Facial dimensions of Malay children with repaired unilateral cleft lip and palate: a three dimensional analysis

Morphometric Assessment of Facial Morphology in Infants with Orofacial Clefts up to two Years of Age: A Three-Dimensional Cross-Sectional Study

OBJECTIVE

To assess modelled facial development of infants with unilateral cleft lip (CL) and cleft lip and palate (UCLP) compared to controls up to two years of age.

DESIGN AND PARTICIPANTS

A total of 209 facial images of children (CL: n = 37; UCLP: n = 39; controls: n = 137) were obtained in four age categories (T0 = 0.2-0.5; T1 = 0.6-1.0; T2 = 1.1-1.5; T3 = 1.6-2.0 years) and were evaluated using stereophotogrammetry and geometric morphometry. All patients underwent lip surgery before T0, patients with UCLP underwent palatoplasty (T0, T1 before palatoplasty; T2, T3 after palatoplasty).

RESULTS

In patients with CL, the forehead was significantly retracted (p ≤ 0.001), while the supraorbital and ocular regions were prominent (p ≤ 0.001). The oronasal region appeared convex (p ≤ 0.001). The lower lip and chin were non-significantly protruded. In patients with UCLP, a significantly retracted forehead and prominent supraorbital region were apparent (p ≤ 0.001). A retrusive oronasal region (p ≤ 0.001) was observed in the middle face. The chin was anteriorly protruded (p ≤ 0.01). No progression of deviations was found with increasing age. After the first year, a slight improvement in the morphological features became apparent. The shape variability of the clefts and controls overlapped, suggesting a comparable modelled facial development.

CONCLUSIONS

The facial morphology of individuals with cleft was comparable to the norm. Shape deviation was apparent in the oronasal region, forehead, and chin, which minimised with increasing age even in complete clefts.

Growth patterns of the nasolabial region following unilateral cleft lip primary repair

Surgical correction is the optimal way of repairing a congenital cleft lip. Patients with this condition often undergo initial surgical treatment at an early age and achieve an acceptable outcome. However, their levels of satisfaction will decrease in later stages of life as facial growth and development will inevitably cause changes in long-term outcomes, especially in the nasolabial region. Therefore, it is important for surgeons to understand nasolabial development after primary treatment and tailor their surgical techniques appropriately. This review focuses on the growth patterns of the nasolabial region after primary repair, so as to provide references for operative strategy.

Three-Dimensional Evaluation of Deformed Noses in Patients With Unilateral Cleft Lip and Palate: A Meta-Analysis

ABSTRACT

Multiple surgeries for patients with cleft lip and palate may be required to repair secondary deformities after the completion of cleft repair. This meta-analysis aimed to evaluate the three-dimensional nasal morphology in patients with unilateral cleft palate who underwent cleft lip and palate repair but did not undergo terminal nasal repair. PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and SINOMED databases were searched from inception until December 2020. Studies involving patients ages ≥6 years with cleft lip and palate who did not undergo terminal nasal repair were included. Quantitative data were obtained through three-dimensional evaluation. Mean weighted effect sizes with 95% confidence intervals, heterogeneities, and publication biases were assessed using raw data obtained from 13 studies. In general, patients with unilateral cleft lip and palate had a significantly wider nose; shorter bridge length and nasal height; larger forehead-nose angle, nasal tip angle, and alar slope angle; and smaller nasolabial angle. The number of studies that included patients with unilateral cleft lip, unilateral cleft lip and alveolus, and unclassified deformities was limited, and their results were similar to those involving patients with unilateral cleft lip and palate. Patients with unilateral cleft tend to have short, flat, and wide noses. Nasal tip elevation and alar base adduction should be prioritized during terminal nasal repair to achieve more normalized cleft-side nostrils.

Validity and reproducibility of the 3D VECTRA photogrammetric surface imaging system for the maxillofacial anthropometric measurement on cleft patients

OBJECTIVES

To validate the accuracy and reproducibility of linear measurements of three-dimensional (3D) images and to compare the measurements with the direct anthropometry method on cleft lip and palate (CLP) patients.

