POLSKI PRZEGLĄD CHIRURGICZNY 2009, 81, 1, 23 27 10.2478/v10035-009-0004-2 LATERAL CEPHALOMETRIC EVALUATION IN CLEFT PALATE PATIENTS PRADEEP JAIN, ANAND AGARWAL, ARVIND SRIVASTAVA Department of Plastic Surgery, Institute of Medical Sciences Banaras Hindu University in Varanasi, India Kierownik: prof. P. Jain The aim of the study. The lateral cephalometric study in children with cleft palate was carried out to find out the cause of maxillary retrusion and to see if there were other changes induced by this entity in the maxillofacial morphology. Material and methods. Lateral cephalometric evaluation of 28 patients with un-operated cleft palate (group A), 12 patients with operated cleft palate (group B) and 10 controls (group C) was done by tracing the lateral cephalographs, marking the various landmarks and taking the mean of each measurements made thrice. Results. It showed significant decrease in maxillary length and S-N-ANS angle indicating maxillary hypoplasia in all group A patients, significantly so in 16-20 years age group. Group B patients having undergone palatal repair in their childhood revealed significant increase in lower anterior facial height, the other parameters being insignificantly altered when compared with control. Conclusions. The findings suggest an intrinsic deficiency not only in maxilla but contrary to the past belief also in mandible. There was no significant difference in the cephalometric measurements between un-operated and operated cleft palate patients. Key words: cephalometry, cleft palate, maxillary retrusion, mid-face hypoplasia The cleft palate and/or lip is one of the most common congenital birth defects affecting the human race. As Surgeons became more and more successful in cleft surgery, they began focusing their attention on facial growth problems in their patients. This led to the trend among some Surgeons to delay hard palate closure until completion of maxillary growth to avoid adverse effect of surgery on it. However, the majority persisted with early one stage closure between 12-18 months of age or even earlier. The present work is an attempt to evaluate the maxillofacial growth in cleft palate patients, both un-operated and operated, to find out the scientific basis for early versus delayed hard palate closure. MATERIAL AND METHODS 40 cases of cleft palate, from 4-20 years of age, were included in the study, both un-operated (group A, n=28) and operated (group B, n=12). All patients in group B were operated using Kilner-Wardill method at the age 18 months till 2 years by one surgeon. These patients were divided according to growth potential in 4-6 yrs, 10-12 yrs and 16-20 yrs age groups. Ten persons of same age and sex were taken as control (group C). None of the patients had any orthodontic therapy, orthognathic surgery or alveolar bone grafting. The lateral cephalometric radiography was done in all the patients and control keeping constant distance between mid position of skull and X-ray tube (5 feet). During the exposure, the teeth were kept in occlusion and the lips in repose. X-ray film was taken for skeletal measurements at 55 k voltage and 25 MAS. The radiographs were traced, the measurements were made three times and the mean was taken as the true value. The cephalometric landmarks marked on the tracings and measurements made were as follows (fig.1)
24 P. Jain et al. Fig. 1. Skaletal pattern: cephalometric landmarks S midpoint of sella turicia, ANS anterior nasal spine, N nasion, Me menton, Ar articulare, Pg prognathion RESULTS The maximum number of un-operated patients in group A (n=12, male 8; female 4) were in 4-6 years age group, closely followed by 10-12 yrs age group (n=10, all male). Surprisingly, 6 un-operated male patients belonged to 16-20 years age group. All the patients in group B (n=12, male 8, female 4) were operated around the age of 2 yrs, 10 years back. Comparison of cephalometric data of unoperated children (4-6 yrs, group A) with control shows significant decrease in anterior cranial base length, maxillary and mandibular length in the former (tab. 1). The other parameters were insignificantly altered. Similar study in 10-12 yrs age group revealed significant decrease in lower anterior facial height, mandibular index and