Cairo Dental Journal (24) Number (I), 77:84 January, Haitham Sayed Attia 3, Mohamed Saied Hamed 1 and Monteser El Koutobey 2

Transcription

1 Cairo Dental Journal (24) Number (I), 77:84 January, 2008 Anthropometric Analysis of cases of Unilateral Cleft Lip Versus cases of Complete Unilateral Cleft Lip and Palate Haitham Sayed Attia 3, Mohamed Saied Hamed 1 and Monteser El Koutobey 2 1. Assistant Lecturer Oral and Maxillofacial Surgery, Seuz Canal University. 2. Dean Faculty of Dentistry Suez Canal University, Professor of Oral and Maxillofacial. 3. Professor and Charmin of Pediatric Surgery Faculty of Medicine, Cairo University. Abstract The aim of this study is to compare the repair results of unilateral cleft lip with complete palatal defect to the repair results of isolated unilateral cleft lip by using anthropometric analysis. 20 patients were selected and divided into two equal groups. Chelioplasty was performed for all patients by one surgeon using modified Millard technique. Anthropometric analyses of the nose was done and statistically analyzed and tabulated for comparison and follow up immediately and up to12 weeks postoperative was done. The results showed a great difference between both groups. INTRODUCTION The occurrence of developmental disturbances in the oro-facial region is not uncommon due to failure of the developmental processes to undergo proper and correct fusion. One of the deformities which may result is the cleft lip and palate which is due to congenital failure of fusion of the lateral maxillary process with the median nasal process. This is associated with maxillary hypoplasia on the affected side, in which the lateral maxillary elements are retro-positioned and collapsed (Millard, 1990). The aim of surgery is to reconstruct both aesthetics and function of oro-facial region, through ideal correction which involves closure of the lip, correction of distorted nose, proper alignment of dental arch, providing physiologic division of oral and nasal cavities i.e. creating normal velopharyngeal opening, by closure of the cleft of the lip, alveolus, hard palate and soft palate (Millard, 1990 and Gaggl et al., 2003). Management of nasal deformity with complete unilateral cleft lip remains controversial, in spite that management of cleft lip is standardized. It is often the residual deformity of the nose, rather than that of the lip, which stigmatizes the children with repaired palatal clefts (Kane et al., 2000). Many surgical techniques have been developed for treatment of nasal deformity through intervention in the soft tissue of the nose only without reference to osseous defect; finally they did not get perfect results (Cho and Baik, 2001). In the perinasal area the alar base become wide, with vertical alar distopia, a short and drooping columella, a deviated nasal septum

2 (78) Haitham Sayed Attia, et al. C.D.J. Vol. 24. No. (I) to the unaffected side, nasal dorsal scoliosis, a symmetric nares, axial rotation of the alar cartilage on the cleft side (Anastassov et al., 1998). The ala is flat, elongated and thickened due to intrusion of the lower lateral cartilage which is described as caudal and inferior displacement with protrusion of the lateral crus which produces an S-shaped fashion of the ala (Salyer, 1994). Nasal tip deformities in the cleft lip nose, deviation of the nasal tip, deviation of the nasal dorsum, dorsally displaced dome and more obtuse angle between the lateral and medial crura, and The nasal septum and the columella are deviated to the non cleft side (Converse et al., 1977). Li et al., in 2002 reveled that there is no statistically significant difference between alar cartilage of the cleft and the non cleft side in weight and size and also no statistical difference in the length of the lower lateral cartilages and no evidence of hypoplasia of the lower lateral cartilage on the cleft side. They concluded that nasal deformity is due to nasal cartilage displacement rather than hypoplasia. From cosmetical point of view, maxillary deficiency (hypoplasia) and deformation are major contributors to the stigmata of cleft lip and palate. This particular appearance is due to lack of normal cheek contour, naso-labial imbalance, lack of nasal tip, and lack of upper lip support. Even if the aesthetic components of the cleft lip and /or nose are repaired and soft tissue landmarks matched perfectly, the deficiency of supporting skeletal tissues (maxillary hypoplasia) results in the cleft appearance (Fonseca et al., 2000). Patients and methods Objectives of the repair A- Nasal repair: Every effort was done to perform soft tissue correction of the nostril on the ipsilateral side to be comparable with the normal one. Soft tissue correction of the nostril was done, keeping in mind to fulfill the following (Fig 1): 1. Equality of the nostril floor on both sides. The floor of the nostril was measured from the lateral edge of the base of the columella to the inner point at the junction of the ala with the nasal floor. Fig (1) this diagram shows point A at the tip of the nose, point B represents inner point at the junction of the ala with the nasal floor. 2. The height of the nostril was measured between two points: * Point A: Central point of the tip of the nose. * Point B: The inner point at the junction of the ala with the nasal floor. Anthropometric measurements (nasal floor width and tip-ala distance) were taken on both sides in both groups, the measurements were tabulated and statistically analyzed for comparison. 3. Correction of the nostril was done without any trial to disturb the alar cartilages (lateral and medial crura). B- Lip repair to be carried out so that at the completion of the repair the lateral edge of the repaired philtral is equal and symmetric to the normal one. Preoperative preparation: Preoperative oral antibiotic e.g. Ampicillin (Ampicillin tri-hydrate) in a dose of mg/kg/day was given to the patients 3 to 4 hours before surgical procedure. All patients fast 4 hours preoperatively. Operative Techniques: A. General Anesthesia: Using Endotracheal intubation with Raye s tube. B. Position: Supine with the head slightly flexed.

