Noncleft Patients Research Articles

Commentary

Commentary

Mandibular asymmetry and antigonial notching in individuals with unilateral cleft lip and palate.

To determine whether asymmetric antigonial notching is associated with the development of mandibular and lower facial asymmetry in individuals with unilateral cleft lip and palate (UCLP). Retrospective mixed-longitudinal investigation including UCLP and nonaffected orthodontic patients. All (24) available patients with UCLP treated in our clinic with complete longitudinal records, and 72 skeletal maturation matched noncleft orthodontic patients that served as controls. Subject records included hand-wrist, panoramic, frontal, and 45 degrees oblique cephalometric radiographs. The development of mandibular asymmetry, measured on oblique cephalometric radiographs, as well as lower facial asymmetry, measured on frontal cephalometric radiographs, was monitored in individuals with UCLP in relation to antigonial notching asymmetry, assessed on panoramic and oblique cephalometric radiographs. First, no statistical differences were found in antigonial notching asymmetry between patients with UCLP and noncleft controls. Second, antigonial notching asymmetry, observed on panoramic and oblique cephalometric radiographs, significantly correlated with the attendant development of mandibular and lower facial asymmetry in individuals with UCLP. Third, the development of mandibular and lower facial asymmetry at pubertal and postpubertal growth spurt stages significantly correlated with antigonial notching asymmetry, measured on panoramic radiographs, at prepubertal and pubertal growth spurt stages, respectively. The degree of antigonial notching noted on panoramic radiographs can be used as an early indicator of developing mandibular and lower facial asymmetry in individuals with UCLP.

Open rhinoplasty through a forked flap incision.

Surgical elongation of the short columella is a challenging problem for the surgeon. Although some flaps from the upper lip are successfully used to correct this deformity on cleft lip patients with a scarred upper lip, these methods cannot be applied to noncleft patients with a smooth upper lip. Distant flaps and composite grafts do not give the best aesthetic results. The use of an external approach for rhinoplasty is preferred by many surgeons, especially for difficult or secondary cases. Most incisions for open rhinoplasty are placed on the columella. This report describes a new incision for open rhinoplasty to be used on patients with a short columella. The incision is a standard forked flap with a columellar base but the legs of the flap extend to the nostril bases instead of to the upper lip. This method was used on eight aesthetic rhinoplasty patients with a short columella between March 1995 and March 1998. The results of the method are discussed.

The lip index: an anthropometric tool to evaluate objectively the result of the Abbe flap procedure.

To evaluate objectively the outcome of the Abbe flap procedure, an anthropometric ratio--the lip index--is introduced. The lip index is the ratio of the labiale superius-tragion to the labiale inferius-tragion. It represents the protrusion of the upper lip in relation to the lower lip. It has been assessed in preoperative and postoperative photographs of 19 patients who underwent an Abbe flap procedure. The values were compared with the values found in noncleft patients. In all 19 patients, postoperative values were found to have normalized. This study indicates that the lips are in better harmony postoperatively than they were preoperatively.

Upper dental arch morphology of adult unoperated complete bilateral cleft lip and palate

Literature has shown that, even with the conservative nontraumatic surgical techniques, early repairing surgeries induce changes in the upper dental arch morphologic characteristics in patients with cleft lip and palate. The evaluation of unoperated adult cleft patients enables us to exclude the influence of treatment, emphasizing the morphologic characteristics inherent to the presence of the cleft and its functional counterbalances, that is, the morphologic pattern imposed by cleft. In this study, the maxillary dental casts of 31 unoperated adult complete bilateral cleft lip and palate patients (20 men and 11 women) were compared to a noncleft sample matched for gender. Intercanine, inter–first premolar, inter–second premolar and inter–first molar arch widths measurements as well as arch length were measured from xerox copies taken of the models. The findings indicate the presence of premaxillary prognathism and a progressive increase in the constriction of the dental arches. This constriction of the maxillary segments, even in the absence of surgical intervention, is a result of the absence of an intact palate between the two maxillary processes. Although gender significantly influenced the size of the maxillary arches in the noncleft patients, similar differences were not observed in the cleft group. It seems that the presence of the cleft in itself has the greater influence on the morphologic characteristics of the maxillary arch than gender.