facial height index (tab. 2). However the measurements in 16-20 yrs. old un-operated cleft palate patients showed significant decrease once again in maxillary length and mandibular length and also in S-N-ANS angle and facial height index (tab. 3). On the other hand, the operated children with 10 years follow-up revealed significant increase in only lower anterior facial height with all other parameters being insignificantly altered generally on the lower side (tab. 4). Comparison of these data between group A and group B did not reveal any significant difference. DISCUSSION The growth and development of maxilla in patients with cleft lip and palate has been of great concern for a long time. The technique of reconstruction and timing of surgical intervention have been blamed to significantly affect the three dimensional growth of maxilla resulting into its collapse. However, many unoperated patients in different age groups have also presented with retarded maxillary growth and marked collapse of dental arch. There are many authors (1-5) who did not report any maxillary retrusion in un-operated adults with unilateral cleft lip and palate. On the contrary, Rusen (6) did not find any incre- Table 1. Cephalometric analysis of skeletal measurements (4-6 yrs) group A vs group C 66,2 69,6 73,6 43,2 58,4 70 1,05 1,11 0,75 +3,3 +3,06 +6,56 +3,66 +3,28 +6,7 +0,07 +0,14 +0,82 70,4 77 86 45 55 77 1,09 1,22 0,81 +1,3 +8,1 +1,82 +6,37 +8,1 +2,58 +0,01 +0,09 +0,10 t value 2,48 4,68 3,65 0,71 2 2 0,94 1,33 1,42 p value <0,05 <0,001 <0,01 >0,05 >0,05 <0,05 >0,05 >0,05 >0,05
Lateral cephalometric evaluation in cleft palate patients 25 Table 2. Cephalometric analysis of skeletal measurements (10-12 yrs) group A vs group C 74,3 79 94,5 52,5 66 67,5 1,06 1,27 0,80 +4,2 +4,8 +9,7 +5,5 +2,9 +3,56 +0,06 +0,07 +0,09 72,5 81,5 99 54 57 71 1,13 1,37 0,94 +2,4 +5,8 +4,1 +1,8 +0,8 +7 +0,12 +0,10 +0,04 t value 0,78 0,84 0,88 0,52 5,97 1,2 1,31 2,20 3,20 p value >0,05 >0,05 >0,05 >0,05 <0,001 >0,05 >0,05 <0,05 <0,01 Table 3. Cephalometric analysis of skeletal measurements (16-20 yrs) group A vs group C 76,5 79,6 111,2 56 72,8 67 1,04 1,46 0,77 +4,2 +1,7 +4,4 +2,4 +2,8 +2,7 +0,04 +0,10 +0,02 79,07 86,9 123,3 59,4 65,5 73,0 1,10 1,56 0,90 +1,4 +7 +8,9 +1,4 +1,6 +2,8 +0,02 +0,08 +0 t value 0,80 5,75 2,71 1,64 3,38 2,65 1,74 1,19 7,17 p value >0,05 <0,01 <0,05 >0,05 <0,05 <0,05 >0,05 >0,05 <0,001 Table 4. Cephalometric analysis of skeletal measurements (10-12 yrs.) group B vs group C 76 77 97 61 69,5 63 1,01 1,27 0,88 +1,4 +2,8 +0,0 +4,2 +7 +1,4 +0,05 +0,02 +0,07 72,5 81,5 99 54 57 71 1,13 1,37 0,94 +2,4 +5,8 +4,1 +1,8 +1,8 +7,0 +0,12 +0,10 +0,04 t value 0,64 0,64 0,30 1,90 6,30 2,16 1,67 2,70 1,60 p value >0,05 >0,05 >0,05 >0,05 <0,001 >0,05 >0,05 >0,05 >0,05
26 P. Jain et al. ase in maxillary retrusion that could be attributed to cleft palate repair. He reported significant degree of maxillary retrusion in both unoperated and operated patients. He also could not find, like us, and some others (4, 7) any significant difference between un-operated and operated patients. Some other research workers (8, 9) have also concluded that maxillary growth is similar in cleft palate patients irrespective of the time of surgery. The length of the maxilla in all our un-operated cleft palate patients, irrespective of the age, was shorter than in controls. It was significantly so in both 4-6 years and 16-20 years age groups. The decrease in S-N-ANS angles in all the un-operated patients also strengthens the fact that there is maxillary hypoplasia significantly so in 16-20 years old ones. Other parameters like upper anterior facial height (<Ż in all), lower anterior facial height (>in all, significantly in older children and adults), maxillary index (<Ż in all) and facial height index (significantly <Ż in older children and adults) in un-operated cleft palate patients indicate to only one conclusion that there is maxillary hypoplasia even in absence of surgical intervention. Had the surgical trauma to the maxillary periosteum been the primary cause inhibiting maxillary growth, there would not have been any degree of maxillary hypoplasia in non-operated patients. Contrary to long held view that the cleft palate affects the growth and development