3 Anthropometric Analysis of cases (79) Marking of incision: The technique used for cleft lip repair was modified Millard technique (Musgrave and Garrett 74, 1977).). Patients were admitted for 24 hours, and observed for any post-surgical complications. Oral feeding liquid meal (milk and fluids) using a spoon or syringe started one hour post operatively. One surgeon performed surgical repair of all cases of unilateral lip. Statistical Methods: Data management and analysis were performed using Statistical Analysis Systems. An IBM Petium 4 was used. factor was performed to test the effect of time and the differences between the sides for each group separately. Results Anthropometric analysis The goal of surgical procedure is to reconstruct the nostril so that, the nasal floor width, is equal on both sides and the same for the ala tip distance. The measurements of the nasal floor width and the ala tip distance of the nose are measured on both sides and in both groups, immediately and postoperatively 4, 8 and 12 weeks after surgical procedure. Data were summarized using means and standard deviations. To study the differences between the groups, side and time, a three-way analysis of variance with repeated measures on two factors was performed (Dawson and Trapp 31, 2001). Further two-way analyses of variance with repeated measures were done to compare the difference between the groups and the changes with time for normal and abnormal, separately. Another two way analysis of variance with repeated measures on one Nasal floor width Relation between the groups, the changes with time and difference between sides (non cleft and cleft), using three-way analysis of variance with repeated measures on two factors (time and side) was done. This analysis showed that there is significant interaction between three factors. Therefore the two-way analysis of variance was done (Table 1). Table (1) Showed relation between two groups regarding nasal floor width in both normal and abnormal sides. Time Group I Normal Abnormal Normal Abnormal Immediate 8.7± ± ± ±1.5 4 weeks 9.1± ± ± ±0.9 8 weeks 9.8± ± ± ± weeks 10.5± ± ± ±1.2 ANOVA Results Effect P-value* Significance Groups No Time <0.001 Yes Side <0.001 Yes Groups*time interaction No Groups*side interaction <0.001 Yes Time*side interaction <0.001 Yes Groups*time*side interaction <0.001 Yes ANOVA= Analysis of variance *P-values 0.05 are considered significant. Values are means ± standard deviations.