Soft tissue changes following maxillary osteotomies in cleft lip and palate and non-cleft patients

A retrospective study of 25 patients with unilateral cleft lip and palate and 25 patients with hypoplastic maxillae without a cleft was carried out to evaluate the effects of maxillary osteotomies at the Le Fort I level on the lip and nose profile. The pre-surgical cephalometric tracing was superimposed twice on the post-surgical cephalogram, on the cranial structures and the anterior maxillary structures, for landmark movement measurement. Results showed statistically significant correlations between soft and hard tissue movement in the cleft group. On average, the ratios of horizontal nasal tip, nasal base and lip movement to underlying hard tissue movement were approximately one fourth, one half and two thirds respectively. The ratio of vertical lip to incisor movement was about one half. The correlations were less significant in the non-cleft group, only the upper lip movement showed statistically significant correlation with hard tissue movement, with a ratio of one half horizontally and one third vertically. It was concluded that in maxillary osteotomy, the cleft group showed a higher soft tissue to hard tissue movement ratio. The correlation between soft and hard tissue movements were more statistically significant in the cleft group than in the non-cleft group. However, though statistically significant, the level of correlation was not strong on an individual basis except in the horizontal lip response of the cleft group. Individual variation was wide and clinical judgement needs to be considered accordingly.

The 3-dimensional stability of maxillary osteotomies in cleft palate patients with residual alveolar clefts

Objectives—To evaluate the stability of maxillary osteotomies in cleft palate patients using miniplate fixation. Design—A prospective clinical study. Subjects—46 consecutive cleft palate patients with residual alveolar clefts and maxillary hypoplasia in one or more dimensions. These patients underwent standardised maxillary osteotomies and simultaneous bone grafting of the alveolar cleft over 44 months during 1988–1992. Titanium mini-plate fixation was used for the maxilla in all patients. Follow-up ranged from 6 to 51 months with a mean of 28 months. Main outcome measures—The 3-dimensional stability of maxillary osteotomies in cleft palate patients in the long term. Results—In the unilateral clefts, relapse in the horizontal plane was 22% and in the vertical plane 22.5%; in bilateral clefts, the relapse was 17.5% and 7% respectively, with no statistically significant difference between the two groups. Longitudinal analysis of the repositioned maxilla over a 3-year period showed that most of the relapse occured in the first 6 months and stabilised at 2 years postoperatively. Relapse in the transverse plane, based on analysis of the study models of 26 cases, ranged from 13.4% to 33.6%. A clockwise rotational relapse of the maxilla was noted in bilateral cases. Postoperative orthodontics compensated for the horizontal relapse by increasing incisor proclination to maintain positive overjet. There was no significant difference between the relapse of bimaxillary cases and that of maxillary osteotomies alone. Conclusion—The long-term 3-dimensional surgical stability, using miniplate fixation, has decreased the relapse of cleft maxillary osteotomies with simultaneous alveolar bone grafting to a level comparable to that of maxillary osteotomies in non-cleft patients.

口唇口蓋裂患者の鼻上顎複合体のＣＴ画像による三次元解析

This study was designed to clarify the three dimensional features of naso-maxillary complex in cleft lip and palate (CLP) by using computed tomography (CT) and to examine its change following an upper dental arch expansion. Sequential CT images with 2mm-thickness were obtained for 11 unilateral CLP boys (UCLP), 6 bilateral CLP boys (BCLP) and 4 boys without cleft (non-cleft). Additionally, two serial sets of upper dental cast before and after dental arch expansion coupled with CT images in UCLP were used to evaluate the effect of dental arch expansion on the naso-maxillary complex. UCLP demonstrated a remarkable naso-maxillary deformity characterized by a decreased volume of maxillary sinus in comparison with the non-cleft patients. Both the volume and shape of nasal cavity were significantly different between the cleft and non cleft side. Naso-maxillary morphology of BCLP, however, was similar to that of the non cleft except for the decreased volume of alveolar arch. Comparative study of UCLP and BCLP showed a significant difference in naso-maxillary morphology. There were some significant correlations between the dental arch expansion and change of each naso-maxillary component, suggesting the effect of expansion stress on the naso-maxillary complex in UCLP. However, deformation caused by expansion stress varied, depending on each component of the naso-maxillary complex.

Quantitative evaluation of the shape and the elasticity of repaired cleft lip.

