Studies of facial growth in patients with congenital

Size: px

Start display at page:

Download "Studies of facial growth in patients with congenital"

Lilian Wilcox
5 years ago
Views:

_ Influence of Nasal Septum on Maxillonasal Growth in Patients with Congenital Labiomaxillary Cleft JEAN DELAIRE, M.D., D.D.S. Davin Precious, D.D.S., M.Sc., F.R.C.P.(C) An interpretation of role of nasal septum on maxillonasal growth in patients with congenital labiomaxiliary clefts is presented.

1 _ Influence of Nasal Septum on Maxillonasal Growth in Patients with Congenital Labiomaxillary Cleft JEAN DELAIRE, M.D., D.D.S. Davin Precious, D.D.S., M.Sc., F.R.C.P.(C) An interpretation of role of nasal septum on maxillonasal growth in patients with congenital labiomaxiliary clefts is presented. Salient features of anatomic pathology and resultant dysfunction of premaxillary-maxillary suture and position and orientation of nasolabial muscles relative to nasal septum are discussed for unilateral and bilateral deformities. The nasal septum plays an important direct role in growth of premaxilla and an indirect role in growth of maxilla. Studies of facial growth in patients with congenital cleft lip and palate have not led to conclusive results. A great deal of attention has been directed at role of cartilaginous nasal septum in facial growth, but results from a wide variety of experiments on laboratory animals have not clarified subject (Delaire and Precious, 1985). The purpose of this paper is to present our interpretation, based on clinical observations, of influence of nasal septum on maxillonasal growth in patients with congenital labiomaxillary clefts. PREMAXILLARY-MAXILLARY SUTURE Congenital labiomaxillary clefts result from absence of fusion or incomplete fusion of maxillary and medial nasal processes. Normally, this fusion takes place on thirty-sixth or thirty-seventh day of gestation at a time when all elements of cartilaginous mesethmoid are already well differentiated (Couly, 1980). By contrast, first poirits of ossification in premaxilla and maxilla appear only toward fortieth day (or end of sixth week), at a time when ectomesenchyme of facial processes forms a continuous mass without a trace of zones of fusion. Premaxillary and maxillary points can thus join and unite outside dental lamina, which is already individu- Dr. Delaire is Professor at Stomatology and Maxillofacial Surgery Clinic, Centre Hospatilier Universitaire, Nantes, France. Dr. Precious is Chairman of Oral and Maxillofacial Surgery at Dalhousie University, Halifax, Canada. 270 alized, at a point that will later correspond to canine region. This fusion is normally complete at end of eighth week. From this date forward, osseous plate thus formed develops in all directions: behind (posterior maxilla), in front (premaxilla), above ( ascending process and pyramidal process), and within. In this last direction osseous elements pass between dental processes, and ossification progresses justto midline at median interincisive suture, which is extended behind nasopalatine foramen to median palatine suture. In plane that joins two canine regions, anor suture forms, classically called in man, incisivocanine suture, but which would better be called premaxillary-maxillary suture as it is in animals. It is equivalent of this suture that separates two skeletal parts (premaxilla and maxilla) in animals. The fact that in man it is filled in at end of eighth embryonic week, outside dental lamina, does not alter its physiologic importance. Indeed, it is a seam of rupture and distention and a place of future adaptive osseous growth (Fig. 1). This external closure of suture results in considerable shortening of human premaxilla relative to animal muzzle. Let us note that incisivocanine suture is not an embryonic vestige of fusion of facial processes that takes place before bone formation has started. It results from a completely different process, namely active osteogenesis on both sides of a plane that will later become this suture. In any case, it is evident that if a congenital labiomaxillary cleft exists, that is to say if

Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CLEFTS 2 re is no union of internal nasal and maxillary processes, points of ossification of premaxilla and maxilla cannot approach each or and