4 (80) Haitham Sayed Attia, et al. C.D.J. Vol. 24. No. (I) Group I: Nasal floor width Immediately after surgery The nasal floor width immediately after surgery on the non cleft side ranged from 7 to 10.5 mm with a mean of mm. On the repaired side the nasal floor width ranged from 7 to 10.5 mm with a mean of mm. The difference in nasal floor width was statistically insignificant p> weeks post operative On the non cleft side the width ranged from 8 to 10.5 mm with a mean of mm. The repaired side width ranged from 8 to 11 mm with a mean of mm. The difference was statistically significant p< weeks post operative Nasal floor width on the non cleft side ranged from 9 to 10.5 mm with a mean of mm. On the operated side the width ranged between 9.5 and 11.5 mm with a mean of mm. The difference between the operated and non operated side was statistically significant p< weeks postoperative The nasal floor width in the non affected side ranged from 8.5 to 11.5 mm with a mean of mm. On the repaired side the width ranged from 10 to 12 mm with a mean mm. The difference between both sides was statistically significant p< Group II Immediately after surgery On the non cleft side the measurements of nasal floor width ranged from 7 to 11 mm with a mean of mm. On the repaired side the measurements of nasal floor width ranged from 6.5 to 11 mm with a mean of mm. The difference between the non cleft and the cleft sides was statistically not significant p> weeks post operative The nasal floor width on the non cleft side ranged from 7 to 11 mm with a mean of mm. On the repaired side the measurements ranged from 9 to 12 mm with a mean of mm. The difference between the non cleft and the repaired side was statistically significant p< weeks post operative The nasal floor width on the non cleft side ranged from 8.5 to 11.5 mm with a mean of mm. For the repaired side the nasal floor width ranged from 10.5 to 13.5 mm with a mean of mm. The difference between the non cleft and the cleft side was statistically significant p< weeks postoperative The nasal floor width on the non cleft side ranged from 8 to 12 mm with a mean of mm. The width on the operated side ranged from 12 to 15.5 mm with a mean of mm. The difference in nasal floor width was statistically significant p< Ala to Tip distance Relation between the groups, the changes with time and difference between sides (non cleft and cleft), using three-way analysis of variance with repeated measures on two factors (time and side) was done. This analysis showed that there is significant interaction between three factors. Therefore the two-way analysis of variance was done (Table 2). Group I: Immediately after surgery The distance on the non cleft side ranged from 10 to 12.5 mm with a mean of mm. On the repaired side the distance ranged from 10 to 12.5 mm with a mean of mm. The difference between the non cleft and operated side was statistically insignificant p>0.05.

5 Anthropometric Analysis of cases (81) Table (2) Shows ala-tip distance relation between two groups through out the study period. Time Group I Group II Normal Abnormal Normal Abnormal Immediate 10.9± ± ± ±1.2 4 weeks 11.4± ± ± ±1.1 8 weeks 11.8± ± ± ± weeks 12.3± ± ± ±1.4 ANOVA Results Effect P-value* Significance Groups No Time <0.001 Yes Side <0.001 Yes Groups*time interaction <0.001 Yes Groups*side interaction <0.001 Yes Time*side interaction <0.001 Yes Groups*time*side interaction <0.001 Yes ANOVA= analysis of variance. *P-values 0.05 are considered significant. Values are means ± standard deviations. 4 weeks post operative The distance on the non cleft side ranged from 10 to 13 mm with a mean of mm. For the repaired side the distance ranged from 10 to 13 mm with a mean of mm. The difference in distance between both non cleft and operated sides was statistically insignificant p> weeks post operative The distance on the non cleft side ranged from 10 to 13.5 mm with a mean of mm. The distance on the operated side ranged from 11 to 13.5 mm with a mean of mm. The difference in distance between two sides was statistically insignificant p> weeks postoperative The distance from the ala to the tip of the nose on the non cleft side ranged between 10.5 to 13.5 mm with a mean of mm. For the repaired side the distance ranged from 11.5 to 13.5 mm with a mean of mm. The difference between two sides was statistically significant p< Group II (Ala to Tip distance) Immediately after surgery The measurements on the non cleft side ranged from 9.5 to 13 with a mean of mm. On the repaired side the ala-tip distance ranged from 9.5 to 13 mm with a mean of mm. The difference between the non cleft and operated side was statistically not significant p>0.05.