MATERIALS AND METHODS

Nineteen linear facial measurements were derived from 16 standardized surface landmarks obtained from 37 cleft patients (20 males, 17 females; mean age 23.84 years, standard deviation ± 6.02). They were taken manually with calipers and were compared with the digitally calculated distance on the 3D images captured using the VECTRA-M5 360° Imaging System with pre-marked landmarks. Another pair of 19 linear measurements were computed on the 3D images 2 weeks apart for intra- and inter-observer agreements. Statistical analyses used were paired t test, the Bland-Altman analysis, and the intra-class correlation coefficient (ICC) index.

RESULTS

Most of the linear measurements showed no statistically significant differences between the proposed method and direct anthropometry linear measurements. Nevertheless, bias of the 3D imaging system is present in the linear measurements of the nose width and the upper vermillion height. The measurements' mean biases were within 2 mm, but the 95% limit of agreement was more than 2 mm. Intra- and inter-observer measurements generally showed good reproducibility. Four inter-observer measurements, the upper and lower face heights, nose width, and pronasale to left alar base were clinically significant.

CONCLUSIONS

Measurements obtained from this 3D imaging system are valid and reproducible for evaluating CLP patients.

CLINICAL RELEVANCE

The system is suitable to be used in a clinical setting for cleft patients. However, training of the operator is strictly advisable.

Three-Dimensional Soft-Tissue Evaluation in Patients with Cleft Lip and Palate

BACKGROUND In cleft lip and palate (CLP) patients, the shape of the facial soft tissues shows variety in 3 dimensions (3D). Two-dimensional (2D) photographs and radiographs are insufficient in the examination of these anomalies. The aim of this retrospective study was to examine the soft tissue and craniofacial characteristics of individuals with nonsyndromic unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), skeletal Class III malocclusions, or skeletal Class I malocclusions using 3D facial imaging. MATERIAL AND METHODS The entire study group consisted of a total of 158 patients, aged 8-32 years: 29 of the patients had UCLP, 22 BCLP, 54 had skeletal Class III malocclusions, and 53 had skeletal Class I malocclusions. 3D stereophotogrammetric soft-tissue recordings of all patients were analyzed. ANOVA and the Kruskal-Wallis test were performed to compare the groups. RESULTS Statistically significant differences were observed among the groups in terms of linear, angular, proportional. and volumetric measurements. While nasal differences were not observed in the Class III group, nose and upper-lip deformities were common in the CLP groups. Upper-lip projection was reduced in all 3 groups. In the Class III patients, the lower lip and chin were more prominent than in the other groups. The facial convexity angle was increased in the CLP and Class III groups. The upper-lip volume was decreased in the BCLP, the UCLP, and the Class III groups. CONCLUSIONS Patients with skeletal Class III or CLP anomalies showed significantly different soft-tissue characteristics than the Class I control group. 3D stereophotogrammetric facial imaging is an easy and noninvasive method that can be used in examination and recording of these facial deformities. It is possible to make volumetric measurements using this method.

Longitudinal Follow-up of Individuals With Cleft Lip Using Three-Dimensional Stereophotogrammetry

The usefulness of three-dimensional (3D) stereophotogrammetry for treating cleft lip (CL) has been well documented. However, there are only a few reliable anthropometric analyses in infants with CL because at this age they cannot assume a resting facial position. Since 2014, we have used a handheld 3D imaging system in the operating room to obtain optimal images of infants with CL and palate under general anesthesia. Currently, 168 infants with a unilateral cleft, 50 infants with bilateral clefts, and 47 infants with an isolated cleft palate are being followed up in this way for a maximum of 30 months. Most patients ≥3 years of age are cooperative and allow staff to obtain 3D images without sedation. We plan to follow them until adulthood, obtaining 3D images at every intervention. Each year, >150 infants can be added to this ongoing longitudinal study. Using an archive of these digital images, various retrospective studies can be attempted in the future, which include comparisons of the long-term outcomes of various surgical techniques and interventions at different time intervals. This is the first 2-year preliminary report of a 20-year longitudinal study.

Using three-dimensional average facial meshes to determine nasolabial soft tissue deformity in adult UCLP patients

BACKGROUND AND PURPOSE

There is limited literature discussing the residual nasolabial deformity of adult patients prior to undergoing orthognathic surgery. The purpose of this study is to determine the site and severity of the residual nasolabial soft tissue deformity between adult unilateral cleft lip and palate (UCLP) patients and a non-cleft reference group, prior to orthognathic surgery.