2 Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CLEFTS 2 re is no union of internal nasal and maxillary processes, points of ossification of premaxilla and maxilla cannot approach each or and ultimately unite. The congenital maxillary cleft refore occupies a territory where incisivocanine suture would normally have formed, but it is not at all same thing. This point should be well understood. NASOLABIAL MUSCLES The superficial muscles of face, which arise from second branchial arch, migrate laterally and medially between epiblast and subjacent ectomesenchyme and normally reach midline in week that follows fusion of facial processes. In case of a complete labiomaxillary cleft, muscles of nasal floor and upper lip obviously cannot bridge congenital cleft nor unite with muscles of opposite side. The muscular architecture of region is refore seriously disturbed, which in turn has a profound effect on underlying skeleton. 271 FIGURE 1 Human premaxillarymaxillary suture at: (A) 10 days and (B) 21 days after birth Normally anterior muscles of face form three rings, schematically arranged as follows: (1) a superior nasolabial ring formed on each side by transverse nasal muscle, levator labii superioris, and levator labii superioris alaeque nasi muscles; (2) a middle labial ring formed on each side by obicularis oris muscles of upper and lower lip; and (3) a lower labiomental ring formed by depressor anguli oris, depressor labii, and mentalis muscles (Fig. 2). The transverse nasal muscle is most important physiological element in upper ring (Delaire, 1974). It extends from anterior border of nasal bone to incisive crest (on both sides of nasal septum) and to adjacent septal perichondrium. Thus, it surrounds nasal orifice and posseses two important functions: (1) nostril constriction, and (2) support of its corresponding half of upper lip, particularly external head of orbicularis oris of upper lip, which itself supports labial commissure. The internal fibers of oblique head of orbicularis oris normally extend into columella and are connected to anterior

272 Cleft Palate Journal, October 1986, Vol. 23 No. 4 I corinhfef int OrSup FIGURE2 Schematicrepresentationofthreerings ofanteriormusclesofface.

3 272 Cleft Palate Journal, October 1986, Vol. 23 No. 4 I corinhfef int OrSup FIGURE2 Schematicrepresentationofthreerings ofanteriormusclesofface. Tr=transversenasal muscle; RS=levator labii superioris alaeque nasi;pt Rp=levator labii superioris; Can=caninus muscle; Zyg=zygomaticusminor; GdZyg=zygomaticusmajor; Bu=Buccinator; Or sup chef ext=external head of obicularisorissuperioris; Orsupchefint=internalhead ofobicularis oris superioris; Or inf=obicularis oris inferioris;tri=depressorangulioris;car=depressorlabii inferioris; Hou=mentalis muscle. borderofnasal septum, itsperichondrium (in front of anterior nasal spine), and skin covering septum, columella.on both sides ofwhich are The nasal normally insertedsimilarly, symmetrical muscles, remains ininterincisive midline. superior median suture is situated along of septum and is united to it by length sep- topremaxillary ligamentand mediancellulous ligament of upper lip (Delaire et al, 1977) (Figs. 3 and 4). UNILATERAL DEFORMITIES In cleft, case ofmuscles totalonunilateral labiomaxillary cleft side remain outside defect and, even ify are correctlyofformed, cannot function normally. Deprived nasal septum as apoint ofanchorage, musclespressure sag abnormally downsegment, and back,tending thus putting on minor to pushitsit anterior back andpartat closer same totimetending to bring midline. Growth of minor segmentofappears reducedof asstimulationto a probable consequence absence nasolabial muscles and lateralof expansion of septopremaxillary ligament Latham (Delaire and Chateau, 1977). Onnoncleft side, musclesthatnormally insert on nasal septum pull(fig.on i5).t andthedragsameit along withnoncleftnostril occursofto amajor lessersegment, degree with median anterior portion interincisivethepremaxillais suture, and lesstwodevelopedthan incisive processes. normal, particularly oncleft side, becauseofdiscontinuity ofperiosteum andattendantabsence ofnormal muscularperiosteal stimulation. Onderdeveloped noncleftbyside, premaxilla is alsodegreeunan amount equal to median6). interincisive suture is bent toto Thewhich this alarsidecartilage (Fig. of bycleftdivergent side sagsmuscuand is pulled down and flattened lar tractionnormalcorresponding degreeseptumof itsis missing support. Theto median FIGURE3 (A)anterior Septopremaxillary ligament, (B) spine, andof(c)upper medianlip.cellulousnasalligament

273 z. Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CLEFTS FIGURE 4 Functioning upper lip demonstrates muscular anchorage at location of inferior part of nasal septum and anterior nasal spine.

4 273 z. Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CLEFTS FIGURE 4 Functioning upper lip demonstrates muscular anchorage at location of inferior part of nasal septum and anterior nasal spine. Note appearance of median cellulous ligament of upper lip. FIGURE 5 Schematic representation of muscular imbalance in unilateral labiomaxillary cleft. FIGURE 6 (A) Occlusal radiograph of 6-month-old infant just prior to performance of primary functional cheilorhinoplasty. Note deviation of median interincisive suture to healthy side. Note also reduction in size of premaxilla on healthy side by an amount equal to degree of deviation of median interincisive suture. (B) Occlusal radiograph of same patient at 16 months of age (8 months after primary functional cheilorhinoplasty) demonstrating an improved orientation of interincisive suture relative to true midline. Good symmetrical premaxillary and anterior maxillary growth can now take place.