only of maxilla, our cephalometric evaluation of both group A and B patients show decrease in mandibular length, mandibular index and also facial height index. Motohashi et al. (10) also showed a considerable degree of facial deformity not only in the midface but also in mandible. Corbo et al. (11) also reported retrusion of both maxilla and the mandible in the children operated for cleft lip and palate. Difference in the results reported by various authors could be due to small sample size, wide age distribution and mixed population with varying cleft severity and of operated, partially operated and un-operated children. Thus our study suggests an intrinsic deficiency in maxillary growth and rules out surgery as the only important cause behind maxillary hypoplasia. This also strengthens the view that one should repair cleft of both hard and soft palate in one stage around 1 year of age and be more concerned with speech development. Gaggl et al. (12) found more severe impairment of the growth of maxilla in sagittal and frontal plane after two stage operation of the cleft palate. Stein et al. (13) advocated early one stage repair of the cleft palate as there was no significant difference in the sagittal and vertical craniofacial dimensions whether the palate was closed in one or two stages. Early timely surgical intervention in developed countries obviates the opportunity to come across large number of un-operated children with cleft palate and a chance to clarify whether the maxillary retrusion could be attributed to surgical intervention alone. It is necessary to examine in detail a large number of patients with unrepaired cleft palate as a part of multicenter study and compare them with operated ones. However, it would be difficult to do so in near future because of free of cost surgery and other financial help from various organizations to the children with cleft lip and palate in the developing countries. REFERENCES 1. Ortiz-Monasterio F, Serrano RA, Barrera PG et al.: A study of untreated adult cleft palate patients. Plast Reconstr Surg 1966; 38: 36. 2. Bishara SE, de Arrendondo RSM, Vales HP et al.: Dentofacial relationships in persons with unoperated clefts. Comparisons between three cleft types. Am J Orthod 1985; 87: 481. 3. Mars M, Houston WJB: 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 1990; 27: 7. 4. Normando ADC, Filho OGS, Filho LC: Influence of surgery on maxillary growth in cleft lip and/or palate patients. J Craniomaxillofac Surg 1992; 28: 111. 5. Filho LC, Taniguchi SM, Filho OGS: Craniofacial morphology of adult unoperated complete unilateral cleft lip and palate patients. Cleft Palate Craniofac J 1993; 30: 376. 6. Rusen KM: Craniofacial morphology in adult nonoperated and operated cleft palate patients. Cleft Palate Craniofac J 1996; 33: 384. 7. Bishara SE: Cephalometric evaluation of facial growth in operated and nonoperated individuals with isolated clefts of the palate. Cleft Palate J 1973; 10: 239-46.
Lateral cephalometric evaluation in cleft palate patients 27 8. Robertson NRE, Jolleys A: The timing of hard palate repair. Scand J Plast Reconstr Surg 1974; 8: 49. 9. Ross RB: Treatment variables affecting facial growth in complete unilateral cleft lip and palate 1. Treatment affecting growth. Cleft Palate J 1987; 24: 5. 10. Motohashi N, Kuroda T, Filho LC et al.: P-A cephalometric analysis of nonoperated adult cleft lip and palate. Cleft Palate Craniofac J 1994; 31: 193-200. 11. Corbo M, Dujardin T, de Maertelaer V et al.: Dentocraniofacial morphology of 21 patients with unilateral cleft lip and palate: a cephalometric study. Cleft Palate Craniofac J 2005; 42: 618-24. 12. Gaggl A, Feichtinger M, Schultes G et al.: Cephalometric and occlusal outcome in adults with unilateral cleft lip, palate and alveolus after two different surgical techniques. Cleft Palate Craniofac J 2003; 40: 249-55. 13. Stein S, Dunsche A, Gellrich NC et al.: One-ortwo-stage palate closure in patients with unilateral cleft lip and palate: comparing cephalometric and occlusal outcome. Cleft Palate Craniofac J 2007; 44: 456-57. Received: 16.07.2008 r. Adress correspondence: Department of Plastic Surgery, Institute of Medical Science, Banaras Hindu University, Varanasi 221005, U.P., India