MATERIAL AND METHODS

Sixteen adult male UCLP patients, who all received primary lip and palate surgery according to a standardised Hong Kong protocol were recruited for this study. Facial images of each individual were captured using three-dimensional (3D) stereophotogrammetry and compared to a previous published Hong Kong non-cleft reference group of 48 male adults. Using two-sample t-tests differences in linear and angular measurements and asymmetry scores were evaluated between the two groups. In addition a "conformed" average UCLP facial template was superimposed and compared to conformed average non-cleft reference group facial template. Reproducibility of the measurements were assessed using Students paired t-tests and coefficients of reliability.

MAIN FINDINGS

Significant differences in linear and angular measurements and asymmetry scores were observed between the two groups (p < 0.05). Adult UCLP patients showed significantly narrower nostril floor widths, longer columella length on the unaffected side, a wider nose, shorter cutaneous lip height, shorter upper lip length and shorter philtrum length. Prior to orthognathic surgery adult UCLP patients showed significantly more facial asymmetry. Superimposition of the average facial meshes clearly showed the site and severity of the deficiency in the x, y and z-directions.

CONCLUSIONS

Many of the nasolabial characteristics reported to be present in children following primary UCLP repair continue into adulthood. The detrimental soft tissue effects of orthognathic surgery for UCLP patients may be different to non-cleft individuals; and as such the site and severity of the residual deformity should be assessed prior to surgery.

3D Assessment of Nasolabial Appearance in Patients With Complete Unilateral Cleft Lip and Palate

OBJECTIVE

Rhinoplasty in patients with complete unilateral cleft lip and palate (UCLP) is challenging, and the surgical outcome of the nose is complicated to evaluate. The aim of this study was to assess the nasolabial appearance of patients with UCLP compared with a control group.

DESIGN

Cross-sectional study.

SETTING

Riga Cleft Lip and Palate Centre, Latvia.

PARTICIPANTS

All consecutive 35 patients born between 1994 and 2004 with nonsyndromic complete UCLP were included. Of 35 patients, 29 came for checkup; the mean age was 14.7 years (range 10-18). In the control group, 35 noncleft participants at 10 years of age were included.

INTERVENTIONS

Nasolabial appearance was evaluated from 3-dimensional images using a 3-dimensional stereo-photogrammetric camera setup (3dMDface System), the results being analysed statistically.

RESULTS

In UCLP group, a statistically significant difference between cleft and noncleft side was found only in alar wing length ( P < .05). The difference of nasolabial anthropometric distances in the control group between the left and right side was not significant. The difference between the UCLP group and the control group was significant in all anthropometric distances except the lateral lip length to cupid's bow.

CONCLUSIONS

The nasolabial appearance with acceptable symmetry after cleft lip and reconstructive surgery of the nose was achieved. Symmetry of the nasolabial appearance in patients with UCLP differed from those in the control group. The 3D photographs with a proposed set of anthropometric landmarks for evaluation of nasolabial appearance seems to be a convenient, accurate, and noninvasive way to follow and evaluate patients after surgery.

A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 1: General concept and validation

PURPOSE

The need for a widely accepted method suitable for a multicentre quantitative evaluation of facial aesthetics after surgical treatment of cleft lip and palate (CLP) has been emphasized for years. The aim of this study was to validate a novel computer system 'Analyse It Doc' (A.I.D.) as a tool for objective anthropometric analysis of the nasolabial region.

MATERIALS AND METHODS

An indirect anthropometric analysis of facial photographs was conducted with the A.I.D. system and Adobe Photoshop/ImageJ software. Intra-rater and inter-rater reliability and the time required for the analysis were estimated separately for each method and compared.

RESULTS

Analysis with A.I.D. system was nearly 10-fold faster than that with the reference evaluation method. The A.I.D. system provided strong inter-rater and intra-rater correlations for linear, angular and area measurements of the nasolabial region, as well as a significantly higher accuracy and reproducibility of angular measurements in submental view. No statistically significant inter-method differences were found for other measurements.

CONCLUSIONS

The hereby presented novel computer system is suitable for simple, time-efficient and reliable multicenter photogrammetric analyses of the nasolabial region in CLP patients and healthy subjects.