5 274 Cleft Palate Journal, October 1986, Vol. 23 No. 4 deviated to noncleft side, and pyriform aperture on cleft side is pushed back and malformed. The cartilaginous deformations can refore be considerable, but, except for rare cases, re is no hypoplasia of cartilage. Indeed, re is frequently no cutaneous hypoplasia, and if skin appears insufficient, particularly at base of columella, it is because it has not been distended (Fig. 7). The nasal bones, influenced by cartilaginous septum, are also deviated to noncleft side. On cleft side, sagging of nasal capsule induces a retrusion of ipsilateral nasal bone, which is often associated with an internal rotation of anterior part of ascending portion of maxilla. This usually results in lateral displacement of medial canthus, giving appearance of unilateral hypertelorism, which is in fact telecanthus. All of se anomalies are exaggerated in case of complete velopalatine cleft associated with a total unilateral labiomaxillary cleft. Inversely, y are reduced in severity by presence of a subnasal cutaneous bridge (Simonart's band). In incomplete labiomaxillary clefts, as one would expect, anomalies are correspondingly less severe. BILATERAL DEFORMITIES In case of total bilateral labiomaxillary clefts with cleft palate, condition of lateral fragments is identical to that seen in unilateral cleft. The anterior medial disposition of se fragments is often particularly accentuated by posterior spreading of two tuberosities. The median fragment has shape of a bar, extending vomerine beam forward from which it is separated by premaxillaryvomerine suture. This bar represents all of premaxilla whose lateral parts have not developed because of congenital bilateral clefts and total absence of stimulation of median intercisive suture. At its anterior part are seated dental processes that extend beyond anterior nasal spine, itself situated furr forward than normal. The premaxilla is longer than normal (Fig. 8), which, according to Pruzansky (1971), results from excessive stimulation of premaxillaryvomerine suture which in turn is caused by absence of a muscular sling of upper lip. We agree that it is this suture that is responsible for excessive elongation of premaxilla, but absence of muscular sling is not sufficient to explain excessive sutural growth. To achieve excessive sutural growth re must be active sutural distention in which pressure of lower lip, situated behind developing upper alveolar process probably plays a principal role. One cannot exclude, however, active role of cartilaginous septum whose growth is in a downward and forward direction and is not controlled by nasolabial muscles. In case of total bilateral labiomaxillary clefts without cleft palate, this excessive growth of median process is even more evident (Fig. 9). It extends markedly in front of anterior portion of maxilla, which ostensibly is well positioned, anteroposteriorly, in relation to mandible. The vertical level of palate is also apparently normal. The study of se observations has led some authors (Bergland and Borchgrevinck, 1974) to think that nasal septum is not an influencing factor on pre- and postnatal growth of human maxillary complex. FIGURE 7 Facial appearance of an infant demonstrating drooped alar cartilage, deviated median septum, and apparent unilateral hypertelorism.

Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CcLErts 275 FIGURE 8 Total bilateral labiomaxillary palatine cleft demonstrating excessive length of premaxilla.

6 Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CcLErts 275 FIGURE 8 Total bilateral labiomaxillary palatine cleft demonstrating excessive length of premaxilla. FIGURE 9 Total bilateral labiomaxillary cleft without cleft palate showing excessive growth of median process. We are diametrically opposed to this opinion because, in se cases, anterior part of maxilla usually presents with a very severe transverse deficiency such that deciduous canine tooth buds are almost in contact. Also, even if anterior position of maxillary canines coincide with that of mandibular canines, this does not signify that maxilla is normally developed. In fact, Burston (1958) has noted that '' bilateral condition is characterized by two retroplaced and small maxillae, very frequently associated with a certain degree of micrognathia of mandible."' Above all, it seems to us erroneous to say that ""except for severely protruded premaxilla facial appearance of infant is fairly normal'' (Bergland and Borchgrevink, 1974). Also, we do not think that findings of normal facial configuration following good repair of muscular sling and orthodontic treatment constitutes "' decisive evidence that nasal septum cannot play an influential role eir in pre- or in postnatal midfacial growth in man' (Bergland and Borchgrevink, 1974). We have observed similar cases, and we believe that good primary surgery reconstituted not only facial estics but also function of nasal-septal complex, nasolabial muscles, and median cellulous septum of upper lip (Delaire et al, 1977), thus restoring function to ensemble, which in turn favors good anterior maxillary and premaxillary growth (Delaire and Chateau, 1977; Delaire, 1983). CONCLUSIONS In unoperated child, absence of nasolabial muscles to nasal septum and resultant deformities demonstrate an important action of septal cartilage, not only directly on premaxilla but also indirectly on growth of maxilla. The dramatic examples reported by Victor Veau (1938) in ''Surgical Monstrosities'' section of his book clearly show necessity of avoiding injury to nasal septum and importance of using its dynamic force in aiding growth of nasomaxillary complex. To achieve good growth it is essential at time of primary functional cheilorhinoplasty to obtain a good, symmetical fixation of nasolabial muscles of cleft side(s) to anteroinferior part of septal cartilage in front and on both sides of anterior nasal spine (Delaire, 1978, 1983). The reconstitution of equilibrium and muscular function of both floor and sill of nose and upper lip encourages premaxillary-maxillary growth (Figs. 10 and 11), which is less likely to occur with