6 (82) Haitham Sayed Attia, et al. C.D.J. Vol. 24. No. (I) 4 weeks post operative The distance on the non cleft side ranged from 9.5 to 13 mm with a mean of mm. On the operated side it ranged from 11 to 14.5 mm with a mean of mm. The difference between both sides was statistically significant p< weeks post operative For the non cleft side the measurements ranged from 10 to 13 mm with a mean of mm. For the operated side the distance ranged between 11.5 to 16 mm with a mean of mm. The difference between the two sides was statistically significant p< weeks postoperative The distance from the tip of the nose to the ala on the non cleft side ranged from 10.5 to 14 mm with a mean of mm. On the other hand, the distance on abnormal side ranged from 14 to 18 mm with a mean of mm. The difference between the non cleft and the cleft side was statistically significant p< Table 9: Ala to tip distance means values through out the study period for group II. Comparison between two groups The present study included 20 patients divided into two groups. Group I consisted of 10 patients with unilateral cleft lip and symmetric maxilla, while Group II consisted of 10 patients with unilateral cleft lip and complete cleft palate. Comparison was done between the non cleft sides and cleft sides of both groups regarding nasal floor width and nasal ala-tip distance, using a twoway analysis of variance. Nasal floor width Non-cleft sides There was no statistical significant difference regarding the non-cleft sides between 2 groups through out the study period from immediately post-operative until the end of the 12 th week post operative p>0.05. Cleft sides There was no statistical significant difference between the cleft sides of both groups immediately after surgery until the end of the 4 th post operative week. From the 8 th postoperative week to the end of the 12 th postoperative week there was a statisticaly significant difference p<0.05. Ala tip distance Non-cleft sides There was no statistical significant difference regarding the non- cleft sides between 2 groups through out the study period from immediately post-operative until the end of the 12 th week post operative p>0.05. Cleft sides There was no statistical significant difference between the cleft sides of both groups immediately after surgery until the end of the 4 th week post operative. From the 8 th week postoperative to the end of the 12 th week postoperative there was a statistical significant difference p<0.05. Post operative changes among both groups The present study included 20 patients with unilateral cleft lip divided into 2 groups, group I included 10 patients with unilateral cleft lip with symmetric maxilla. While the other 10 patients (group II) having unilateral cleft lip with complete cleft palate. The post operative mean difference percentage changes throughout the study period regarding nasal floor width and ala tip distance was done using two-way analysis of variance. Nasal floor width The mean difference Percentage of the nasal floor width in the present study changed as follows: Immediately after surgery: For group I with symmetric maxilla the change was 1.15%, for group II with palatal defect it was 0 %. 4 weeks post-operative: In group I the changes, occurring immediately after surgery to 4 weeks post-

7 Anthropometric Analysis of cases (83) operative, were 3.8%, while for group II the changes were 18.18%. 8 weeks post-operative: The changes occurring 4 weeks post-operative to 8 weeks post-operative; in group I were 5.6%, for group II the changes were 21.64%. 12 weeks post-operative: The changes occurring 8 weeks post-operative to 12 weeks post-operative in group I were 6.7%, for group II the changes were 33.16%. Nasal ala-tip distance The mean difference Percentage of the nasal ala-tip distance in the present study changed as follows: Immediately after surgery: For group I with symmetric maxilla the change was 0.45%, for group II with palatal defect it was 0.91 %. 4 weeks post-operative: The changes occurring immediately after surgery to 4 weeks post-operative; in group I were 0.9%, for group II the changes were 11.87%. 8 weeks post-operative: The changes occurring 4 th week s post-operative to the end of the 8 th week postoperative; in group I changes were 1.6%, for group II the changes were 18.37%. 12 weeks post-operative: The changes occurring 8 weeks post-operative to 12 weeks post-operative in group I were 4.47%, for group II the changes were 32.5%. Patients subjected to surgery were photographed immediately, 4 weeks, 8 weeks, and 12 weeks after surgery. Discussion The present study includes 20 patients; 10 patients with unilateral cleft lip without palatal defect (group I) and 10 patients with unilateral cleft lip with palatal defect (group II). The aim of the study is to compare the results of repair of cleft lip with complete palatal defect usually associated with hypoplastic maxilla and repair of cleft lip without palatal defect and with symmetric maxilla, and consequently to clarify the role of hypoplastic maxilla in the cleft lip nasal repair. The age of patients ranged between 3 to 6 months, with a mean age of 4.9 month for group I, and a mean of 4.5 month for group II. Comparable age groups were recorded by Millard et al. (1999). The sex distribution for group I was 6 males and 4 females, while for group II was 5 males and 5 females. Pre-operative assessment of all patients included in this study was conducted to exclude the presence of associated congenital malformation or systemic diseases affecting other systems, either by thorough clinical examination or using different investigatory modalities (e.g. laboratory techniques and echocardiography.etc). The modified Millard technique under general anesthesia is the one used for cleft lip repair for all patients in both groups of this study. Proper soft tissue repair of lip defect in both groups was done, resulting in equality of the nasal floor width and ala tip distance in both groups. After surgical correction all patients were subjected to anthropometric measurements through out the study period in order to estimate the changes occurring in the nasal floor width and the ala-tip distance in both groups. Immediate assessment of the nasal floor width and alatip distance was similar in both groups. With follow up gradual variation occurred in group II and reached the peak at the 12 th week postoperative. This could be attributed to the adherence of the nasal floor to the underlying posteriorly displaced hypoplastic maxilla and the starting maturating fibrosis between the floor of the nose and the hypoplastic maxilla. Changes in group I occurred similarly but to lesser extent. Changes in the nasal floor width and ala-tip distance in group II was quite evident, while in group I it was less evident. This study showed that changes in the nasal floor width comparing the abnormal sides in both groups, was statistically insignificant (p>0.05) immediately after surgery and up to the end of the 4 th week post-operatively. By the end of the 8 th week to the end of the 12 th week postoperatively the nasal floor width showed a statistically significant difference between the two groups (p<0.05).