A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 2: Comparative anthropometric analysis of patients with repaired unilateral complete cleft lip and palate and healthy individuals

PURPOSE

The aim of this study was to use a novel system, 'Analyse It Doc' (A.I.D.) for a complex anthropometric analysis of the nasolabial region in patients with repaired unilateral complete cleft lip and palate and in healthy individuals.

MATERIALS AND METHODS

A set of standardized facial photographs in frontal, lateral and submental view have been taken in 50 non-cleft controls (mean age 20.6 years) and 42 patients with repaired unilateral complete cleft and palate (mean age 19.57 years). Then, based on linear, angular and area measurements taken from the digital photographs with the aid of the A.I.D. system, a photogrammetric analysis of intergroup differences in nasolabial morphology and symmetry was conducted.

RESULTS

Patients with cleft lip and palate differed from the controls in terms of more than half of analysed angular measurements and proportion indices derived from linear and area measurements of the nasolabial region.

CONCLUSIONS

The findings presented herein imply that despite primary surgical repair, patients with unilateral complete cleft lip and palate still show some degree of nasolabial dysmorphology. Furthermore, the study demonstrated that the novel computer system is suitable for a reliable, simple and time-efficient anthropometric analysis in a clinical setting.

A three-dimensional photogrammetric analysis of the facial esthetics of the Miss Korea pageant contestants

Objective

The aims of this study were to measure and compare the facial dimensions of the Miss Korea pageant contestants and a selected group of women from the general population by using three-dimensional (3D) image analysis, as well as to compare various facial ratios to the golden ratio within each group.

Methods

Three-dimensional images of 52 Miss Korea pageant contestants (MK group) and 41 young female adults selected from the general population (GP group) were acquired. Fifty-four variables and ratios were measured and calculated. Intergroup comparisons were performed using multivariate analysis of variance.

Results

Compared to the GP group, the MK group showed greater total facial height and eye width, lesser lower-facial height, and lesser facial, lower-facial, and nasal widths. Moreover, compared to the GP group, the MK group had more protruded noses with greater nasolabial angle, greater vertical curvature of the foreheads, lesser horizontal curvature of the cheek, and lesser lower-lip-and-chin volume.

Conclusions

The MK group had longer faces but smaller lower lips and chins than did the GP group. The golden ratio was not matching the current facial esthetic standards. These data might be beneficial for treatment planning of patients undergoing orthognathic and plastic surgeries.

Three-dimensional facial analysis of Chinese children with repaired unilateral cleft lip and palate

We analyzed the facial features of Chinese children with repaired unilateral cleft lip and palate (UCLP) and compared them with a normal control group using a three-dimensional (3D) stereophotogrammetry camera. This cross-sectional study examined 3D measurements of the facial surfaces of 20 Chinese children with repaired UCLP and 40 unaffected Chinese children aged 7 to 12 years old, which were captured using the VECTRA 3D five-pod photosystem and analyzed using Mirror software. Twenty-five variables and two ratios were compared between both groups using independent t-test. Intra- and inter-observer reliability was determined using ten randomly selected images and analyzed using intra-class correlation coefficient test (ICC). The level of significance was set at p < 0.0018. Intra- and inter-observers’ reliability was considered fair to excellent with an ICC value ranging from 0.54 to 0.99. Statistically significant differences (p < 0.0018) were found mainly in the nasolabial region. The cleft group exhibited wider alar base root width, flattened nose and broader nostril floor width on the cleft side. They tended to have shorter upper lip length and thinner upper vermillion thickness. Faces of Chinese children with repaired UCLP displayed meaningful differences when compared to the normal group especially in the nasolabial regions.

Three-dimensional evaluation of facial morphology in pre-school cleft patients following neonatal cheiloplasty

PURPOSE

To evaluate the facial morphology of pre-school patients with various types of orofacial cleft after neonatal cheiloplasty in pre-school aged children; and to compare facial variability and mean shape with age-corresponding healthy controls.

MATERIALS AND METHODS

The sample included 40 patients with unilateral cleft lip (CL), 22 patients with unilateral cleft lip and palate (UCLP), and 10 patients with bilateral cleft lip and palate (BCLP). Patients were divided into two age categories, with a mean age of 3 years and 4.5 years, respectively. The group of healthy age-matched controls contained 60 individuals. Three-dimensional virtual facial models were evaluated using geometric morphometry and multivariate statistics methods.