7 276 Cleft Palate Journal, October 1986, Vol. 23 No. 4 FIGURE 10 Total bilateral labiomaxillary cleft without cleft palate (same patient as Fig. 9) (A) at 6 months of age before primary functional cheilorhinoplasty and (B) 10 years after. FIGURE 11 Total unilateral labiomaxillopalatine cleft (A) at 5 months of age before primary functional cheilorhinoplasty and (B) at 8 years of age, in repose and (C) during function. Note absence of marked nasolabial asymmetry and particularly midline position of nasal septum.

8 _ Delaire and Precious, NASAL SEPTUM IN LABIOMAXILLARY CLEFTs 277 or techniques, even though y may be estically excellent. Good symmetry of muscular insertions on septum also prevents deviation of anterior border of nasal septum into noncleft nostril and resultant corresponding deviation of nasal spine, median interincisive suture, maxillary dentoalveolar midline, and anterior border of nose. It also contributes to limit severity of vomerine deviations of cleft side, as does avoidance of use of vomerine mucosa in closure of velopalatine clefts (Delaire and Precious, 1985). Thus, se clinical observations suggest that nasal septum both directly influences growth of premaxilla and indirectly influences growth of maxilla and in so doing plays an important, active role in facial growth of patients with congenital labiomaxillary clefts. References BERGLAND O, BORCHGREVINK H. The role of nasal septum in mid-facial growth in man elucidated by maxillary development in certain types of facial clefts. Scand J Plast Reconstr Surg 1974; 8:42. BUrsTON WR. Early orthodontic treatment of cleft palate conditions. Dent Pract 1958; 9:41. CoULyY G. Le mesethmoide cartilageneux humain. Rev Stomatol Chir Maxillofac 1980; 81:135. DELAIRE J. Considerations sur l'accroissment du premaxillaire chez l'homme. Rev Stomatol Chir Maxillofac 1974; 75:951. DELAIRE J. Interet de la rhinoplastie primaire:considerations techniques. Chir Pediat 1983; 24:286. DELAIRE J. Theoretical principles and technique of functional closure of lip and nasal aperture. J Maxillofac Surg 1978; 6:109. DELAIRE J, FEvE JR, CHaTEAU JP, CoURrTAY D, TULSANE JF. Anatomie et physiologie des muscles et du frein median de la levre superieure. Rev Stomatol Chir Maxillofac 1977; 78:93. DELAIRE J, CHATEAU JP. Comment le septum nasal influence-t-il la corissance pre-maxillaire et maxillaire. Rev Stomatol Chir Maxillofac 1977; 78:241. DELAIRE J, Precious DS. Avoidance of use of vomerine mucosa in primary surgical management of velopalatine clefts. Oral Surg 1985; 60:589. PRUZANSKY S. The growth of pre-maxillary-vomerine complex in complete bilateral cleft lip and palate. Danish Dental J 1971; 75:1157. V. Bec de Lievre, Formes Cliniques, Chirurgie. Paris: Masson, 1938.

Bones Ethmoid bone Inferior nasal concha Lacrimal bone Maxilla Nasal bone Palatine bone Vomer Zygomatic bone Mandible

splanchnocranium - Consists of part of skull that is derived from branchial arches - The facial bones are the bones of the anterior and lower human skull Bones Ethmoid bone Inferior nasal concha Lacrimal