Tight lip in repaired cleft lip patients with or without cleft palate (CL[P]) has been discussed as one of the causal factors of maxillary growth retardation and malocclusion. The purpose of this study was to evaluate the shape and the elasticity of repaired cleft lip quantitatively. Forty-one Japanese CL(P) patients were examined. Fifty-four noncleft patients under orthodontic treatment were used as a control group. An apparatus to stretch the anguli oris bilaterally was devised and the extensibility of the lip was measured to evaluate lip elasticity. Standardized photos of the lips were taken to examine lip shape. CL(P) patients showed poor elasticity of the lip. This trend was more apparent in bilateral CL(P) patients than in unilateral CL(P) patients. The upper lip of CL(P) patients was significantly shorter in vertical height. These results clearly demonstrated the tightness and shortness of the repaired lip in CL(P) patients.

Quantitative Evaluation of the Shape and the Elasticity of Repaired Cleft Lip

Tight lip in repaired cleft lip patients with or without cleft palate (CL[P]) has been discussed as one of the causal factors of maxillary growth retardation and malocclusion. The purpose of this study was to evaluate the shape and the elasticity of repaired cleft lip quantitatively. Forty-one Japanese CL(P) patients were examined. Fifty-four noncleft patients under orthodontic treatment were used as a control group. An apparatus to stretch the anguli oris bilaterally was devised and the extensibility of the lip was measured to evaluate lip elasticity. Standardized photos of the lips were taken to examine lip shape. CL(P) patients showed poor elasticity of the lip. This trend was more apparent in bilateral CL(P) patients than in unilateral CL(P) patients. The upper lip of CL(P) patients was significantly shorter in vertical height. These results clearly demonstrated the tightness and shortness of the repaired lip in CL(P) patients.

Velocardiofacial syndrome: analysis of phoniatric and other clinical findings.

We present 18 children with velocardiofacial syndrome. A palatal or a submucous cleft was observed in 10 patients, while 8 had no cleft. Seven patients had minor anomalies in the CT scan, but their significance is unclear. These anomalies as well as structural cardiac malformations occurred more often in the non-cleft patients. Cleft palate and velopharyngeal insufficiency were not the only causes of speech problems in these children. In the velocardiofacial syndrome speech disorder should be recognized and carefully analyzed with phoniatric and neuropsychological methods.

Effects of Orthognathic Surgery on Nasal Form and Function in the Cleft Patient

Management of common problems of nasal airway obstruction in cleft and noncleft patients by the subnasal approach through the maxillary Le Fort I osteotomy are discussed. The effects of maxillary surgical repositioning on the esthetics of the nose and upper lip are presented, as well as the sequencing and timing of orthognathic surgery and nasal reconstruction in the cleft patient. Case presentations illustrate the results of this treatment approach.

A cephalometric analysis of the Le Fort I osteotomy in the noncleft patient

A cephalometric analysis of the Le Fort I osteotomy in the noncleft patient

Midfacial osteotomies in patients with cleft lip, alveolus and palate.

Surgical/orthodontic strategies in patients with hypoplastic midfaces and cleft of lip, alveolus and palates after completion of skeletal growth are guided by cephalometric data, with the soft-tissue profile playing the most important role. The Le Fort I, the extended Le Fort I and, less frequently, the Le Fort II procedure depend on the extent of midfacial hypoplasia. Osteotomy planning should consider that in cleft patient's maxilla, the anterior nasal spine and A-point need to be advanced and caudally rotated to a larger extent than is necessary in non-cleft patients. A slight overcorrection of ANB-angle is necessary to achieve a harmonious and attractive soft-tissue profile since upper lip and nasal soft tissue require more bony support. In severe bimaxillary disturbances the midfacial advancement has to be combined with mandibular osteotomies. Stabilization after midfacial osteotomies should be done by corrosion-resistant Vitallium or titanium miniplates. This technique provides sufficient stability to restore early function immediately after surgery. Intermaxillary fixation following surgery is no longer necessary. Several decisive advantages are provided by this technique over the previously applied wire suspension concepts or wire suturing techniques. The most advantageous points are: No intermaxillary fixation is required immediately postoperatively; Normal soft food intake is resumed after 8-10 days when wound healing is completed; Rigid plate fixation leads to a considerable improvement in bone healing, while 'pumping-effects' induced by micromovements from the masticatory muscles are avoided; Plate fixation allows immediate functional 'antirelapse-treatment' against relapse tendencies, using functional treatment by means of soft intermaxillary elastics.