RESULTS

Statistically significant differences were found between each of the cleft groups and the controls. Color-coded maps showed facial shape deviations, which were located mainly in the nasal area and philtrum in all groups examined, and also in the buccal region and the chin in patients with UCLP or BCLP. These differences became more apparent, but not significantly so, in the older age category.

CONCLUSION

Facial deviations typical of patients with clefts were observed in all of the patient groups examined. Although the analysis showed statistically significant differences in overall facial shape between patients and controls among all groups tested, the facial morphology in patients who have undergone only neonatal cheiloplasty (CL) is influenced to a small extent and may be considered satisfactory. More severe cleft types (UCLP, BCLP) together with palatoplasty, are reflected in more marked impairments in facial shape.

A Pilot Study on the Influence of Facial Expression on Measurements in Three-Dimensional Digital Surfaces of the Face in Infants With Cleft Lip and Palate

OBJECTIVE

Three-dimensional surface imaging is an increasingly popular modality for face measurements in infants with cleft lip and palate. Infants are noncompliant toward producing specific facial expressions, and selecting the appropriate moment of acquisition is challenging. The objective was to estimate amount and spatial distribution of deformation of the face due to facial expression in infants with cleft lip and palate and provide recommendations for an improved acquisition protocol, including a method of quality control in terms of obtaining images with true neutral expression.

MATERIAL AND METHODS

Three-dimensional surface images of ten 4-month-old infants with unrepaired cleft lip and palate were obtained using a 3dMDface stereophotogrammetric system. For each subject, five surface images judged as representing a neutral expression were obtained during the same photo session. Mean and maximum deformations were calculated. A formalized review was performed, allowing the image exhibiting the "best" neutral expression to be selected, thus decreasing errors due to residual facial expression.

RESULTS

Deformation due to facial expression generally increased from forehead to chin. The amount of deformation in three selected regions were determined: nose (mean, 1 mm; maximum = 3 mm); cleft region (mean, 2 mm; maximum = 5 mm); chin region (mean, 5 mm; maximum = 12 mm). Analysis indicated that introduction of a formalized review of images could reduce these errors by a factor of 2.

CONCLUSIONS

The continuous change of facial expression in infants represents a substantial source of error; however, this may be reduced by incorporating a formalized review into the acquisition protocol.

3D Facial Morphometry in Children with Oral Clefts

Objectives

The aim of this study was to characterize three-dimensional (3D) facial morphological variation of children with cleft lip and palate compared to an age- and sex-matched control group.

Design

Cross-sectional, case-controlled observational morphometric study.

Materials and Methods

Subjects were 103 children aged 8 to 12 years old with cleft lip and palate—40 with unilateral cleft lip and palate, 23 with unilateral cleft lip and alveolus, 19 with bilateral cleft lip and palate, and 21 with isolated cleft palate (ICP)—and 80 sex- and age-matched control subjects. Subjects were scanned using 3D stereophotogrammetry. Thirty-nine landmarks were digitized for each scan, and the x, y, and z coordinates for each landmark were extracted. Linear and angular facial measurements were computed. Multivariate analysis of covariance was undertaken to detect significant differences in facial morphometry between the groups.

Results

Statistically significant differences ( P < .05) were observed between all groups. The greatest morphometrical impact was seen in those groups where both lip and palate were affected and repaired; the group with ICP was the most similar to the control subjects.

Conclusions

Significant differences were seen in 3D soft-tissue measurements, mainly in the nasolabial region, between the cleft groups where the lip is affected and the ICP and control groups.

Reliability of nasolabial anthropometric measures using three-dimensional stereophotogrammetry in infants with unrepaired unilateral cleft lip

BACKGROUND

Surgical and orthodontic treatment of unilateral cleft lip +/- palate can produce dramatic changes in nasolabial form; however, the lack of ideal methods with which to objectively document three-dimensional form limits the ability to assess treatment outcomes. The purpose of this study was to determine the reliability of three-dimensional stereophotogrammetry for anthropometric assessment of the unilateral cleft lip +/- palate deformity in infants before cleft lip repair.

