 (1984) 554 Bishara, S. E. : Cephalometric evaluation of facial growth in operated and non-operated individuals with isolated clefts of the palate. Cleft Palate J. 10 (1973) 239 Bishara, S. E., D. L. Sierk, K. S. Huang : A longitudinal study on unilateral cleft lip and palate subjects. Cleft Palate J. 16 (1979) 59
CONCLUSIONS
Silva Filho, O. G. da, A. de O. Cavassan, .4. D. C. Normando : Influ~ncia da palatoplastia no padr~o facial de pacientes
This comparative study of facial pattern between adults having clefts operated and not operated on involving the three main cleft types, lead us to the conclusion that reconstructive surgery, performed during infancy, produces different maxillary changes for each cleft type. Lip repair in unilateral cleft lip and alveolus patients
Capelozza Filho, L., A. de O. Cavassan, O. G. da Silva Filho :
Avaliaq~o do crescimento craniofacial em portadores de fissuras transforame incisivo unilateral: estudo transversal. Rev. Bras. Cirurg. 77 (1987) 97 Dahl, E. : Craniofacial morphology in congenital clefts of the lip and palate. Acta Odont. Scand. 28 (Suppl. 57) (1970) 1 Eisbach, K. J., J. Bardach, E. C. Klausner : The influence of primary cleft lip repair on facial growth: Part II. Direct cephalometric of the skull. Cleft Palate J. 15 (1978) 109 Hagerty, R. F., M. J. Hill: Facial growth and dentition in the unoperated cleft palate. J. Dent. Res. 42 (1963) 412 Hayashi, L, M. Sakuda, K. Takirnoto, T. Miyazaki : Craniofacial growth in complete unilateral cleft lip and palate: a roentgenocephalometric study. Cleft Palate J. 13 (1976) 215 Krogman, IV. M., M. Mazaheri, R. L. Harding et al. : A
longitudinal study of the craniofacial growth pattern in children with clefts as compared to normal, birth to six years. Cleft Palate J. 12 (1975) 59 Mars, M., W. J. B. Houston: A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J. 27 (1990) 7 Miyahara, M., L. Capelozza Filho : Caracterx'sticascefalom&ricas da face no flssurado unilateral adulto. Ortodontia 18 (I985) 5 Ross, R. B. : The clinical implications of facial growth in cleft lip and palate. Cleft Palate J. 7 (1970) 37 Ross, R. B. : Treatment variables affecting facial growth in cleft lip and palate: Part 4. Repair of the cleft lip. Cleft Palate J. 24 (1987a) 45 Ross, R. B. : Treatment variables affecting facial growth in unilateral cleft lip and palate: Part 6. Techniques of palate repair. Cleft Palate J. 24 (1987b) 64 Silva Filho, O. G. da, R. Rocha, L. Capelozza Filho : Padr~o facial do pacien te portador de fissura pr~-forame incisivo unilateral completa. Rev. Bras. Cirurg. 79 (1989a) 197 portadores de fissura prs-forame incisivo. Rev. Bras. Cirurg. 79 (1989b) 315 Silva Filho, O. G. da, A. D. C. Normando, L. Capelozza Filho :
Mandibular morphology and spatial position in cleft lip and/or palate patients: intrinsic pattern or influenced by surgical procedures? Cleft Palate J. (1992) (Accepted for publication) Silva Filho, O. G. da, A. D. C. Normando, L. Capelozza Filho."
Mandibular growth in clef~lip and/or palate patients: the
118
Journal of Cranio-Maxillo-Facial Surgery
influence of cleft type. Amer. J. Orthodont. Dentofacial Orthop. (1992) (Accepted for publication) Smahel, Z., M. Brejcha: Differences in craniofacial morphology between complete and incomplete unilateral cleft lip and palate in adults. Cleft Palate J. 20 (1983) 113 Smahel, Z., Z. Mullerova : Craniofacial morphology in unilateral cleft lip and palate prior to palatoplasty. Cleft Palate J. 23 (1986) 225
Professor L. Capelozza Filho, DDS, MDS Rua Silvio Marchione 3-20-Cx. Postal 620 CEP: 17.043-Bauru/SP Brazil Paper received 19 June 1991 Accepted 8 November 1991