Auditory tube function and audiogram changes following corrective orthognathic maxillary and mandibular surgery in cleft and non-cleft patients.

Orthognathic surgery is frequently undertaken to correct maxillary hypoplasia and mandibular deformity in both the cleft and non-cleft patient. These procedures lead to surgical disruption of the pterygoid fossa. Lying within this area is the auditory tube and the muscles of the soft palate. Hearing sensitivity testing methods, auditory tube function tests and middle ear pressure measurements show that in the early post-operative period the auditory tube is not functioning normally and that there is fluid collecting in the middle ear. For some patients these tests are still abnormal when repeated 6-8 weeks post-operatively and indicate that during the postoperative period auditory tube functioning tests may be required to prevent permanent hearing impairment.

Comparative Studies on the Orthodontic Changes in the Crossbite Between Unilateral Cleft Lip/Pa l a t e and Non-cleft Patients.

Comparative Studies on the Orthodontic Changes in the Crossbite Between Unilateral Cleft Lip/Pa l a t e and Non-cleft Patients.

唇・顎・口蓋裂患者の治療例

In orthodontic treatment, patients with cleft lip and/or palate have the following difficulties as compared with non-cleft patients. 1. Anterior and posterior cross-bite due to collapse of the maxillary arch. 2. Poor growth of the maxilla. 3. Strain of the upper lip after surgical treatment. 4. Congenitally missing teeth, supernumerary teeth and transversion, etc.. Therefore, we examined two cases with unilateral cleft lip and palate and one case with bilateral cleft lip and palate who received orthodontic treatment at Kyushu Dental College Hospital. In all cases edgewise technique was used at final step of orthodontic treatment. These cases needed the lateral and antero-posterior expansion of the maxillary arch, the aesthetic and functional recovery by restoration for missing teeth, the permanent fixation against relapse or the secondary plastic surgery of the upper lip and nose.

A cephalometric analysis of the le fort II osteotomy in the non-cleft patient

The hard and soft tissue changes brought about by Le Fort II osteotomies on 13 non-cleft patients were studied using pre-operative, immediate post-operative and follow up lateral cephalograms. The cephalometric analysis was carried out using a digitizer linked to a microcomputer. The results are compared with a similar study previously reported for cleft patients.

Ultrastructure of the Middle Ear Mucosa in Secretory Otitis Media

A semiquantitative study of secretory otitis media (SOM) was carried out using transmission electron microscopy. Mucosal specimens from different types of ear pathology in cleft palate patients were compared with specimens from SOM of unknown etiology, chronic otitis media, and normal middle ear mucosa. 39 specimens from cleft palate patients were examined and compared with 7 specimens from non-cleft patients. Special interest was focused on the ciliated cells and the secretory cells. in SOM with mucoid effusion up to 10% of all cilia were abnormal. Compound cilia could have many forms, while the remaining cilia seemed normal. Microknobs on the ciliary wall were frequently found in SOM ears and could perhaps represent a secretory entity. the microvilli on secretory cells had external filaments, especially dominant in SOM with mucoid effusion. Fluid reabsorption probably takes place in the microvilli. Ventilating tubes in the ear drum reduced the height of the mucosa and microvilli.

Movement of maxillary segments after expansion and/or secondary bone grafting in cleft lip and palate: A roentgen stereophotogrammetric study with the aid of metallic implants

The study was undertaken to examine the effects of expansion treatment and secondary bone grafting in cleft lip and palate. Movement of the lateral maxillary segments in four patients with complete bilateral cleft lip and palate (BCLP) was complicated and asymmetric, and a greater relative widening of the dental arch was observed. The least expansion was found in the oldest patient. Bone grafting did not bring about a stable relationship between the segments. The width of the dental arch was mostly maintained despite segmental movement. In one patient with unilateral cleft of the lip and primary palate (UCL) growth in the midpalatal suture followed the pattern observed in noncleft patients but was less extensive. Accurate and comprehensive recording of the relatively small maxillary movements requires that implant stability is checked and that a reference is established outside the maxilla.