METHODS

Preoperative three-dimensional images were acquired from 26 consecutive patients with unrepaired unilateral cleft lip +/- palate. Three raters performed indirect anthropometry on each image on two separate occasions, with at least 1 week between rating sessions. One rater performed direct measurements on participants before surgery while in the operating room. Twenty-six linear and angular measurements were considered, and intrarater, interrater, and intermethod reliability were assessed.

RESULTS

Regarding intrarater and interrater reliability, most measurements had Pearson coefficients greater than 0.75, mean differences less than 0.8 mm, and mean proportional differences less than 0.1. For measurements involving vermilion height, nostril remnants, or Cupid's bow width, Pearson coefficients ranged from 0.3 to 0.75, mean differences ranged from 0.4 to 0.9 mm, and mean proportional differences ranged from 0.1 to 0.3. Regarding intermethod reliability, correlation coefficients ranged from 0.4 to 0.75 for most measurements. The mean differences for nose and lip measurements were less than 1 mm and between 0.8 and 1.3 mm, respectively.

CONCLUSION

Three-dimensional stereophotogrammetry provides a reliable method for many anthropometric measurements of nasolabial form in infants with unrepaired unilateral cleft lip +/- palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Three-dimensional imaging methods for quantitative analysis of facial soft tissues and skeletal morphology in patients with orofacial clefts: a systematic review

Background

Current guidelines for evaluating cleft palate treatments are mostly based on two-dimensional (2D) evaluation, but three-dimensional (3D) imaging methods to assess treatment outcome are steadily rising.

Objective

To identify 3D imaging methods for quantitative assessment of soft tissue and skeletal morphology in patients with cleft lip and palate.

Data sources

Literature was searched using PubMed (1948–2012), EMBASE (1980–2012), Scopus (2004–2012), Web of Science (1945–2012), and the Cochrane Library. The last search was performed September 30, 2012. Reference lists were hand searched for potentially eligible studies. There was no language restriction.

Study selection

We included publications using 3D imaging techniques to assess facial soft tissue or skeletal morphology in patients older than 5 years with a cleft lip with/or without cleft palate. We reviewed studies involving the facial region when at least 10 subjects in the sample size had at least one cleft type. Only primary publications were included.

Data extraction

Independent extraction of data and quality assessments were performed by two observers.

Results

Five hundred full text publications were retrieved, 144 met the inclusion criteria, with 63 high quality studies. There were differences in study designs, topics studied, patient characteristics, and success measurements; therefore, only a systematic review could be conducted. Main 3D-techniques that are used in cleft lip and palate patients are CT, CBCT, MRI, stereophotogrammetry, and laser surface scanning. These techniques are mainly used for soft tissue analysis, evaluation of bone grafting, and changes in the craniofacial skeleton. Digital dental casts are used to evaluate treatment and changes over time.

Conclusion

Available evidence implies that 3D imaging methods can be used for documentation of CLP patients. No data are available yet showing that 3D methods are more informative than conventional 2D methods. Further research is warranted to elucidate it.

Systematic review registration

International Prospective Register of Systematic Reviews, PROSPERO CRD42012002041

Three-dimensional quantitative evaluation of facial morphology in adults with unilateral cleft lip and palate, and patients without clefts

The aims of this study were to assess the quantitative values of measurements using proportion indices in the craniofacial region in patients with repaired, non-syndromic, complete unilateral cleft lip and palate (UCLP), and compare them with a control group who did not have clefts using the non-invasive systems of 3-dimensional technology. Three-dimensional measurements of the facial surfaces of 15 Malay patients who had UCLP repaired and 100 Malay control patients aged 18-25 years were analysed. The 3-dimensional images of the respondents' faces were captured using the VECTRA-3D Stereophotogrammetry System. Eleven craniofacial proportions were assessed using a combination of 18 linear measurements obtained from 21 anthropometric soft tissue landmarks. These measurements were used to produce proportion indices to find the differences in the morphological features between the groups, and assessed using the independent sample t test and z scores. There were significant differences between the groups in 7 out of 11 craniofacial proportion indices (p=0.001-0.044). Z scores of 2 indices were disproportionate. They were nasal index (which was severely supernormal) and upper lip index (which was moderately supernormal). Patients with UCLP had higher mean z scores, indicating that patients with UCLP tended to have larger faces than the control group. There were clinically important differences mainly in the nasolabial area, where the nose and the upper lip were wider, larger, or flatter in patients with UCLP.