8 (84) Haitham Sayed Attia, et al. C.D.J. Vol. 24. No. (I) The same was for ala-tip distance between the two groups regarding the abnormal sides; there was no statistically significant difference immediately after surgery until the end of 4th week post-operative p>0.05. A statistically significant difference between the abnormal sides of the two groups was reported by the end of the 8 th week up to the 12 th week post-operative (p<0.05). For nasal floor width the changes ranged from 1.15% immediately after surgery to 6.7% on 12 weeks postoperative in group I, while for group II the changes ranged from Zero% immediately after surgery to 33.16% at the 12 weeks post-operatively. For nasal ala-tip distance the changes ranged from 0.45% immediately after surgery to 4.47% at 12 weeks post-operative in group I, while for group II the changes ranged from 0.91% immediately after surgery to 32.5% at 12 weeks post-operatively. Li et al. in 2002 had proven that there is no statistically significant difference between alar cartilage of the cleft and non cleft side; in weight, size and length. They concluded that the nasal deformity is due to cartilage displacement rather than cartilage hypoplasia. On the contrary (Avery, 1976) and (Stark and Kaplan, 1973) reported that the primary cause of secondary cleft lip nasal deformity is the hypoplasia of the lateral crus of alar cartilage by measuring the lateral nasal cartilage forming capacity. References 1. Anatassou G.E., Joos U. and Zollner B.: Evaluation of the results of delayed rhinoplasty in cleft lip and palate patients. Functional and esthetic implications and factors that affect successful nasal repair. B.J. Oral Maxillofac. Surg., 36: , Cho B.C. and Baik B.S.: Correction of cleft lip nasal deformity in Orientals using a refined reverse-u incision and V-Y plasty. British Journal of Plastic Surgery. 54, , Conserve J.M., Hogan V.M. and Barton F.: Secondary deformities of cleft lip, cleft lip and nose, and cleft palate. In Conserve, J.M. (Ed): Reconstructive plastic plastic surgery. 2 nd Ed. Chapter 47, page 2165, Philadelphia, W.B. Saunders Company, Dado D.V. and Kernahan D.A.: Radiographic analysis of the midface of a stillborn infant with a unilateral cleft lip and palate. Plastic and Reconst Surg, 78, no 2, , Millard D.R., Jr: Unilateral cleft lip deformity. In plastic surgery cleft lip, palate and craniofacial anomalies, W.B. Sauders, vol 4, chapter 52, Gaggle A., Schultes G., Feichtinger M., Santler G., Mossabocle R., Karacher H.: Difference in cephalometric and occlusal outcome of cleft palate patients regarding different surgical techniques. Journal of Cranio-Maxillfacial Surgery: 31, 20-26, Kan A.A., Pligram T.K., Moshiri M., Marsh J.L.: Long-term out come of cleft lip nasal reconstruction in childhood. Plastic Reconst Surg, 105: 1600, Li A.Q., Sun Y.G., Wang G.H., Zhong Z.K. and Cutting C.: Anatomy of the nasal cartilages of the unilateral complete cleft lip nose. Plast. Reconst. Surg. 109: 1835, Fonesca R.J., Turvey T.A., Wellford L.M.: Orthognathic surgery in the cleft patient. In Fonesca R.J. (Ed): Oral Maxillofacial Surgery 1 st ed. Volume 6 Cleft/ Craniofacial /Cosmetic Surgery. Chapter 6, page 87, William M. Winn, Musgrave R.H. and Garrett W.S.: The unilateral cleft lip. In Conserve, J.M. (Ed): Reconstructive plastic plastic surgery. 2 nd Ed. Philadelphia, chapter 43, page 2016, W.B. Saunders Company, Millard D.R., Jr, Lantham R., Huifuen X. and Spiro S.: Cleft lip and palate treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA) compared with previous lip adhesion method: A preliminary study of serial dental casts. Plastic Reconstr surg, 103: , Salyer K.E.: Primary correction of the nasal deformity associated with cleft lip. In M.cohen, mastery of plastic and reconstructive surgery. New york, little, Brown, pp , 1994.